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64th Annual CSI Conference and SAARC Cardiac CongressDECEMBER 06e09, 2012, NEW DELHI, INDIA

Echocardiography

Poster Presentation

NT-proBNP levels on admission predictspulmonary hypertension persistence in patientswith acute pulmonary embolism

Anuj Sathe, Mahesh Ghogare, Abhishek Wadkar, Pankaj Patil,

Kesavan S., Anup R. Taksande, Hetan Shah, Ajay U. Mahajan, P.J.

Nathani

LTMMC & LTMGH, Sion, Mumbai, India

Chronic thromboembolic pulmonary hypertension (CTEPH) is

a rare, but due to its unfavorable prognosis, feared complica-

tion of thromboembolic disease. We assessed the incidence

and risk factors for pulmonary hypertension (PH) in a cohort of

consecutive patients admitted with acute pulmonary embo-

lism in our Hospital during the period from February 2011 to

June 2012.

Methods: In our cohort of 83 consecutive patients with proved

pulmonary embolism (PE) we studied the course of biochemical

and echocardiographic parameters with regard to risk factors

predicting pulmonary hypertension at the end of hospitalization.

The correlation between high initial NT-proBNP levels and

persistence of pulmonary hypertension on discharge was studied.

Results: Echocardiographic signs of pulmonary hypertension

were present at the time of discharge in more than one half

(58.8%) of patients admittedwith pulmonary embolism. Predictors

of persisting pulmonary hypertension were initial pulmonary

hypertension, high initial NT-proBNP levels and age >60 years.

Conclusion: Residual pulmonary hypertension at discharge was

present in 58.8% cases, at this time there was a strong relationship

between PH and elevated NT-proBNP on admission. The patients

will be followed-up and possible development of CTPEH will be

evaluated at 6, 12 and 24-month period.

Echocardiographic evaluation of chronicobstructive pulmonary disease patients and itsco-relation with the severity of disease

A. Muralidharan, S. Venkatesan, V.E. Dhandapani, M.S. Ravi, G.

Karthikeyan, D. Muthukumar, S. Meenakshi, N. Swaminathan

The author underlined is the Presenting author.

http://dx.doi.org/10.1016/j.ihj.2012.10.023

Dept Of Cardiology, Madras Medical College, Chennai, India

Aim: To assess the cardiac changes secondary to COPD by

echocardiography and to find out the correlation between

echocardiographic findings and severity of COPD.

Materials and methods: The study cohort comprises a total 41 of

patients of COPDwere selected and staged by pulmonary function

test (PFT) according to GOLD criteria and evaluated by

Echocardiography.

Echocardiographic evaluation of all patients was done using

Philips HD7XE machine in our Echo lab.

Results: On echocardiographic evaluation of COPD, 48.8% cases

had normal echocardiographic parameters. Measurable

tricuspid regurgitation (TR) was observed in 26/41 cases

(67.5%).

Pulmonary hypertension (PH), which is defined as systolic

pulmonary arterial pressure (sPAP) >30 mmHg was observed in

21/26 (63%) cases in which prevalence of mild, moderate, and

severe PH were 13/21 (58.82%), 5/21 (23.53%), and 3/21 (17.65%),

respectively.

The frequencies of PH in mild, moderate, severe, and very

severe COPD were 15%, 50%, 80%, and 100%, respectively.

RV systolic dysfunction was seen in 3/41 (7%) of cases; 7% of

cases had left ventricle (LV) systolic dysfunction and 46% cases

had evidence of LV diastolic dysfunction defined as A � E (peak

mitral flow velocity of the early rapid filling wave (E), peak velocity

of the late filling wave caused by atrial contraction (A) on mitral

valve doppler tracing). Left ventricle hypertrophy was found in

22% of cases.

Conclusion: 1. Prevalence of Pulmonary Hypertension has a linear

relationship with severity of COPD. 2. Severe Pulmonary Hyper-

tension is present only in severe or very severe COPD. 3. LV dia-

stolic dysfunction was seen in a majority of patients with severe

and very severe COPD.

Name of Corresponding Author: DR. A. Muralidharan; Designation:

D.M (Cardiology) Post Graduate, Madras Medical College,

Chennai; Address for Correspondence: 17/8, Temple Road, Med-

avakkam Tank Colony, Kilpauk, Chennai; Mobile: 09444321248;

Email: drmurali75@gmail.com

Mild COPD (20)(FEV1 >80%predicted)

Moderate COPD (12)(50% < FEV1 <80%

predicted)

Severe COPD (5)(30% < FEV1 < 50%

predicted)

Very severe COPD (4)(FEV1 < 30% predicted)

Normal 13 (65%) 5 (42%) 2 (40%) 0

Pulmonary hypertension 3 (15%) 6 (50%) 4 (80%) 4 (100%)

RV systolic dysfunction 0 0 1 (20%) 2 (50%)

LV diastolic dysfunction 4 (20%) 7 (58%) 4 (80%) 4 (100%)

LVH 3 (15%) 2 (17%) 2 (40%) 2 (50%)

LV systolic dysfunction 0 0 1 (20%) 2 (50%)

i n d i a n h e a r t j o u rn a l 6 4 ( 2 0 1 2 ) S 8 1eS 9 4S82

The utility of global longitudinal strain inevaluating and prognosticating patientspresenting with acute myocardial infraction

Anup M., Gopi A. MD, DM, Satish Govind MD, Keshav R. MD, DNB,

Shrikanth Shetty MD, DM, Pradeep MD, DM

Fortis Hospital, Cunningham Road, Bangalore, India

Aim: To evaluate the effect of acute myocardial infarction and

primary percutaneous coronary angioplasty on heart by assessing

global longitudinal strain in additional to routine ECHO

parameters.

Methods: All patients admitted with myocardial infarction for

the first time and undergoing primary percutaneous coronary

angioplasty were taken up for the study. Patients who were in

complete heart block, cardiogenic shock, pulmonary edema or

on ionotropes or vasopressors, or if they were previously

thrombolysed at admission were excluded from the study. Those

with previous IHD, myocardial infraction were also excluded.

The echocardiography was done in emergency department and

recorded using standard protocol for image acquisition with

VIVID 7 (GE). Images were again recorded at discharge. Routine

echo parameters like EF, Wall motion scoring and Doppler

parameters were acquired. The image post processing was done

by echopac (GE). Speckie tracking was used to calculate Global

Longitudinal Strain (GLS).

Results: A total of 50 patients were taken up for the study.

However 17 patients had to be excluded due to improper image

acquisition. A total of 33 patients were studied. Among the total, 4

were women, 29 weremen. Mean age ofmenwas 51.13 yr, women

was 64.205 yrs, mean duration of pain on presentation was 6.75

hrs, only diabetes was found in 3 patients, hypertension in 5

patients, Diabetes and Hypertension in 12 patients. Mean BMI was

26.22. Parameters like EF, GLS Peak systolic strain (PS), post

systolic shortening (PSS), and wall motion scoring (WMS) were

assessed before and after angioplasty. Those segments withWMS

or equal to 3 were analyzed along with those with WMS of 2.

The results are as below:

Parameter Beforeangioplasty

Afterangioplasty

EF 40.4% 43.48%

GLS �11.23% �12.7%

Peak syst stain (WMS 3) 2.68% 5.83%

Post systolic shortening 6.52% 8.1%

Peak syst starin (WMS2) 7.3% 8.68%

Post systolic shortening 8.1% 8.78%

WMS (wall motion scoring) 27.8 21.42

Conclusion: Those with low EF at presentation had lower

GLS. Those with higher wall motion score had lower peak

systolic strain and lower post systolic shortening. Following

angioplasty WMS, EF, GLS improved suggesting that GLS can

be used to access LV function. Speckie tracking echocardi-

ography was better in identifying regional myocardial

function.

Impact of successful percutaneous transluminalmitral valve commissurotomy on rightventricular function

C. Santosh Kumar, D. Rajasekhar, V. Vanaja, C.H. Shashank, M.L.

Srinivas

Sri Venkateswara University of Medical Sciences, Tirupati, India

Background: Abnormalities of right ventricular function (RVF)

play an important role in the development of clinical symptoms

and the overall prognosis of patients with mitral stenosis (MS).

RVF may be affected either by the rheumatic process directly or

through haemodynamic changes due to pulmonary vascular

alterations. Haemodynamic and radionuclide studies have

demonstrated long-term improvement in RV function after

percutaneous transluminal mitral commissurotomy (PTMC).

However, few studies have examined the immediate impact of

mitral valvuloplasty on echocardiographic markers of RV systolic

and diastolic function.

Aims and objectives: The aim of this study is to evaluate the

Immediate and short term follow up impact of successful

percutaneous transluminal mitral valve commissurotomy on RV

function in patients with mitral stenosis using Two-dimensional

echocardiography and Doppler tissue imaging (DTI)

echocardiography.

Methods: During the study period (August 2011 to April 2012)

Eighty four patients (mean age 29 þ 7 years) with rheumatic MS,

all in sinus rhythm, were studied before and 24e48 hrs after

PTMC.

Multiple parameters of global and longitudinal RV functionwere

assessed by conventional and tissue Doppler imaging

echocardiography.

Results: Immediately following PTMC, mitral valve area increased

from 0.891 þ 0.19 cm2 to 1.76 þ 0.33 cm2 (P e 0.0001) and RV

outflow tract fractional shortening (RVOTfs) increased from 57 þ15% to 72 þ 12% (P e 0.002).

There was a significant decrease in systolic pulmonary artery

pressure from 46.4 þ 22.1 mmHg to 32.1 þ 13.4 mmHg (P, 0.02), in

the RV Tei index from 0.42 þ 0.025 to 0.27 þ 0.17 (P, 0.021).

i n d i a n h e a r t j o u r n a l 6 4 ( 2 0 1 2 ) S 8 1eS 9 4 S83

In contrast, tissue Doppler velocities at the septal tricuspid

annulus remained unchanged.

Conclusions: Immediately after successful PTMC, significant

improvement in parameters of infundibular and global RV func-

tion as assessed by RVOTfs and Tei index was observed.

