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ABSTRACT: Conflicting data exists regarding relationship between the Framingham risk score (FRS) and presence of metabolic syndrome (MS). Strong influence of age on FRS may further modify this relationship as prevalence of MS at younger age increases in South-Asian countries including India. However, only limited information is available about the prevalence of MS and its relationship with FRS in such populations at present.
Clinical examination and biochemical investigations were performed in 1905 asymptomatic office executives who underwent routine health check-up at a tertiary care centre in India during the year 2005. Diagnosis of MS and FRS were based on the modified National Cholesterol Education Program-Adult Treatment Panel III guidelines.
Mean age of the subjects was 45.2 +/- 10.3 years and 71.8% were males. MS was present in 47.5% (905 of 1905) subjects. Overall, 76.8% patients with MS had 10-year cardiovascular (CV) risk < 10%, 20.6% had 10-20% risk and only 2.7% had > 20% risk according to FRS. In the lowest age-quartile, 95.9% patients had 10-year risk < 10%, 4.1% patients had 10-20% risk and none had > 20% risk. In contrast, in the highest age-quartile, less than half of the patients had 10-year risk <10% and nearly half had 10-20% risk of CV events.
Although the prevalence of MS is markedly high in young asymptomatic Indians, majority have low 10-year risk of CV events as estimated by FRS. These findings necessitate continued emphasis on detection of MS in these populations as reliance on FRS alone may result in underestimation of CV risk in them.
The Journal of the Association of Physicians of India 01/2009; 57:17-22.
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ABSTRACT: Conventional cardiovascular risk factors (CVRFs) are known to influence short-term and long-term outcome following coronary artery bypass graft surgery (CABG). There has been recent increase in prevalence of CVRFs in general population in India. However no information is available regarding the prevalence of same in patients undergoing CABG.
In this cross-sectional study, one thousand consecutive patients undergoing elective CABG were included and data on major CVRFs was obtained in them. Mean age of the patients was 59.73 +/- 9.5 years and 884/1000 (88.4%) patients were males. 505/994 (50.8%) patients had BMI > or = 25.0 kg/m2 and 747/994 (75.2%) had BMI > or = 23.0 kg/m2. Diabetes mellitus was present in 475/1000 (47.5%) patients (46.5% men and 55.2% women), hypertension in 709/1000 (70.9% overall; 70.8% men and 71.6% women) and dyslipidemia in 781/913 patients (85.6% overall; 84.5% men and 93.9% women). 213/913 (23.3%) patients had LDL > or = 100mg/dl, 662/913 (72.5%) patients had low HDL and 338/913 (37.0%) patients had elevated triglycerides. 199/1000 (19.9%) patients (18.7% men and 29.3% women) had family history of premature CAD and 545/1000 (54.5%) patients (53.4% men and 62.9% women) had at least one family member having CAD (irrespective of the age of onset). 94/1000 (9.4%) patients (10.4% men and 1.7% women) were current smokers and another 302/1000 (30.2% overall; 33.7% men and 3.4% women) had history of smoking in the preceding one year. 876/913 (95.9%) of all the patients had at least one of the five major CVRFs and only 37/ 913 (4.1%) patients (4.1% men and 4.3% women) were free of all these risk factors. Sixty-one of the 1000 patients (6.1%) were younger than 45.0 years of age. As compared to older patients, dyslipidemia, family history of premature CAD and smoking were commoner in patients less than 45 years of age. In contrast, diabetes and hypertension were more prevalent in the older individuals.
The present study showed high prevalence of most of the conventional CVRFs, esp. diabetes, hypertension and dyslipidemia in Indian population undergoing CABG.
The Journal of the Association of Physicians of India 05/2006; 54:371-5.
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ABSTRACT: Dobutamine stress echocardiography is often used as a non-invasive diagnostic modality for detection of coronary artery disease. In terms of accuracy it rivals SPECT scintigraphy. Application of non-coronary artery disease has made it an attractive diagnostic tool. However, like all diagnostic modalities it has its inherent limitations. Quantitation of stress echocardiography can resolve most of the problems surrounding its use.
The Journal of the Association of Physicians of India 09/2004; 52:653-7.