Name of Corresponding Author: DR. C. Santosh Kumar; Designation:

PostGraduate;Address forCorrespondence: Departmentof cardiology,

sri venkatesware instituite of medical sciences (svims), Tirupati,

Andhra Pradesh; Telephone/Fax: 9494490198; Mobile: 9494490198;

Email: Chennamaneni3@gmail.com

Fragmented narrow QRS complex: Predictor ofleft ventricular dyssynchrony in nonischemicdilated cardiomyopathy

J. Yusuf, D.K. Agrawal, S. Mukhopadhyay, V. Mehta, V. Trehan,

S. Tyagi

GB Pant Hospital, New Delhi, India

Aims & objective: Cardiac resynchronization therapy (CRT) is an

important therapeutic modality in drug refractory symptomatic

patients of heart failure (HF) with wide QRS (�120 ms) on elec-

trocardiogram (ECG). However, wide QRS (considered as a marker

of electrical dyssynchrony) occurs in only 30% of HF patients,

making majority of drug refractory HF patients ineligible for CRT

as per present treatment guidelines. Significant number of

patients with narrow QRS have echocardiographic evidence of left

ventricular (LV) dyssynchrony. However, there is sparse data

about additional features on the surface ECG which can predict

intraventricular dyssynchrony (IVD). This study was undertaken

to assess the utility of fragmented narrow QRS complex (fQRS),

a marker of electrical dyssynchrony, on the surface ECG to predict

significant IVD in symptomatic patients of non-ischemic dilated

cardiomyopathy (DCM).

Method: 100 symptomatic patients of nonischemic DCM with

narrow QRS complexes were recruited. This included 50 patients

each of fragmented and normal QRS complexes. All patients

underwent detailed echocardiography, including color coded

tissue Doppler imaging (TDI) of 12 myocardial segments, to assess

extent of systolic dyssynchrony as per Yu index.

Results: 78% patients (n ¼ 39) in fQRS complex group and 14%

(n ¼ 7) in normal QRS complex group had significant IVD

(c2 ¼ 20.61; p <0.000005). The presence of fQRS complexes on the

surface ECG was found to detect systolic IVD with 84.78% sensi-

tivity, 79.62% specificity, a positive predictive value (PPV) of 78%

and negative predictive value (NPV) of 86%. fQRS complexes also

indicated either the most delayed segment or one of the dyssyn-

chronous segments with a sensitivity and specificity of 93% and

90% respectively.

Conclusion: fQRS on ECG is a marker of electrical dyssynchrony

resulting in significant IVD in patients of nonischemic DCM and

a narrow QRS interval. fQRS on the surface ECG is also helpful for

localizing the dyssynchronous segment and might be useful in

identifying patients who can benefit from CRT.

Name of Corresponding Author: Dr Devendra Kumar Agrawal;

Designation: Senior Resident; Address for Correspondence: 124,

pocket-C, Phase-IV, Ashok Vihar, Delhi-52; Mobile: þ91

9968940244; Email: drdevendra_123@yahoo.co.in

The effect of percutaneous transcatheter deviceclosure of atrial septal defect on right ventricularremodeling: A 6 month follow-up study

P.K. Dash, R. Dixit, B. Jain, B. Barooah, S. Sola, R. Varyani, Anand L.,

Avanti, P. Kini, A. Patil, R. Mujawar

Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield,

Bangalore, India

Aims and objectives: To study the long-term impacts of trans-

catheter device closure of atrial septal defect on right ventricular

(RV) remodeling (form and function).

Methods: 75 consecutive inpatients of both genders; adult as well

as children with Ostium Secundum ASD with or without symp-

toms with anatomy suitable for device implantation were studied

prospectively. The patients were assessedwith echocardiography,

and electrocardiogram 1 day before the procedure and at 6

months following procedure. The following parameters were

recorded PR interval and QRS duration on ECG and Right ventric-

ular myocardial performance index-(RVMPI), Right ventricular

end diastolic diameter-RVEDD, Right atrial Size (height in four

chamber view), paradoxical IVS and Right ventricular systolic

pressure-RVSP on echocardiography.

Results: Data revealed a significant decrease in the PR interval

(161.5� 14.5 vs. 146.8 � 12.5 ms, p value¼ 0.001) and QRS duration

(94.9 � 12.4 vs. 84.9 � 9.6 ms, p value ¼ 0.001) at six months.

Analysis of Echocardiogram parameters showed that before the

procedure, mean RVSP was 43.3 � 7.1 mmHg. At 6 months after

the device closure, mean RVSP was 22.5 � 3.4. Thus, RVSP was

decreased by 47.3 � 9.5% which is statistically significant (P-value

¼ 0.001). At baseline, 71 patients (94%) had RVSP >30 mmHg while

only 2 patients (2.8%) had RVSP > or ¼ 30 mmHg at 6 month post

device closure. At baseline, 29 (38.7%) patients had paradoxical

septal motion detected on echocardiogram, which improved

significantly (p ¼ 0.001) after device closure of ASD. Post device

closure, no patient showed paradoxical septum suggesting

improvement in RV volume overload. The RV MPI showed an

improvement from 0.38 � 0.08 to 0.26 � 0.05, a 30% change (p ¼0.001) after closure. Before device closure, 65 patients out of 75 had

abnormal RVMPI. After device closure, 12 patients (16%) still

showed persistent abnormal RVMPI while remaining 63 patients

(84%) showed normal RVMPI. Mean four-chamber basal RV end

diastolic diameter (RVEDD) showed a significant decrease at 6

months to within the normal limits from 47.8 � 8.1 mm to 34.7 �7.1 mm (p ¼ 0.001). Right ventricular enlargement (four chamber

RVEDD �42 mm) was present in 72 of 75 patients at baseline.

3 patients showed no significant enlargement of the right

ventricle. (Qp:Qs was >1.5:1 in all). Post device closure 62 patients

(82.7%) reached normal RVEDD (<42 mm) after 6 months. Thus, at

the end of 6 months, 12 patients (17.3%) had persistent RV

enlargement. Only age (25 years vs. �25 years) of the patient at

device closure and significantly dilated RV (markedly dilated >50

mm RVEDD vs. less dilated �50 mm RVEDD) at baseline were

associated with persistent RV enlargement post device closure,

while Pre-procedure RVSP (moderate PAH vs. mild PAH), Pre-

procedure QP/QS (large vs small shunt flow) and size of ASD

(large vs. small) showed no significant relationship. Mean right

atrial size (superoinferior diameter in apical view/major diameter

in apical view) showed significant shortening at sixmonths (53.6�7.6 to 37.8 � 6.5 mm) (p ¼ 0.001). Dilated RA is defined as super-

oinferior diameter in apical 4 chamber view >52 mm. 68 patients

i n d i a n h e a r t j o u rn a l 6 4 ( 2 0 1 2 ) S 8 1eS 9 4S84

had evidence of RA enlargement at baseline and post device no

patient showed RA enlargement.

Conclusion: Transcatheter device closure of atrial septal defect

leads to significant improvement in right ventricular remodeling

(form and function). 83% of patients had improved right heart

remodeling at six months, corresponding to published data on

patients who have undergone surgical and percutaneous repair.

Age of patient and amount of RV dilatation at the time of device

closure were the predictors of impaired remodeling. Further

follow up is required to study complete remodeling.

Name of Corresponding Author: Dr. P.K. Dash, MD, DM(Cardiology),

FACC; Designation: Professor & HOD of Cardiology, Sri Sathya Sai

Institute of Higher Medical Sciences, Whitefield, Bangalore;

Address for Correspondence: Sri Sathya Sai Institute of Higher

Medical Sciences, EPIP area, Whitefield, Bangalore 560066;

Telephone: 08028412561, Fax: 0802441150 2, Mobile: 09448517990;

Email: drdashpk@rediffmail.com

Comparison of paradoxical split of S2 in pacedvs. non paced LBBB

Jinesh Thomas M., Prabha Nini Gupta, Sunitha Vishwanathan,

A. George Koshy, K. Sivaprasad, Mathew Iype, Krishnakumar B.,

Praveen Velappan

Department of Cardiology, Government Medical College, Trivandrum,

India

Aims and objectives of the study: This study sought to compare

the degree of paradoxical split of second heart sound in patients

with paced and non-paced LBBB. This study also studies the

duration of split in patients without LBBB and also aims to assess

the correlation between QRS duration (QRSD) and heart rate (HR)

with the degree of paradoxical split.

Methods: 10 patients without LBBB, 10 patients with VVI paced

LBBB and 10 patients whowere incidentally found to have LBBB on

their ECG were enrolled in the study. Standard 12 lead ECG was

taken and QRS duration and heart rate were assessed. Echo is

done with ECG gating. Pulse wave Doppler (PWD) is done at the

Aortic and Pulmonary Valves at end inspiration. The Q-A2 and Q-

P2 intervals are then measured. The spike at the end of Aortic and

Pulmonary PWD was presumed to correspond to A2 and P2

respectively. The difference between the Q-A2 and Q-P2 interval

gives the degree of split whether normal or paradoxical.

Results: There were 14 males and 16 females in the study. The

mean duration of S2 (A2-P2) split as assessed by Echo in patients

without LBBB was 24.9 � 11.5 ms. The mean duration of para-

doxical split (P2-A2) in patients with paced LBBB was 31.1 � 12.5

ms and in non-paced patients, themean P2-A2 interval was 29.8�16.6 ms (p ¼ 0.845). The mean heart rate in patients without LBBB

was 74 � 7.54 beats/min, in those with paced LBBB was 60 � 1.7

beats/min and in those with non paced LBBB was 72 � 6.8 beats/

min. Themean QRSwidth in patients without LBBBwas 81� 17.92

ms. Themean QRSwidth in non-paced LBBB was 123� 6.7 ms and

in those with paced LBBB was 139 � 3.2 ms (p ¼ <0.001). Para-

doxical split correlated with HR in paced (r ¼ 0.017, p ¼ 0.96) and

non-paced LBBB (r¼�0.419, p¼ 0.229). Paradoxical split correlated

with QRSD in paced (r ¼ 0.167, p ¼ 0.645) and non-paced LBBB (r ¼�0.097, p ¼ 0.790).

Conclusions: This study describes a novel technique to assess

splitting of second heart sound using ECG gating and Pulse Wave

Doppler. The degree of paradoxical split in patients with paced

LBBB was higher compared to those who did not have paced LBBB,

although not statistically significant. The QRSwidth in paced LBBB

was wider than those without paced LBBB. No significant corre-

lation between QRS duration and heart rate with the degree of

paradoxical split was seen in the study. Further studies and larger

sample sizes are needed to elucidate the matter further.