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ABSTRACT: Among the various causes of blood pressure in the elderly population, isolated systolic hypertension (ISH) is the commonest. Its prevalence increases with age. Age related rigidity of aorta is the primary cause of ISH. Systolic rise in blood pressure is at least as important as the diastolic blood pressure. Several non-pharmacological and pharmacological therapies are well-established for reduction of blood pressure in this age group. Among different groups of anti-hypertensive drugs, the preference depends primarily on co-morbidities and overall cardiovascular risk. Lifestyle modification should also be an integral part of therapy for each patient. Various studies suggest that control of blood pressure definitely decreases the incidence of mortality as well as coronary artery disease, stroke and other morbidities.
The Journal of the Association of Physicians of India 07/2004; 52:479-85.
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The Journal of the Association of Physicians of India 03/2004; 52:125.
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The Journal of the Association of Physicians of India 08/2003; 51:706-13.
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ABSTRACT: Endothelial function as assessed by brachial artery flow mediated vasodilatation (FMD) has been shown to be impaired in patients with coronary artery disease (CAD). Since diabetes mellitus (DM) has been considered to be CAD risk-equivalent, we sought to determine whether endothelial dysfunction is present in patients with DM independent of presence of CAD.
One hundred and ninety eight individuals were included in the study and divided into four groups: Group 1--patients with risk factors for CAD, but no DM or CAD; Group 2--patients with DM but no CAD; Group 3--patients with CAD but no DM and Group 4--patients with both DM and CAD. Brachial artery FMD assessment was performed once in all subjects and FMD was calculated as percentage increase in brachial artery diameter in response to increase in brachial artery flow.
Mean FMD was significantly higher in Group 1 (7.03 +/- 2.87%) compared to the other three groups. Mean FMD in Group 2 (5.51 +/- 2.12%) was similar to that in Group 3 (4.56 +/- 2.70%; p value 0.195) but significantly higher than that in Group 4 (4.26 +/- 1.93%; p value 0.038). There was no statistically significant difference in mean FMD in Group 3 and Group 4 (p value 0.65).
Endothelial function as assessed by FMD is significantly impaired in diabetics compared to non-diabetics in absence of CAD. In addition, similar degree of impairment in endothelial function is seen in diabetics without CAD and non-diabetic patients having CAD, implying CAD risk-equivalence of diabetes.
The Journal of the Association of Physicians of India 05/2003; 51:355-8.
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ABSTRACT: BACKGROUND: Perioperative stroke is a devastating complication after coronary artery bypass grafting (CABG). The reported incidence of neurologic complications after conventional CABG is 3% to 7%. With improved monitoring and surgical techniques, we have been able to achieve a drastic reduction in the stroke rate in our institution. This study evaluates the incidence of neurologic sequelae in patients who underwent off-pump CABG. METHODS: Over a 10-year period from January 1990 to September 2000, off-pump coronary artery bypass (OPCAB) operation was performed on 2,800 patients of the 18,037 patients undergoing CABG during that time frame at the Escorts Heart Institute and Research Centre. Initially, OPCAB was performed selectively in the high-risk group of patients (atheromatous aorta, renal impairment, chronic obstructive pulmonary disease, octogenarians, etc). Lately we performed multivessel OPCABs electively in about 60% to 65% of the patients undergoing CABG. Results. Mean age of the patients was 58.0 +/- 9.91 years (range 27 to 85 years) and mean number of grafts was 2.9 per patient. Neurologic complications (stroke/transient ischemic attack) occurred in 0.14% of patients. Overall hospital mortality in OPCAB patients was 2.14%, whereas mortality from neurologic complications was 0.07%. Predicted mortality (National Society of Thoracic Surgeons Cardiac Surgery Database Risk Model for CABG) for the entire patient group was 3.86% (p < 0.001). Conclusions. Although current techniques of monitoring and surgical procedures have significantly reduced the risk of stroke from CABG, our data strongly support OPCAB as a technique to further reduce stroke after CABG, especially in the high-risk group of patients.
The Annals of Thoracic Surgery 09/2001; 72(3):S1026-32. · 3.74 Impact Factor
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ABSTRACT: Discrete subvalvular aortic stenosis is a relatively rare condition in adults. It is often diagnosed during first decade of life especially in association with other congenital malformations. Isolated form of discrete subvalvular aortic stenosis may however silently progress from innocent murmurs of childhood and adolescence to symptomatic left ventricular outflow tract obstruction in adults. Certain overt and subtle morphological abnormalities may underlie the initial expression as well as high recurrence rates after surgical resection of sub aortic membrane. Though surgical resection is the only treatment available, debate on the surgical technique and appropriate timing of surgery continues. Close followup with serial echocardiographic examinations in patients detected to have functional murmurs during childhood may be helpful in early detection of subvalvular aortic stertosis.
The Journal of the Association of Physicians of India 04/2001; 49:369-71.
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ABSTRACT: Mobile atheromas of the thoracic aorta have been identified as a major cause of stroke after coronary artery bypass grafting (CABG). This prospective study was undertaken to identify mobile atheromas and to determine the incidence of immediate postoperative embolic events after suitable surgical modifications. Late clinical events attributable to embolization were also studied.
Between January 1993 and July 1997, 3,660 patients scheduled for CABG underwent intraoperative transesophageal echocardiography to identify aortic atheromatous disease. The disease was graded as follows: grade I, plaques extending less than 5 mm into the aortic lumen; grade II, plaques extending more than 5 mm into the aortic lumen; and grade III, plaques with a mobile element. Only patients with grade III atheromas were included in the study. Various surgical modifications were done depending on the location of the lesion, eg, aortic arch atherectomy, CABG combined with transmyocardial laser revascularization, off-pump CABG by median sternotomy, and minimally invasive direct coronary artery bypass. Measured outcomes were death, stroke, and other vascular events, both early (within 1 week) and late (1 to 5 years) after operation.
Of the 3,660 patients, 104 (2.84%) had mobile atheromas. The perioperative stroke rate was 0.96%, and the incidence of other vascular events was 1.92% at 1 week. There was no embolic event in the group of 88 patients who underwent off-pump CABG. Of the study group, 98.07% are in regular follow-up. At 5 years, 1 patient had had a nonfatal stroke, and 2 patients had died of causes unrelated to atheromatous disease.
The stroke rate was very low in patients with mobile aortic atheromas who underwent CABG after modification in surgical technique, especially off-pump CABG. A follow-up of 5 years showed that patients with mobile atheromas have a very low incidence of spontaneous embolization.
The Annals of Thoracic Surgery 12/2000; 70(5):1558-64. · 3.74 Impact Factor
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ABSTRACT: Discrete Subaortic Stenosis is one of the many lesions responsible for left ventricular outflow tract (LVOT) obstruction. It may present as in an isolated from as membranous or fibromuscular ring below the aortic valve or in association with other congenital anamolies such as VSD, PDA, coarctation of aorta, hypoplastic aortic annulus, double chamber right ventricle among others. The condition is rarely diagnosed antenataly or in infancy but often manifests in the first decade of life with features of progressive LVOT obstruction, LV hypertrophy and dysfunction aortic regurgitation due to damage to the aortic cusps because of the jet from the subaortic narrowing which may also render the aortic valve prone to infective endocarditis. Interaction of genetic predisposition and morphologically deformed long and narrow LVOT cause rheological abnormalities and increased shear stress in the region of subaortic stenosis and seem to be the main etiological factor alongwith poorly defined role of more extensive but subtle changes in the LV endocardium. Condition can be easily diagnosed by cross-sectional and Doppler echocardiography and confirmed by demonstrating a pressure gradient below aortic valve on cardiac catheterisation and LV angiography. Surgical membranectomy alongwith myotomy or myomectomy remain the mainstay of treatment but long term results are not satisfactory as there is a high rate of recurrences requiring reoperations. A close follow up with serial echocardiographic examinations is very helpful in early detection of subaortic obstruction in patients who have so called functional murmurs in the childhood.
The Journal of the Association of Physicians of India 12/2000; 48(11):1103-6.
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ABSTRACT: Perioperative stroke represents one of the major complications following coronary artery bypass grafting (CABG). The present study was designed to evaluate the use of an individualized surgical approach for reducing neurological injury in patients undergoing CABG at high risk of stroke from aortic atherosclerosis or carotid disease.
Between January 1993 and June 1999, 6,138 patients undergoing elective CABG were evaluated by intraoperative transesophageal echocardiography. Patients were screened preoperatively for internal carotid artery disease. Based on the intraoperative transesophageal echocardiography findings the surgical technique was individualized: hypothermic circulatory arrest with aortic atherectomy, CABG combined with transmyocardial laser revascularization on the beating heart, off-pump CABG by midsternotomy, ministernotomy, minimally invasive direct CABG, hybrid procedure, and so on. Patients were divided into four groups: a low-risk group (no significant aortic or carotid disease); an aortic atheromatous disease group (A.ATH); a carotid disease group (CD); and a carotid disease combined with aortic atheromatous disease group (CD + A.ATH).