Name of Corresponding Author: Dr. Jinesh Thomas M; Designation:

Senior Resident, Department of Cardiology, Government Medical

College, Trivandrum; Address for Correspondence; Dr. Jinesh

Thomas, Flat B4, Rubicon Mansions, Opposite Government

Medical College, Trivandrum Pin Code: 695 011; Telephone:

0471 2556842; (Residence); Mobile: 09446076842; Email:

jineshthomasm@yahoo.com

Risk factors of sclerotic aortic valve

Kalaivani, Kiron Varghese, C.B. Patil, G.G. Shetty, Santhosh M.J.,

Srilakshmi

St Johns Medical College Hospital, Bangalore, India

Aim: Aim of the study is to see the association of atherosclerotic

risk factors with sclerotic aortic valve in our hospital settings.

Background: Clinical and experimental studies suggest that aortic

valve sclerosis is associated with atherosclerotic risk factors.

Methods: This is a prospective non-randomized study. A Total of

200 Inpatients were taken, of which 100 consecutive patients had

sclerotic aortic valve (in echocardiography) & 100 consecutive had

non-sclerotic aortic valve. The two groups were compared for

multiple risk factors.

Results: Out of 200 patients, 108 were males & 92 were females (p

¼ 0.67). The mean age was 62.7 years in sclerotic & 59.3 years in

non-sclerotic (p ¼ 0.08). Of 127 hypertensive cases, 64 were scle-

rotic (p¼ 1.00). Of 101 diabetic patients, 45 were sclerotic (p¼ 0.16).

47 had dyslipidemia, of which 20 were sclerotic (p ¼ 0.32). 36

patients had coronary artery disease, of which 20 were sclerotic (p

¼ 0.58). Of 19 cases of cardiac failure, 11 were sclerotic (p ¼ 0.63).

Among 14 cases of chronic kidney disease, 10 were sclerotic & 4

were non-sclerotic. Of 42 cases of smoking, 20 were sclerotic (p ¼0.86). The mean Aortic peak gradients in sclerotic cases was 1.35

mmHg, in non-sclerotic was 1.06 (p<0.001). Patients with sclerotic

Aortic valve had mean body mass index of 25.4 kg/m2 & non-

sclerotic had 25.9 kg/m2 (p ¼ 0.49). Our Prospective Study

showed that sclerotic aortic valve was not significantly associated

with Multiple assessed risk factors.

Conclusion: This study showed that sclerotic aortic valve was not

associated significantly with Multiple Atherosclerotic risk factors.

Name of Corresponding Author: Dr. M. Kalaivani; Designation: Regis-

trar, Cardiology Address for Correspondence: FF2, Ittina Sarva

Apartment, Hongasandra, Bangalore-560068; Mobile: 9986070785;

Email: dr.kalaikumar@gmail.com

Newer insights in ECG changes during ballooninflations during PTCA

M. Saravanan, S. Venkatesan DM, G. Gnanavelou DM,

V.E. Dhandapani DM, M.S. Ravi DM, G. Karthigeyan DM,

K. Meenakshi DM, D. Muthukumar DM, N. Swaminathan DM

Madras Medical College, Chennai, India

i n d i a n h e a r t j o u r n a l 6 4 ( 2 0 1 2 ) S 8 1eS 9 4 S85

Introduction: ECG changes are commonly reported in the past

during balloon inflation in PTCA. With the number of PCI

increasing over the years, significance of ECG changes is largely

undermined. In this context, we analysed the ECG changes that

occurred during PCI procedure in the current era.

Materials and methods: Patients undergoing PCI in our institu-

tion, between (MayeJune 2012), where the subjects of the study.

Patient population included stemi, nstemi, chronic stable angina.

PTCA was done by standard protocol. The average balloon infla-

tion time was 35e60 sec. Total of 10 significant lesion underwent

PTCA. ST segment shift was defined as 1 mm ST deviation. The

patient where observed for angina.

Results: In this study, 5 out of the 10 lesion had ST segment

deviation and 3 out of the 10 lesion developed angina during

balloon inflation. Patients with lad lesion were more likely to have

ECG changes. All the 3 nstemi patients had ST segment changes.

Patients with multivessel diseases are more likely to have ECG

changes.

Conclusion: We conclude that ECG changes in the form of ST

deviation are still prevalent during PTCA, it occurred in 50% of

patients in our study. The mechanisms of ECG changes and the

determinants are not clear; can be multifactorial. Whether the

ECG changes during balloon inflation, represents myocardial

viability needs to be explored.

Name of Corresponding Author: DR. M. Saravanan m.d; Designation:

resident in cardiology; Address for Correspondence: madras medical

colllege Chennai; Telephone: 0442530538; Mobile: 980878373;

Email: sivanthipeace@gmail.com

Left ventricular diastolic dysfunction asa predictor of prognosis in patients with heartfailure

Mahesh Ghogare, Amit K. Singal, Chandrakant Upadhyay, Anup R.

Taksande, Hetan Shah, Ajay U. Mahajan, Pratap J. Nathani

LTMMC and LTMGH Sion, Mumbai, India

Heart failure (HF) may be a result of isolated or combined systolic

and diastolic dysfunction. LV systolic dysfunction has been used

as a prognostic indicator in patients with HF. We evaluated the

role of LV diastolic dysfunction in predicting the prognosis in HF.

50 consecutive patients admitted with HF in ICCU were included

LV diastolic functionparameters

Pregnancy (trimester) Chronic kidney diseasewith AV fistula

AnemiaHb 6e8 gms%

Second Third

Number of patients 25 25 10 10

Age (years) 20e30 20e30 20e30 20e30

E/A ratio 1.4 � 0.4 1.2 � 0.4 1 � 0.4 O.6 � 0.4

E/E’ cm/sec 7 � 2 6.5 � 2 13.8 � 7.2 10 � 4

DT ms 160 � 20 120 � 20 140 � 20 100 � 20

IVRT ms 70 � 5 72 � 5 96 � 19 80 � 8

in the study and prospective clinical and echocardiographic

evaluation was done. End points were death, event-free survival,

readmission, worsening HF, and duration of hospital stay. The

mean age of patients was 52.2 � 15.9 years. 32 (64%) were males

and 18 (36%) were females. Mean follow up was 6.2 � 1.5 months.

LV diastolic dysfunction was present in 36 (72%) patients. Among

these 12 (24%) patients had isolated diastolic dysfunction,

whereas 24 (48%) patients had associated systolic dysfunction.

Patients were grouped according to grade of diastolic dysfunction

and NYHA class as follows: Diastolic dysfunction grade I-17 (34%),

grade II-07 (14%), grade III-10 (20%), grade IV-02 (04%). Mitral

deceleration time (DT) was significantly lower in patients in NYHA

class III and IV (n¼ 43) compared to those in NYHA class I and II (n

¼ 07) (187.26 � 90.12 msec v/s 288.37 � 70.54 msec, respectively).

Conclusion: Patients with diastolic dysfunction needed signifi-

cantly prolonged (>2 days) ICCU stay (17 of 36 patients vs 03 of 14

patients). Similarly, more patients in the diastolic dysfunction

group required>7 days hospital stay (12 of 36 v/s 02 of 14 patients).

In-hospital mortality was higher in patients with grade III and IV

diastolic dysfunction (3 of 12 patients) compared to those with

grade I and II diastolic dysfunction (02 of 24) (25% v/s 08.33%).

Patients who had event-free survival (no death, readmission or

worsening of heart failure) tend to have longer mitral DT

compared to others (268.72 � 73.15 v/s 216.23 � 69.78 msec).

Name of Corresponding Author: Dr Mahesh Subhash Ghogare; Desig-

nation: DM Cardiology Registrar Final Year; Address for Correspon-

dence: Department of Cardiology, Secondfloor, Emergency Building,

LTMMC & LTMGH, Sion, Mumbai-400022, Telephone: 022-4076381;

Mobile: 09028170123; Email: mahesh811_1980@yahoo.co.in

Left ventricular diastolic function in high cardiacoutput states

Cecily Mary Majella J., Dhandapani V.E., Ravi M.S., Karthikeyan G.,

Meenakshi K., Muthukumar D., Swaminathan N., Gnanavelu G.,

Venkatesan S., Prathapkumar G.

Madras Medical College, Chennai 03, India

Introduction: LV systolic function is preserved, often peaks in high

output states. Still, cardiac failure is diagnosed with high output

states. It is not clear whether abnormal diastolic function

contributes to the symptoms and cardiac failure in these patients.

The aim of this study was to evaluate left ventricular (LV) diastolic

function in various high output states.

Methods & materials: Diastolic function was assessed using

transmitral flow pattern, mitral annular Doppler tissue imaging

and pulmonary venous flow pattern. Patients with comorbid

states were excluded.

Results:

Conclusion: Diastolic function is altered differently in physiologic

and pathologic high output states.

Name of Corresponding Author: Cecily Mary Majella J; Designation:

Fellow in Cardiology; Address for Correspondence: Department of

Cardiology, Madras Medical College, Chennai -03; Telephone:

04425305438; Mobile: 9443584151; Email: drmajella@gmail.com

i n d i a n h e a r t j o u rn a l 6 4 ( 2 0 1 2 ) S 8 1eS 9 4S86

A study of left atrial appendage flow velocityusing transesophageal echocardiography insevere rheumatic mitral stenosis and itsresponse to balloon mitral valvotomy

Rajendra Chavan, Pranjal Patil, Dhirender Singh, Brijesh Agrawal,

Snehil Mishra, Irfan Khan, Vinay Kumar, Pritesh Punjabi, Sohan

Sharma, Sachin M. Mukhedkar, Madhusudan A. Yemul, Sandeep

N. Patil, Jaywant M. Nawale, Ajay S. Chaurasia

TNMC and BYL Nair Ch. Hospital, Mumbai, India

Aims & objective: Reduced LAA flow velocity is frequently seen in

patients with rheumatic mitral stenosis and has been shown to be

a predictor of thrombus formation and future thromboembolic

events. The aim of our study was to study the prevalence and

predictors of Reduced LAA flow velocity in these patients by

transesophageal echocardiography and to assess its response to

successful balloon mitral valvotomy.

Methods: Consecutive patients with rheumatic MS who were

planned for BMV underwent assessment of LAA flow velocity

using transesophageal echocardiography. The LAA filling velocity

profiles were obtained by pulsed-wave Doppler interrogation 1 cm

within the orifice of the LAA. After successful PTMC, the patients

underwent repeat TTE and TEE to assess the response of the LAA

flow velocity to the procedure.

Results: Out of 48 patients, 28 patients were in atrial fibrillation

& 20 in sinus rhythm. The mean LAA flow velocity was

decreased in both groups (18.7 cm/sec in AF group & 25.6 cm/

sec in the sinus rhythm group). The presence of spontaneous

echo contrast in LA, larger LA size and atrial fibrillation were

predictors of reduced LAA flow velocity. Following successful

BMV, there was a significant increase in mean LAA flow velocity

in both groups (30.2 cm/sec in AF group & 35.6 cm/sec in the

sinus rhythm group), which could be attributed to improvement

in LA appendage function as well as overall reduction in LA

size.

Conclusions: Our study suggest that LAA flow velocity is signifi-

cantly reduced in patients with rheumatic MS, irrespective of the

rhythm, and improves after successful BMV. We conclude that

early BMV in patients with rheumatic mitral stenosis improves

LAA flow velocity & thus reduces the thromboembolic risk.

Name of Corresponding Author: Rajendra Chavan; Designation: Senior

Resident, Department of Cardiology; Address for Correspondence:

Topiwala National Medical College & BYLNair Charitable Hospital,

Mumbai 400008; Telephone: 022-23081758; Fax: 022-23542540;

Mobile: 9970410058; Email: rajendrarvc@rediffmail.com

Endothelial function in patients with typicalangina, positive TMT and normal coronaries andits comparison with patients of typical angina,positive TMT & coronary artery disease oncoronary angiography and patients with typicalangina and negative TMT

Rajeev Merwaha, P.C. Negi, Sanjeev Asotra, Rajeev Bhardwaj,

Arvind Kandoria, Neeraj Ganjoo, Ravi kumar

Indira Gandhi Medical College, Shimla, India

Abstract category: echocardiography

Introduction: Endothelial dysfunction is an early phenomenon in

atherosclerosis and often precedes structural changes and clinical

manifestations. Flow-mediated vasodilation (FMD) indicates

Impaired endothelium-dependent vasomotion (EDV) and is a non-

invasive test using high-resolution ultrasound for the assessment

of endothelial function in the brachial artery.

Aims and objectives: To study the endothelial function of patients

with typical angina and positive stress test with normal coro-

naries and to compare it with patients having coronary artery

disease and a group with atypical chest pain with negative stress

ECG.

Methods and materials: All consecutive patients attending

Cardiology OPD of IGMC hospital for evaluation of chest pain

syndrome were the target population screened for possible

enrolment in the study. These were divided into 3 groups group 1

typical angina and positive stress test with normal coronaries

group 2 patients having significant coronary artery disease and

group 3 atypical chest pain with negative stress ECG.

It was a prospective case control observational study in tertiary

care center for one year i.e. Sept. 2010 to Sept. 2011.

Results: 124 patients with a mean age of 54.97 � 7.35 were

included in this study. 70 (56.5%) participants were males. The

distribution of risk factors among the three groups was not

statistically different. Overall mean FMD was 10.08 � 5.57. The

mean FMDwasminimum in group 1: 7.598� 3.02, in group 2 it was

9.672 � 4.33 and in group 3 it was 13.33 � 7.23. There was statis-

tically significant difference between the FMD of 3 groups (p ¼000). The difference was also statistically significant between

group 1 and 2 (p ¼ .012), and between group 1 and 3 (p ¼ .000) and

between 2 and 3 (p ¼ .008).

Discussion: Patients with typical angina, positive stress test and

normal coronaries (syndrome X) have endothelial dysfunction

as cause for angina and positive stress test. These patients have

subclinical disease and subtle elevations in conventional CV

risk factors compared to patients with obstructive CAD repre-

senting the continuum of process of atherosclerotic vascular

disease.

FMD is an important non invasive tool for detection of endo-

thelial dysfunction.

Name of Corresponding Author. Dr. Rajeev Merwaha, Senior Resi-

dent, Department of Cardiology, Indira Gandhi Medical College,

Shimla, India; Phone þ91 9418041925; Email: rajeev_merwaha@

rediffmail.com

Role of dobutamine stress echo in the riskstratification of chronic liver disease patientsundergoing liver transplant surgery

Rajeshwari Nayak, Subramanyan K., I. Sathyamurthy, Anand

Khakhar, Anand Ramamurthy, Mahesh GopaSetty, Manish Varma

Apollo Hospitals, Chennai, India

Aim: Liver transplant surgery is done with very good success rate

in our centre. Cardiac evaluation for risk assessment plays a very

important role to improve the post operative outcome. Aim of this

study is to assess the role of dobutamine echo in risk stratification

of patients undergoing liver transplant surgery.

Material & methods: 135 patients underwent liver transplant

surgery from 2006e2012. All patients underwent cardiac evalua-

tion by dobutamine echo or MIBI scan. High risk patients under-

went coronary angiogram.

Results: Total no of patients e 135, M:F ratio 4:1, age ranged from

2e68 yrs, mean age being 47.7 yrs, major cardiac risk factors HTN:

i n d i a n h e a r t j o u r n a l 6 4 ( 2 0 1 2 ) S 8 1eS 9 4 S87

12%, DM: 36.7%, smoking: 24.6%, alcohol: 19%, history of MI or

previous coronary revascularization 4.44%. The etiology of

chronic liver disease was alcohol: 12.2%, cryptogenic 33.3%,

Hepatitis C 14.44%, HbsAg: 4.44%, HCC: 5.5%, Wilson’s disease

4.4%, hemochromatosis: 3.33% and others in 21.11%. 82.7%

underwent dobutamine echo, 3.8% MIBI scan and 13.7% coronary

angiogram. Dobutamine echo was positive in one patient who

underwent coronary angiogram showing TVD. Porto pulmonary

shunting, baseline and peak dobutamine PAH, baseline and peak

dobutamine LVEF was assessed. Post op NSTEMI was noted in

4.44%, pulmonary edema 2.22% and LV systolic dysfunction 3.33%

and arrhythmia 5.55%. AF being the commonest arrhythmia fol-

lowed by unexplained sinus bradycardia needing temporary

pacing in 2%. Failure of LVEF to improve by >10% at peak dobut-

amine has been found to be a variable which can predict postop

cardiac morbidity. Liver transplant success rate is 80%, mortality

21.1%, early death 10%, late death 11.1%.

Conclusion: Dobutamine echo is a simple, cost effective investi-

gatory modality to assess the cardiac risk of patients undergoing

liver transplant surgery. Failure of LVEF to improve by >10%

during peak dobutamine echo was noted as a risk factor for post

transplant cardiac morbidity.

Name of Corresponding Author: Dr. Rajeshwari Nayak H; Designation:

Consultant Cardiologist; Address for Correspondence: Apollo hospi-

tals, Greams road, Chennai-6; Telephone: 044 28296753; Fax: 044

28294429; Mobile: 9962636462; Email: drrajeshwari2006@yahoo.

com

Role of echocardiography combined withbiomarkers in patients with acute submassivepulmonary embolism

V.S. Yogeeswari, D. Sasirekha, G.N. Prasad, K.M. Cherian

Frontier Lifeline Hospital and Dr. K.M. Cherian Heart Foundation,

Chennai, India

Background: There has been a change in strategy in the manage-

ment of acute submassive Pulmonary thromboembolism (PTE).

Clear indications have evolved in the use of fibrinolytic agents in

this hitherto “grey area” in the management of “PTE”. We report 3

cases of successful thrombolysis of submassive pulmonary

embolism with RV dysfunction, identified based on echocardiog-

raphy and elevated biomarkers with good short term outcomes.

Materials and methods: We report 3 patients of submassive PTE

from our hospital from Jan 2012 to July 2012. Based on the ECHO

features and raised biomarkers suggestive of RV dysfunction, all

of our patients were thrombolysed with streptokinase (2.5 lakhs

bolus followed by 1 lakh/hour infusion for 12e24 hours). Echo

parameters used to assess RV dysfunction were RVID >30 mm,

RVID/LVID ratio >0.9, TAPSE <15 mm, TDI <0.11 m/sec and

biomarkers that were measured included BNP (>90 ng/ml) and

Troponin I (>0.4 ng/ml). All the patients improved symptomati-

cally on follow up at 1e4 months.

Results: All 3 of our patients responded to thrombolysis with

Streptokinase and showed significant improvement Clinically

(from NYHA Class IV to II), echocardiographically as evidenced by

improvement in RV function (RV dimensions reduced on an

average from 45 � 2 mm to 20 � 2 mm, TDI improved from an

average of 0.05e0.06 to 0.10e0.11 TAPSE improved from an

average of 9e10 mm to 16e18 mm). This improvement correlated

biochemically as well as evidenced by significant decrease in BNP

levels.

Conclusion: Echo parameters for RV dysfunction combined with

biomarkers, especially BNP aids us in identifying patients of sub-

massive PE who would benefit from thrombolysis Role of echo-

cardiography combined with biomarkers in patients with acute

submassive pulmonary embolism

Name of Corresponding Author. Dr. D. Sasirekha; Staff Cardiologist,

R-30-C Ambattur Industrial Estate Road, Mogappair, Chennai 101,

India; Tel: 044 42017575; Mobile: þ91 9840063280; Email:

drsasirekha@gmail.com

Left atrial volume index and its relation to targetorgan damage in hypertension

Shristi, Patil C.B., Varghese Kiron, Shetty G.G., Santhosh M.J.,

Srilakshmi M.A.

St. John’s Medical College Hospital, Bangalore, India

Objective: The purpose of this study is to determine whether left

atrial volume index (LAVI), assessed by 2D-Echocardiography has

any relation to target organ damage in hypertensive patients.

Methods: A total of 96 consecutive hypertensive patients

prospectively underwent assessment of left atrial volume index

and target organ damage. Independent t-test and Mann Whitney

test were used to calculate the significance between LAVI and

target organ damage.

Results:Among the study patients, 60%weremales. Themean age

of the study patients was 62.7 � 13.3 years. The mean left atrial

volume index was 23.4 ml/m2. Among the assessed target organ

damage, most common was cardiovascular followed by renal,

ophthalmic, cerebrovascular and peripheral artery disease. After

statistical analysis, it was found that LAVI was significantly higher

in patients with target organ damage vs without target organ

damage, involving the heart (24.7 vs 20.4 ml/m2; p-value <0.001),

brain (26.8 vs 22.5 ml/m2; p-value 0.004), kidney (26.1 vs 21.4 ml/

m2; p-value <0.001), eye (27.3 vs 21.7 ml/m2; p-value <0.001) and

peripheral artery disease (27.8 vs 23.6 ml/m2; p-value 0.04).

Conclusion: Among hypertensive patients, those with target

organ damage had a significantly higher left atrial volume index

as compared to those without target organ damage.