The incidence of stroke in the low-risk group (n = 5,043) was 0.92% compared with 0.96% in the A.ATH group (n = 918). In the CD group (n = 166) the incidence of stroke was 0.6% whereas it was 0% in the CD + A.ATH group (n = 11).
Preoperative and intraoperative screening can detect extensive atherosclerosis of the proximal aorta and internal carotid artery. Selective use of surgical techniques in this group of high-risk patients can prevent adverse neurologic sequelae while achieving complete myocardial revascularization.
The Annals of Thoracic Surgery 10/2000; 70(3):1037-45. · 3.74 Impact Factor
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ABSTRACT: This study evaluates the feasibility of minimally invasive mitral valve surgery. The aim of the study was to minimize surgical access to achieve better cosmetic results, less postoperative discomfort, and faster recovery.
From September 1997 to October 1998, 76 patients underwent mitral valve surgery through a right anterolateral minithoracotomy at the fourth intercostal space. The mitral valve was either repaired (n = 21) or replaced (n = 55). In all cases, open femoral artery-femoral vein cannulation was used for cardiopulmonary bypass. In 27 cases, an endoluminal aortic clamp was used, but in 49 cases, the aorta was cross-clamped with a transthoracic, sliding-rod-design clamp.
There were no approach-related limitations to surgical intervention. Intraoperative transesophageal echocardiography revealed excellent results after valve repair and no paravalvular leak in any patient after mitral valve replacement. Mean duration of intensive care and postoperative hospital stay was 32+/-5.2 hours and 7+/-1.1 days, respectively. There were no major complications related to femoral vessel cannulation. In 1 patient, transient neurological problems developed, with subsequent complete recovery. There was one hospital mortality (85-year-old male patient died of upper GI bleeding).
Minimally invasive port access mitral valve surgery can accelerate recovery and decrease pain, while maintaining overall surgical efficacy. It also provides better cosmetic results to our patients, and now it has become our standard approach for isolated mitral valve surgery.
The Annals of Thoracic Surgery 11/1999; 68(4):1520-4. · 3.74 Impact Factor
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ABSTRACT: To evaluate transesophageal echocardiography (TEE) as an intraoperative monitoring modality and to assess its safety, reliability, and overall utility in real-time use during cardiac surgery.
Prospective, observational cohort study performed from January 1993 to June 1997.
Operating room of a tertiary care hospital for cardiology and cardiovascular surgery.
Five thousand and sixteen adult patients with acquired heart disease, who underwent 1,356 valve procedures and 3,660 coronary artery bypass graftings (CABGs).
All patients were monitored with radial artery and pulmonary artery catheters, along with continuous TEE monitoring with a multiplane transducer.
Prebypass imaging yielded unsuspected findings that either helped or modified the surgical plan in 158 of 1,356 valve procedures (11.65%) and in 993 of 3,660 CABGs (27.13%). There were 3,217 TEE-guided hemodynamic interventions in 944 patients (25.79%) in the CABG group and 629 in 142 patients (10.47%) in the valve group. TEE was the sole guiding factor in initiating therapy in 23.53% of events, whereas it was supportive to other monitoring modalities in 76.46% of events. Postbypass TEE identified the need for graft revision in 29 patients (0.8%), intra-aortic balloon pump (IABP) requirement in 29 patients (0.8%), and inadequate valve repair in 28 patients (2.08%). For the entire series, 38.78% of patients benefited from prebypass and 39.16% from postbypass use of TEE. There were no complications attributable to the use of TEE in the entire series. There was 87% concordance between online interpretation by a trained anesthesiologist and offline analysis by a cardiologist.
Intraoperative TEE is useful in formulating the surgical plan, guiding various hemodynamic interventions, and assessing the immediate results of surgery. It is safe and the results are reliable in the hands of trained anesthesiologists.
Journal of Cardiothoracic and Vascular Anesthesia 01/1999; 12(6):625-32. · 1.64 Impact Factor
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ABSTRACT: We investigated the role of three-dimensional echocardiography in assessing mitral valve anatomy in greater detail in patients immediately before and after balloon mitral valvuloplasty (BMV).