Name of Corresponding Author: DR Shristi; Designation: Registrar,

Cardiology Department; Address for Correspondence: St. John’s

Medical College Hospital, Koramangala, Bangalore-560034; Mobile:

9886127916; Email: shristi.rangaswamygowda@gmail.com

Feasibility of routine Real Time threeDimensional Trans esophagealEchocardiography (RT-3D-TEE) utility for OS-ASDassessment for transcatheter closure.

Suresh. H DM, C.N. Manjunath DM, K.S. Ravindranath DM,

PrabhavatiBhat DM, C. Dhanalakshmi RDCS

Department of cardiology, ShriJayadeva Institute of cardiovascular

sciences and research, Bangalore, INDIA

Objectives: Assessment of ASD anatomy may be difficult by two-

dimensional (2D) echocardiography. The aim of this study was

to test the Feasibility of routine RT-3D TEE utility for OS-ASD

assessment for transcatheter closureas it may provide more

i n d i a n h e a r t j o u rn a l 6 4 ( 2 0 1 2 ) S 8 1eS 9 4S88

accurate morphologic assessment of ASDs than multiplane 2D

TEE.

Methods: Thirty patients with ASDs were imaged using 2D TEE

and real-time 3D TEE. Twelve of the 30 patients underwent

transcatheter ASD closure. 3D acquisition and reconstruction

times were measured in each patient, ASD shape and size were

assessed using 3D TEE. Maximal ASD dimensions obtained by 3D

TEE were compared with 2D TEE and balloon-stretched

dimensions.

Results: All 30 patients were evaluated with RT 3D TEE echo, ASD

dimensions were compared with 2D TEE, balloon sizing

measurements, RT-3D TEEmeasurements correlated well with 2D

TEE and balloon sizing measurements.Of the 12 ASDs, 3 (25%)

were circular, 6 (50%) were oval, and 3 (25%) were complex in

shape. The mean maximal dimension by 3D TEE was compared

with 2D TEE (24.25�3.81mmvs24.00�3.43 mm, P < .001) and

stretched balloon diameter (24.25�3.81mm vs25.42�4.01 mm).

Three dimensional mean acquisition time was 2�1 minutes and

mean reconstruction time (postprocessing time included) was 5�2

minutes. The total time required for these 2 processes (7�3

minutes) was less than that needed to complete the balloon-

stretching maneuver (11�4 minutes).

Correlation of 2D TEE and 3D TEE-Size L with Baloon size

Baloon Size

R value P value Identity line

2D TEE 0.720 0.008** 4.06þ0.902*x

3D TEE (Size L) 0.974 <0.001** 0.98þ1.01*x

Conclusion: RT-3D TEE allows accurate assessment of ASD size,

rims, shape and its location. Maximal dimensions on 3D TEE were

well correlated with balloon-stretched and 2D TEEdimensions. RT

3D TEE is quicker than both 2D TEE and stretched balloon timings,

can be routinely used for transcatheter closure of OS-ASD, and

balloon sizing can be avoided during the procedure and exposure

to radiation can be reduced.

Name of Corresponding Author: Dr. Suresh. H; Designation: Associate

professor; Address for Correspondence: House no 49 bhuvaneshwari

nagar keshwapur hubli 23; Mobile: 09343423939; Email: drsuresh.

h72@gmail.com

RV Tei index No of patients (%)

No PHT 0.19e0.28 24 (48%)

Mild PHT 0.26e0.48 6 (12%)

Moderate PHT 0.32e0.58 8 (16%)

Severe PHT 0.56e0.78 12 (24%)

Echocardiographic assessment of right ventricleon Indians e An early report

T. Sinha, M.K. Das

Kothari Medical Centre, Kolkata, India

Introduction: Right ventricular (RV) assessment remained under

reported for suboptimal understanding of its anatomy and phys-

iology. In 2010 European Association of Echocardiography and

Canadian Society of Echocardiography jointly published a guide-

line for assessment of right ventricle in adults based on 16

measurements.

Objective: This study attempts to: A. Find a set of RV assessments

that can be routinely done at OPD. B. Find ‘normal’ ranges for

Indians. C. Indicate tests with highest reproducibility. D. Indicate

tests with least inter-observer variability. We believe this study is

first of its kind in India.

Inclusion criteria: 867 (Me 512, Fe 355) consecutive cases (18 to 83

years), from April to June 2012 were included. Patients with

valvular heart disease, congenital heart disease, prosthetic valves,

LV ejection fraction <50%, HR <60 and >100/min and those with

pacemakers were excluded. Methodology: All investigations were

done on GE Vivid 7 Pro with 3S transducer. About 50% of all cases

were cross examined by both investigators. Statistical calculations

weredoneon confidence interval (CI) and standarddeviations (SD).

Results: A. Routine measurements (average time 6 min/case) can

be done (with average CI 84%) at OPD for: 1. Diastolic RV basal, 2.

Diastolic RVOT proximal and distal, 3. RA major, 4. RV wall

thickness. 5. Tricuspid annular plane systolic excursion (TAPSE),

6. Pulse Doppler peak Tricuspid annulus velocity, 7. RV inflow E/A

ratio and 8. TV e E/E’ ratio, 9. Pulse Doppler peak velocity at TV

annulus. B. Normal range for Indians is 14e20% lower than lowest

SD values for RV, RA dimensions as in guideline. Normal range

should have reference to BMI. C. TAPSE, RV wall thickness, RV

basal and RVOT distal measurements has highest reproducibility

(SD�2>92%). D. TAPSE, RVwall thickness and pulse Doppler peak

velocity at TV annulus had least inter-observer variability (93%CI).

Limitations: Statistical power is low for small number of patients.

Right ventricular TEI Index in rheumatic heartdisease

N. Viswanathan, A. Muralidharan, A. Rudrappa, S. Venkatesan,

G. Gnanavelu, V.E. Dhandapani, M.S. Ravi, G. Karthikeyan,

D. Muthukumar, K. Meenakshi, N. Swaminathan

Dept of Cardiology, Madras Medical College, Chennai, India

Background: Right ventricular systolic dysfunction is recognized

to occur in RHD. RV systolic function is a key determinant of

outcome after mitral valve intervention. There is no simple

modality to assess RV systolic function. RV dp/dt, RVEF require

complexmethodology. In this context we analyze the utility value

of RV TEI Index in assessing RV systolic function in RHD.

Aim: To analyze the utility value of RV TEI Index in assessing RV

systolic function in RHD.

Materials and methods: 50 patients with RHD were meticulously

evaluated with echocardiography. R V TEI Index is calculated

using the formula a�b/b. where a is right ventricular IVCT þIVRT þ ET and b is right ventricular ET. Pulmonary hypertension

severity is assessed using tricuspid regurgitation peak gradient

and it is correlated with RV systolic function. Echocardiographic

evaluation of all patients was done using Philips HD7XE machine

in our Echo lab.

Results: 50 patients with RHD were selected. 32 females and 18

males. 36 mitral valve disease and 14 aortic valve disease. Age

mean age 40 (18e62). 24 (48%) patients with no pulmonary

hypertension had RV TEI Index between (0.19e0.28). 12 (24%)

patients with severe pulmonary hypertension had RV TEI Index

between (0.56e0.78). 8 (16%) patients with moderate pulmonary

hypertension had RV TEI Index between (0.32e0.58). 6 (12%)

patients with mild pulmonary hypertension had RV TEI Index

between (0.26e0.48).

Conclusion: 1. RV TEI Index increased with severity of pulmonary

hypertension. 2. RV TEI Index is a simple and useful parameter to

assess RV SYSTOLIC FUNCTION.

i n d i a n h e a r t j o u r n a l 6 4 ( 2 0 1 2 ) S 8 1eS 9 4 S89

Name of Corresponding Author: DR. N. Viswanathan; Designation:

D.M (Cardiology) Post Graduate, Madras Medical College, Chennai;

Address for Correspondence: 29, Driver Street, Pudupet, Chennai-2;

Mobile: 9840841085; Email: drmalathy19@yahoo.in

Concomitant versus sequential trastuzumabwith thoracic radiotherapy: Anechocardiographic study in rats

G. Yavas1, S. Demirkol2, M. Gultekin1, O. Yildiz2, M. Seyrek2,

F. Yildiz1

1 Dept. of Radiation Oncology, Hacettepe University, Faculty of Medicine,

Ankara, Turkey; Depts. of 2Cardiology and 3Medical Pharmacology,

Gulhane School of Medicine, Ankara, Turkey

Aims: The purpose of this experimental study is to compare the

effect of Trastuzumab (T) on radiation induced cardiovascular

toxicity when used either sequentially or concomitantly.

Objects of the study: 108 female Wistar albino rats were divided

into 6 groups (G) composed of 18 animals. Rats were sham-

irradiated in G1, G2 and G3 were defined as control, T and radio-

therapy (RT) groups, respectively. G4 and G6 were the sequential

RT e T groups in which T was administered either one week

before and after RT, respectively. G5 was concomitant RT-T group

in which T was administered 6 h before RT. T was applied intra-

peritoneally with a dose of 6 mg/kg. 15 Gy RT was in the form of

single anterior field with 6 MV photon beams and the dose was

prescribed to 2 cm depth. Echocardiographic studies were per-

formed 21 and 70 days after RT. Left parasternal and left apical

echocardiographic images of anaesthetised rats lying in the dorsal

recumbency position were obtained using Vivid S (5 MHz

frequency transducer, 10 � 13 mm footprint, General Electric).

Results: RT induced significant decreases in ejection fraction, left

ventricular mass and fractional shortening (p <0.05). T showed

additional decrease in echocardiographic parameters when added

to RT either concomitantly or sequentially (p <0.05).

Conclusions: T and high dose RT may lead to cardiotoxicity that

seems at least additive. Echocardiography is a powerful technique

for non-invasive and serial determination of cardiac structure and

function in cardiotoxicity studies.

Reference:

1. Yavas G et al. Ann Oncol. 2011;22(5):1120-6.

Name of Corresponding Author: Oguzhan yildiz; Designation: MD,

PhD, Chief of Dept. of Medical Pharmacology at Gulhane School of

Medicine; Address for Correspondence: Dept. of Medical Pharma-

cology at Gulhane School of Medicine, 06018 Ankara, TURKEY;

Telephone:þ90 312 3044766; Fax: þ90 312 3042150; Mobile þ90 533

3645976; Email: oyildiz@gata.edu.tr

Evaluation of characteristics, predictors, andclinical implications of iatrogenic atrial septaldefects after percutaneous transluminal mitralcommisurotomy (PTMC) with real time 3dimensional echocardiography (RT3DE)

Sarath Babu D., Rajashekar D., Vanaja V., Sashanka C.H., Srinivas

M.L.

Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra

Pradesh, India

Introduction: While there is a paucity of data regarding iatro-

genic ASDs, standard imaging techniques of quantification are

also suboptimal. With the increased utilization of transseptal,

transcatheter procedures, the frequency and size of iatrogenic

ASDs may rise and their sequelae and clinical implications are

unknown. 3D echocardiography is a new imaging modality

which may be useful in these difficult to study iatrogenic

ASDs.

Aims: A comparison of usefulness of RT3D echo with the tradi-

tional 2D echocardiographic methods in the detection of iatro-

genic atrial septal defects after transseptal access in PTMC.

1) Evaluating the incidence, anatomic location, variations,

and quantification of iatrogenic atrial septal defects in the

context of percutaneous transluminal mitral commissurotomy

(PTMC).

2) To study the profile, progression and clinical sequelae of atrial

septal defects secondary to transseptal puncture during PTMC

with Real time 3 Dimensional echocardiography.

3) To investigate the sensitivity and accuracy of various 3D echo

techniques for imaging the iatrogenic atrial septal defect in

a group of consecutively imaged patients and to determine the

acoustic window or perspective from which the atrial septum,

location of ASD, defect area and inter atrial shunt are best visu-

alized and quantitated.

Methods: Clinical, procedural data and catheterisation data were

obtained. Pre & post procedural Echo were done. Presence of ASD

was determined in 4C, short axis views, confirmed and quanti-

tated by Doppler in the sub costal views. RT3DE was done on IE33

Philips and X Matrix transducer. Colour 3D, Live 3D, zoom images

and full volume data setswere acquired. Post processingwas done

with QLAB software, with various cropping and image enhancing

techniques and quantification were done. Follow upwas done at 1

month and six months.

Results: 118 patients underwent PTMC in the period from July 2011

to April 2012, of whom 1 was referred for MVR for iatrogenic MR.

The mean age of patients was 34 years. 13 (11%) were undergoing

repeat PTMC, and 2 had undergone previous CMV. Pre PTMC

evaluation showed aneurysmal IAS in 5 patients but no significant

ASD or PFO. Post PTMC, 5were excluded due to poor echowindow.

ASD with inter-atrial shunt was detected in all the rest in the

immediate period. Mean area was 27 � 5 mm. ASD location was

variable, most commonly in the fossa ovalis area e 67 (76%), IVC

part of the septum e 34 (30%), and least frequently in the basal

part e 5 (6%). Shunt across IAS could be quantitated by conven-

tional Doppler in 90 (80%). RT3DE increased sensitivity of ASD

detection (Color 3De 100%) and facilitated direct visualisation and

quantitation, including the dynamic size of defects. 20 patients

had severe PAH, 2 of them high RA pressures with organic TR had

bidirectional shunt at atrial level detected with 3D contrast echo.

On follow up at 1 month, ASD could be detected in 72 (64%) at 1

month, in 84 patients with 6 month follow up period in 30 (26%).

There was no significant difference in the rate of stroke and/or

systemic embolism during the follow-up period in patientswith or

without iatrogenic ASD.

Conclusions: Transseptal puncture plays a major role in the

procedural success of PTMC. Iatrogenic ASDs are frequent in the

immediate period following trans septal access. Available

evidence suggests iatrogenic ASDs are difficult to detect or

quantitate with traditional imaging techniques and a majority

resolve over time but late term follow-up of predictors and

sequelae is limited. Our study suggests that post PTMC an atrial

septal defect is frequent, does not always occur in the fossa ovalis,

i n d i a n h e a r t j o u rn a l 6 4 ( 2 0 1 2 ) S 8 1eS 9 4S90

and has variable shapes and area. Our study suggests that colour

3D imagingmay be themost sensitive while post processing of full

volume acquisition images is the best for quantification. Rare

cases of bidirectional shunt can also be encountered at the atrial

level with high RA pressures or organic TR. Understanding the

rare but serious clinical implications of iatrogenic ASD and the

need for systematic surveillance in the future is warranted.

Name of Corresponding Author: Sarathbabu. D; Designation: Senior

Resident (DM Cardilogy); Address for Correspondence: Sarath

Babu. D, Dept of cardiology, SVIMS, Tirupati, Andhrapradesh;

Telephone: 9640132282; Mobile: 9640132282; Email: sarathpgi@

gmail.com

Evaluating the role of late revascularisation intotally occluded infarct related artery in acute MIas assessed by systolic strain rate

D. Seshagiri Rao, A.N. Patnaik, B. Srinivas, M.S.N. Pavan Kumar,

C. Vijay Amarnath Reddy

Nizams Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India

Aim: Evaluating the role of late revascularisation, that is after 48

hrs, in totally occluded infarct related artery in patientswith acute

MI. Benefits of revascularisation are assessed by regional strain

rate in systole.

Materials and methods: Inclusion criteria are 1) Coronary angio-

gram showing totally occluded artery 2) Coronary angiogram done

after 48 hrs and with in 1 month 3) patients treated with all other

conventional medications, who are thrombolysed or not. Exclu-

sion criteria: 1) multivessel disease 2) previous PCI or CABG 3)

valvular heart disease 4) CHF/NYHA class III, IV 5) mechanical

complications of MI 6) renal failure with sr.creatinine of >2.5 mg/

dl. Routine PCI was performed after diagnostic angiography.

Echocardiographic examination was performed at baseline not

less than 24 hours before angioplasty and repeated 24 hours & 6

months. We measured peak systolic SR (SSR).

Results: 38 patients with acute MI were included in the study.

There was a mortality of 8% (3 patients) with all deaths occurred

with in hospital stay, all of them had no TIMI III flow immediately

after PCI. 24 pts were male and 14 were female. Mean age of

patients was 59. PCI was done in 30 patients in first 2 weeks and in

8 patients in last 2 weeks. Patients SSR values were significantly

lower in the pre PCI group between ischemic and non ischemic

segments (0.9 � 0.7/s vs 2.3 þ 0.6/s, P value <0.005). There was no

significant difference from pre to post PCI. In the affected

segments (0.9 � 0.7/s vs 1.1 � 0.9/s, P ¼ 0.06). But six months post

PCI SSR improved significantly from pre PCI values (0.9 � 0.7/s vs.

1.6 � 0.9/s P<0.05).

Conclusion: In STEMI patients PCI showed an improvement in

peak systolic strain. This effect was consistent regardless of time

frame of intervention.

Floating aortic root thrombus e A rare case report

Elangovan S., Madhu Prabhu Doss C.R., Subramanian R.,

Jaganathan V., Kathiresan M., Harshavardhan K.

S.R.M. Medical College and Hospital, Kattankulathur, Tamilnadu, India

Case summary: A 37 year old gentleman presented to our cardi-

ology outpatient department with dyspnoea on exertion which

amounts to class II-III by New York Heart Association classifica-

tion. Apart from dyspnoea he was apparently free of other

symptoms. Clinically no specific findings were made out. Electro

cardiogram done revealed complete right bundle branch block

with old anterior wall myocardial infarction features. Trans

thoracic and Transesophageal echocardiogram were done and it

showed a oscillating mass probably a thrombus arising from the

aortic root e left sinus just above the origin of left coronary artery.

Features of old anterior wall myocardial infarctionwith severe left

ventricular dysfunction and left ventricular clot were present. 64

Slice C.T. Angiogram confirmed the findings. His coagulation

profile was normal. Patient underwent emergency surgery and

aortic root thrombus was excised and Histopathological report

confirmed the thrombus. His postoperative period was unevent-

ful. Floating thrombus in ascending aorta is very rare. Only few

cases were reported till now in the literature. Majority of the cases

with thrombus in ascending aorta neither has atherosclerotic

lesion nor abnormal coagulation profile. Surgical excision seems

to be the best management.

Conclusion: 1. Free floating thrombus in ascending aorta

complicated by myocardial infarction is very rare. 2. Embolic

episode could complicate the picture. Surgical removal seems to

be the best option.

Relations between Doppler tracings ofpulmonary regurgitation in acute rightventricular infarction complicating inferior leftventricular infarction

SundarChidambaram,DhandapaniV.E., Ravi.M.S., KarthikeyanG.,

Meenakshi K., Muthukumar D., Swmainathan N., Venkatesan S.,

Gnanavelu G., Prathapkumar G., Rudrappa A.

Aim: To test the hypothesis that flow characteristics from

pulmonary regurgitation (PR) can predict right ventricular (RV)

involvement in patients with inferior wall acute myocardial

infarction.

Methods: We prospectively recorded continuous-wave Doppler

tracings and electrocardiogram (ECG) in 32 consecutive patients

with inferior wall acute myocardial infarction and PR. ECG of the

patients enabled the identification of 19 patients with (group 1)

and 13 without (group 2) RV involvement. In patients with RV

involvement, the pulmonary regurgitant flow pattern was char-

acterized by a rapid rise in flow velocity to a peak level followed by

an abrupt deceleration in mid-diastole, whereas in patients

without RV involvement, the deceleration in mid-diastole was

gradual.

Results: The pressure half-time of PR (PHTPR) and the lowest mid-

diastolic to peak early diastolic velocity ratio were significantly

lower in group 1 than in group 2 (87� 28 vs. 208� 52ms [p<0.001],

0.33 � 0.06 vs. 0.56 � 0.11 [p <0.001], respectively). The best diag-

nostic accuracy (95%) was obtainedwith cut-off values of PHTPR<

or ¼ 150 ms and the lowest mid-diastolic to peak early diastolic

velocity ratio < or ¼ 0.5: sensitivity 100%, specificity 89%, positive

predictive value 94%, and negative predictive value 100%.

Conclusion: PHTPR is a useful echocardiographic parameter to

predict RV involvement in Inferior MI. A characteristic dip and

plateau pattern in PR jet may be a classical sign to identify RV

infarction.

Name of Corresponding Author: Sundar Chidambaram; Designation:

D.M; Postgraduate; Address for Correspondence: No 22 A, Melandi

i n d i a n h e a r t j o u r n a l 6 4 ( 2 0 1 2 ) S 8 1eS 9 4 S91

street,West Tambaram,Chennai-600045; Telephone: 044 22262424;

Mobile: 9444185058; Email: sundarvimal@yahoo.com

Assessment of RV function by 2d and 3d echo,before and after ASD device closure

Vidya Sagar A., Rajasekhar D., Vanaja V., Shashanka C.H.,

Thejanandan Reddy C.S.

Sri Venkateswara Institute Of Medical Sciences, Tirupati, India

Background: Atrial septal defects (ASDs) account for 10% of all

congenital heart lesions and represent the third most common

congenital cardiac defect seen in adults. ASD closure provides

symptomatic relief andmay prevent the progression of right heart

dysfunction. There is limited data on alterations in novel right

ventricular (RV) function indices like tricuspid annular plane

systolic excursion (TAPSE), tricuspid annular systolic velocity

(TASV), myocardial performance index (MPI) i.e., Tei index and 3D

volume after transcatheter atrial septal defect (ASD) closure.

Aims: 1) To assess Right ventricular function by 2D and 3D echo-

cardiography, before, immediately after one month and at six

months in patients of Secundum Atrial Septal Defect who undergo

device closure. 2) To compare indices of RV function including a)

Tricuspid annular plane systolic excursion (TAPSE) b) Tricuspid

annular systolic velocity (S0) c) Myocardial performance index (MPI)

i.e., Tei index d) 3D volume before, immediately after one month

andat sixmonthspost device closure inpatients of SecundumASD.

Methods: All patients, who are admitted to Sri Venkateswara

Institute Of Medical Sciences, Tirupati between June 2012 and

June 2013 and were given a diagnosis of hemodynamically

significant ostium secundum ASD that is suitable for trans-

catheter closure, and accepted for an elective procedure after

transesophageal echocardiographic (TEE) examination were

enrolled for the study. To be eligible, patients had to be asymp-

tomatic or minimally symptomatic, New York Heart Association

(NYHA) class I or II, and without any other hemodynamically

significant structural cardiac anomaly. Patients with depressed

right and/or left ventricular function, previous myocardial

infarction, angiographically confirmed coronary artery disease,

severe valvular disease, chronic obstructive pulmonary disease,

cardiomyopathy, and residual shunt after percutaneous closure

are excluded. The patients with significant rhythm and conduc-

tion disturbances (atrial flutter, atrial fibrillation, atrioventricular

[AV] block and left bundle branch block) are also excluded.

All patients will undergo TTE with tissue Doppler imaging,

12e24 hours before and 1 and 6months after successful closure of

ASD percutaneously. Echocardiographic evaluation will be per-

formed in left lateral decubitus position with a Philips iE33 echo-

cardiographymachinewithmeasurements taken according to the

American Society of Echocardiography recommendations. Images

will be digitally stored and analyzed offline at the end of each

study.

Results: In this ongoing study still now 9 patients were enrolled

and 6 patients had completed there one month follow up. Mean

age was 37 � 20. Mean diameter of ASD measured by echocardi-

ography were 21 � 6 mm. One month after closure, there were

significant decreases in RV end-diastolic diameters (43.3 � 10.7

mm vs. 34.9 � 5.5 mm), RV/left ventricular (LV) end-diastolic

diameter ratio (1.1 � 0.3 vs. 0.87 � 0.1), TASV (16.9 � 3.2 cm/sec

vs. 14.3 � 3.3 cm/sec), early diastolic tricuspid annular velocity

(15.3 � 3.1 cm/sec vs. 13.4 � 2.4 cm/sec and TAPSE (29.9 � 6.2 mm

vs. 22.4 � 7.4 mm). LV end-diastolic diameter (38.0 � 6.9 mm and

40.0 � 4.5) was increased, whereas there was no change in LV

ejection fraction. 3D Echocardiography done showed decrease in

end diastolic volume (50.0 � 24.5 vs 40.4 � 20.3) and end systolic

volume (40.6 � 18.3 vs 20.8 � 9.9).

Conclusion: Closure of ASD by using devices led to decrease in

right heart chamber size, tissue Dopplerederived tricuspid

annular velocities, TAPSE, EDV and ESV in early period.

Oral Presentation

Study of correlation between severity of mitralstenosis and subclinical LV dysfunction byspeckle tracking echocardiography

Kothawala A.A., Bansal N.O.

Sir J.J. Hospital, Mumbai, India

Aims & objectives: To evaluate the role of 2D strain by speckle

tracking in the assessment of subclinical LV systolic dysfunction

in MS, and assess relationship between stenosis severity and LV

dysfunction.

Materials and methods: 100 patients with isolated MS and 50

healthy control subjects were studied over a period of one year

(Pts with hypertension, DM, atrial fibrillation, AV conduction

anomalies, moderate to severe valvular heart diseases other than

MS, COPD, impaired LV systolic function (EF <50%), and CAD were

excluded). Study was carried out using the GE Vivid 7 system with

a 3.5-MHz transducer, and offline analysis was done with (Echo

PAC PC; GE Vingmed Ultrasound AS).

LVEF was calculated using the Simpson’s formula. LA size,

PASP, MVA-planimetry, MVA-PHT; peak and mean gradients

were measured according to standard guidelines. All images

were evaluated by two experienced cardiologists. For measure-

ment of strain by speckle tracking 2D echo images were obtained

from LV apical 4-chamber (4C), LAX (long axis) and 2-chamber

(2C) views. All images were obtained during breath holding,

and stored in cine-loop format from three consecutive beats. The

frame rate for images was between 50 and 90 frames. All data

were transferred to a workstation for further offline analysis.

After defining the endocardial border manually, an epicardial

tracing was automatically developed by the software system for

each view. Strain measurements were reported as the peak

longitudinal strain (LS) for 4C, LAX, and 2C views, and global

strain (GS) was calculated by averaging the three apical views.

Strain measurements were reported for each of the 17 segments

analysed in all the three views.

Interesting Observational and analytical data will be presented

during the CSI meeting.

Name of Corresponding Author: Dr. Aziz Kothawala; Designation: SR3

cadiology j.j. hospital Mumbai; Address for Correspondence: Depart-

ment of cardiology sir j.j. group of hospitals byculla, Mumbai-

400008. Mobile: 09960505252; Email: azizahra786@gmail.com

Study of pulmonary hypertension

Gururaj B., Srilakshmi, C.B. Patil, Kiron Varghese, G.G. Shetty,

Santosh M.J.

St John’s Medical College & Hospital, Bangalore, India

Aim: The aim of the observational study was to evaluate the

different etiological factors of pulmonary hypertension.

i n d i a n h e a r t j o u rn a l 6 4 ( 2 0 1 2 ) S 8 1eS 9 4S92

Method: 129 consecutive patients with PAHwho were admitted to

our hospital from 1-10-2010 to 30-12-2011 were studied. Echo-

cardiographically patients were divided into two groups:

Moderate PAH: PASP >40 mm of Hg to <60 mm of Hg. Severe PAH:

>60 mm of Hg.

Results: The most common symptoms of pulmonary hyperten-

sion were dyspnea (96%), orthopnea (46%), PND (38%), cough (34%)

and chest pain (26%). The most common signs noted were

elevated JVP (96%), loud P2 (77%), pedal edema (54%), TR murmur

(49%) and S3 (41%).

52.7% were male & the mean age was 54.5 years. 59.9% patients

had severe PAH. Of 129 patients, 21 had more than one cause of

PAH. Among the remaining, the most common causes of PAH

were left sided atrial or ventricular heart disease e 71 (55%) left

sided valvular heart disease e 19 (14.7%), chronic pulmonary

thromboembolism e 6 (4.6%), COPD e 4 (3.1%), congenital

systemic to pulmonary shunts e 4 (3.1%), collagen vascular

diseases e 2 (1.5%) and idiopathic PAH e 2 (1.5%).

Conclusion: Our study showed that left sided atrial or ventricular

heart disease contribute to the major share of pulmonary hyper-

tension, followed by left sided valvular heart disease, chronic

pulmonary thromboembolism and COPD.

Name of Corresponding Author: Gururaj B; Designation: Junior Resi-

dent In Cardiology Department; Address for Correspondence: #2102,

Third Cross, Smt Chikkammanni Devaraj Urs Layout, Davangere-

577005, Karnataka; Mobile: 9844000615; Email: gururaj.bandagar@

gmail.com

Myocardial contrast echocardiography (MCE) e Isit a new promising imaging modality to predictand identify the angina related artery (ARA) overconventional echocardiography, in cases ofunstable angina (UA); a comparison andcorrelation study with coronary angiographic(CAG) findings

Janardhana Rao Babburi, Sajith K.P., Ramya Shree C., Vijaya

Chaitanya B., Raghav Sharma, S. Thanikachalam, J.S.N Murthy,

Asha Moorthy, Manokar P.

Sri Ramachandra Medical Centre, Porur, Chennai, India

Objectives: To determine whether contrast enhanced echocar-

diography is superior to conventional echocardiography for the

qualitative and quantitative assessment of the LV volumes and

function and to study whether MCE improves the ability to

accurately predict the anatomical localization of the culprit

vessel.

Materials and methods: The study was done on 50 patients

(36males, and 14 females), who got admittedwith the first episode

of chest pain and clinically diagnosed as Unstable Angina with

subtle ECG changes. Patients with prior episodes of chest pain/

Unstable Angina/NSTEMI/MI/Post PCI and post CABG were

excluded from the study. Both conventional and contrast echo-

cardiograms were done for all the patients and the following

parameters were analyzed. 1. Wall motion segment analysis and

perfusion of the endocardial segments in apical 4 chamber,

3 chamber and 2 chamber views to look at the 17 myocardial

segments. 2. Systolic and diastolic volumes (EDV, ESV) and

systolic function of the left ventricle (LVEF%) by both Mmode and

2D modes. The patients with perfusion defects were subjected to

Coronary Angiogram (CAG). The angiographic data was analyzed

and compared with that of perfusion defects detected during

conventional and contrast echocardiography.

Results: In the present study, the average number of visualized

segments by conventional and contrast echocardiographies were

11.4 and 16.2 respectively and the average number of visualized

abnormal segments by conventional and contrast echocardiog-

raphy were 3.2 and 5.4 respectively. The sensitivities of conven-

tional and contrast echocardiographies for SVD (Single Vessel

Disease) were 73% and 89%, and for DVD (Double Vessel Disease)

were 79% and 81% and for TVD (Triple Vessel Disease) were 81%

and 86% respectively. The specificities of conventional and

contrast echocardiographies for SVD were 81% and 89% and for

DVD were 80% and 79% and for TVD were 86% and 81% respec-

tively. There were gross differences in the estimation of volumes

and EFs between conventional and contrast echocardiography

and the volumes measured by contrast echocardiography were

found to be much higher than compared with conventional

echocardiography. The % of patients with correct correlation of

conventional echocardiography with angiographic findings was

69% and the % correlation between contrast echocardiography

and angiographic findings was 81%.

Conclusions: This study has proved that the correlation coeffi-

cient was higher between contrast echocardiography and

angiographic findings as compared with conventional echocardi-

ography and angiographic data. MCE is a very promising and

useful tool to accurately assess the regional myocardial perfusion

and to predict the culprit vessel involved. MCE should become

more widely practiced imagingmodality in the next coming years.

Name of Corresponding Author: Dr. Janardhana Rao Babburi; Desig-

nation: Registrar In Cardiology; Address for Correspondence: Sri

Ramachandra Medical College & Research Institution; Telephone:

044 24766991; Fax: 044 27466990; Mobile: 0 - 9676404044; Email:

drbabub4u@gmail.com

Acute myocardial infarction in youngBangladeshis: A comparison with older patients

P.K. Das, M. Murshed, B. Bhatterchjee, A. Awal

Chittagong Medical College Hospital, Chittagong, Bangladesh

Background: Coronary artery disease (CAD) is now an emerging

epidemic in developing countries including Bangladesh. Young

peoples are being afflicted more and more here.

Aims: Young individuals with acute myocardial infarction (AMI)

may have unique presentation, risk factor, angiographic profile

and outcome compared with older persons that may have an

influence on the preventive strategies. This study is an attempt to

investigate the same.

Study design: Prospective observational.

Methods: Profile of 183 young patients (age �40 yrs) with AMI

admitted to the coronary care unit (CCU) of Chittagong Medical

College Hospital, Bangladesh over a period of one year were

compared with 168 older patients with age �40 years (age

range 41e70 year). Presentation of the patients, risk factor of

CAD, in-hospital complications and mortality were compared.

Location and types (STEMI, NSTEMI) of AMI were determined

by ECG and serum troponin-I assay. Blood for fasting glucose

and lipid profile were drawn within 24 hours of admission.

Coronary angiography was done within 6 week of hospital

discharge.

Statistical analysis: SPSS software.

i n d i a n h e a r t j o u r n a l 6 4 ( 2 0 1 2 ) S 8 1eS 9 4 S93

Results: Age ranges of 183 young patients were 21e40 years

(average 34.21 � 5.07 yrs). There were 157 male (85.5%) and 26

(14.2%) female. Male:female ratio was 6.03:1. A family history

of premature CAD was more common in young (28.6% vs

19.8% in older). More young patients were current smokers

(64.5% compared with 59.4% in older). Dyslipidaemia was

found more among young (49.7% vs 38.8%, p <0.001). More

young (55.4%) presented to the CCU lately (after 12 yours)

compared with 17.5% in older age group (p<0.001). A previous

history of chest pain and MI were less often in younger (17.3%

vs 26.8% in older). In-hospital mortality was only 3.2% in

young compared with 10.7% in the older (p <0.001). Pre-

discharge echocardiographic examination revealed a lower

ejection fraction in the older patients (0.47 � 0.15 vs 0.51 �0.13 in young). The mean hospital stay was 8 � 3 days in the

young and 10 � 4 days in the older group. Coronary angiog-

raphy done within a period of 6 weeks of hospital discharge

revealed a lesser degree of coronary lesions and a higher

multivessel CAD among the older.

Conclusion:Young patientswith AMI presented lately to CCUwith

more atypical features, had more dyslipidaemia, positive family

history of CAD, raised hs CRP, and history of smoking compared

with the older counterpart. They had a better in-hospital outcome.

Less extensive angiographic lesions suggest that early percuta-

neous coronary interventions along with control of risk factors

may be beneficial among the youngs. A search for emerging CAD

risk factors and their control may prevent MI among them.

Name of Corresponding Author: Dr. Prabir K. Das; Designation:

Assistant Professor of Cardiology, CMCH, Bangladesh; Telephone:

0088-031-654151; Mobile: 01711761175; Email: dr_prabir_ctg@

yahoo.com

Exercise stress echocardiography afterrevascularization; a single centre study

Praveen Kulkarni DM, Suvarna Tilak DM, Nilesh Gautam DM,

Santosh Kumar Dora DM, Ankit Agrawal DM, Santosh Khandekar

DNB

Asian Heart Institute, Mumbai, India

Background: Exercise stress echocardiography (ExSE) is routinely

utilized in the follow up of post coronary revascularization

patients. In asymptomatic patients who have undergone CABG or

PTCA, the clinical utility of ExSE in terms of patient outcome is not

well known. It may also lead to downstream repeat revasculari-

zation. We did a retrospective analysis of all the ExSE done in

asymptomatic post revascularization patients at our centre.

Methods: ExSE was performed in 870 asymptomatic patients over

a 2 year period. 617 (71%) were post CABG and the remaining 252

(29%) were post PTCA. 713 (82%) were males. The average time

from revascularization to ExSE was 1.8 years in post CABG

patients and 1.6 years in post PTCA patients. Ischemia was iden-

tified as new or worsening regional wall motion abnormality.

Exercise time, effort tolerance, rhythm, symptoms were analysed.

Results: Of 73 patients with ischemia (8.3%), only 31 (41%)

underwent subsequent revascularization. Mortality (21 patients

[2.4%]) was associated with ischemia (hazard ratio, 1.8; P ¼ .03) in

groups tested both early (P ¼ .03) and late (>2 years after PCI or >5

years after CABG). However, the main predictors of outcome were

clinical and stress testing findings rather than echocardiographic

features. Subgroup analysis showed that asymptomatic patients

with normal ejection fraction (>50%), and normal exercise

capacity (>7 METs) were unlikely to have a positive test result or

events. Even high-risk patients did not seem to benefit from

repeated revascularization.

Conclusion: In patients who have undergone coronary revascu-

larization, routine stress echocardiographic evaluation in

asymptomatic patients and subsequent treatment did not alter

the clinical outcome, irrespective of the study result. Ischemia

was an independent predictor of higher mortality.

Comparison of two dimensional transthoracic,transesophageal and real time-threedimensional transesophageal echocardiographyfor OS-ASD size with balloon sizing and surgicalmeasurement

Suresh H. DM, C.N. Manjunath DM, K.S. Ravindranath DM,

Prabhavati Bhat DM, C. Dhanalakshmi RDCS

Shri Jayadeva Institute of Cardiovascular Sciences and Research,

Bangalore, Karnataka, India

Objectives: To compare the efficacy of 2D TTE, 2D TEE and RT3D

TEE with balloon sizing (trans catheter arm) and surgical

measurement (surgical arm) in the assessment of OS-ASD size.

Methods: Thirty patients hospitalized for OS-ASD closure, either

trans catheter (12 pts) or surgical (18 pts) were included in the

study. All 30 patients were evaluated with 2D TTE, 2D TEE and RT

3D TEE by independent observers, OS-ASD dimensions were

compared with balloon sizing (transcatheter arm) and surgical

measurements.

Results: The mean size of OS-ASD by RT 3D TEE24.25 � 3.81 mm,

correlated very well with balloon sizing (trans catheter arm)

25.42 � 4.01 mm (R value 0.974, P value <0.001) and in surgical

arm OS-ASD size by 3D TEE 31.94 � 5.56 mm correlated with

surgical measurements 33.95 � 7.18 mm (R value 0.874, P value

<0.001), as compared to mean size of OS-ASD size by 2D TTE

30.75 � 4.24 mm in trans catheter arm (R value 0.621, P value

0.31) 37.11 � 4.27 mm in surgical arm (R value 0.393, P value 0.96)

and 2D TEE 24.00 � 3.43 mm in trans catheter arm (R value 0.720,

P value 0.008), 28.89 � 5.73 mm in surgical arm (R value 0.606, P

value 0.006).

Conclusion: RT-3D TEE allows accurate assessment of OS-ASD

size and its location and correlates very well with balloon sizing

and surgical measurements compared to 2D TEE and 2D TTE.

Name of Corresponding Author: Dr. Suresh. H; Designation: Associate

professor; Address for Correspondence: House no 49 bhuvaneshwari

nagar keshwapur hubli 23; Mobile: 09343423939; Email: drsuresh.

h72@gmail.com

Not all flaps on echocardiography are dissections

Chatterjee Aparajita, Shetty Ranjan, G. Vivek, Dias Lorraine,

Acharya Raviraja

Background: Although echocardiography is one of the most

preferred modalities for non-invasive imaging of the heart & the

great vessels, its efficacy in detecting dissection is often limited.

Furthermore, intimal flaps which are considered to be diagnostic

of dissection are not just exclusive to them, but maybe noted in

other cases also. Here we present a case wherein an undulating

flap noted in ECHO first lead us to consider a diagnosis of

i n d i a n h e a r t j o u rn a l 6 4 ( 2 0 1 2 ) S 8 1eS 9 4S94

dissecting aneurysm of aorta but which on CTwas proven to be an

aneurysm of celiac artery.

Case report: 58 year old lady, known case of epilepsy on anti-

epileptics presented to the hospital with complaints of diffuse

pain abdomen & low backache since 15 days. Examination was

unremarkable. Labs showed anemia with high ESR & high gamma

globulins. Bone marrow biopsy however did not show any

evidence of myeloma. Ultrasound abdomen had shown an aneu-

rysmal dilatation of abdominal aorta. ECHO showed normal LV

function with an undulating flap, with sluggish flow in one of the

lumen suspicious of dissection. However, CT abdomen done

which showed a large fusiform dilatation at the origin of the celiac

artery measuring 4 � 3.3 cm s/o celiac artery aneurysm with no

evidence of dissection. A smaller aneurysm measuring 1.9 � 1.4

cm was also noted at the origin of superior mesenteric artery.

Coronary & mesenteric angiography were performed which

showed left anterior descending, superior mesenteric & celiac

artery aneurysm with normal inferior mesenteric artery & renal

arteries. Vasculitis work-up was negative except for rheumatoid

factor positivity. Since there was initial suspicion of infective

etiology of the aneurysms, she also received gram positive

coverage. She was advised surgery.

Conclusion: 1. The presence of a flap in the aorta although highly

suggestive of dissection, is not diagnostic of the same. This needs

to be borne in mind as it can mislead the clinician. 2. Use of

advanced modalities of imaging like CT, MRI or TEE may help in

early & accurate diagnosis of both dissection & aneurysms

involving the aorta & its branches.