Three-dimensional echocardiography is a recently developed, evolving imaging technique that allows visualization of intracardiac structures from any perspective.
We studied 19 patients undergoing BMV using transesophageal echocardiography (TEE) (Chicago, Illinois) to image the mitral valve. The TEE was interfaced to a TomTec three-dimensional workstation that allows electrocardiographic and respiratory cycle gated image acquisition. The acquired images are digitized, and after postprocessing a three-dimensional image is reconstructed. The mitral valve was viewed "en-face" as if looking up from the left ventricle.
The mean mitral valve area (by pressure half-time from the Doppler of the two-dimensional echocardiogram) increased after BMV from 0.86+/-0.06 cm2 to 2.07+/-0.10 cm2, p < 0.0001. This was similar to the mitral valve areas obtained by planimetry from the three-dimensional images. The three-dimensional reconstructions showed a complete commissural split in 10 patients and partial splitting in 9 patients. In three of the eight patients who had an increase in the amount of mitral regurgitation secondary to BMV, the three-dimensional reconstructions were able to detect tears within the valve leaflet. One leaflet tear actually extended up to the mitral valve annulus and was associated with the only case of severe mitral regurgitation.
The three-dimensional echocardiographic reconstruction enabled visualization of the mitral valve so that commissural splitting and leaflet tears not seen on the two-dimensional echocardiogram became visible.
Journal of the American College of Cardiology 11/1998; 32(5):1405-9. · 14.16 Impact Factor
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ABSTRACT: Coronary artery bypass grafting has been based on cardiopulmonary bypass, myocardial protection, and the median sternotomy. The recent concept of minimally invasive coronary artery bypass grafting in selected patients has dramatically affected surgical management of coronary artery disease. Coronary artery bypass grafting of anterior coronary arteries with in situ internal mammary artery through a limited anterior thoracotomy is a procedure that is gaining acceptance.
Fifty-one patients were operated on by minithoracotomy and direct coronary artery bypass grafting without cardiopulmonary bypass. Left internal mammary artery-to-left anterior descending coronary artery anastomosis was done in 50 patients, and in 1 patient, left internal mammary artery-to-left anterior descending artery and right internal mammary artery-to-right coronary artery anastomoses were constructed through bilateral minithoracotomies. Left anterior minithoracotomy through the fourth intercostal space and right anterior minithoracotomy through the fifth intercostal space were used for left internal mammary artery and right internal mammary artery dissection, respectively. With this approach, a 4- to 6-cm length of mammary artery was easily dissected. Mammary-to-coronary anastomosis was performed on a beating heart without cardiopulmonary bypass through window pericardiotomy.
Twenty-five patients were extubated in the operating room and 26 in the intensive care unit 4 to 6 hours after operation. None of these patients required blood transfusion or inotropic support. Postoperative predischarge angiography in 42 patients revealed adequate mammary-to-coronary flow in 40 patients. Doppler flow studies were also in accordance with angiographic findings. Forty-five patients are in our regular follow-up (mean follow-up, 6.23 +/- 1.34 months); 44 of them are in functional class I.
In our experience minithoracotomy is a safe, simple, and minimally invasive procedure. Favorable cost/benefit ratio has been achieved owing to no early or late mortality and minimal early morbidity. Postoperative angiography and Doppler flow study revealed excellent predictive long-term results.
The Annals of Thoracic Surgery 07/1997; 63(6 Suppl):S114-8. · 3.74 Impact Factor
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Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital 02/1997; 24(2):140-1. · 0.65 Impact Factor
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The Journal of the Association of Physicians of India 10/1996; 44(9):649-52.
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ABSTRACT: To study the incidence of spontaneous echo contrast in left atrium of Indian patients with rheumatic mitral stenosis in normal sinus rhythm and to define its relations.
Transthoracic and multiplane transoesophageal echocardiographic studies were performed in 89 consecutive patients with rheumatic mitral stenosis who were in normal sinus rhythm.
Spontaneous echo contrast in the left atrium was seen in 57.3% of patients on multiplane transoesophageal echocardiography and in only 5.6% on transthoracic echocardiography. The mean mitral valve area was 1.07 (SD 0.33) cm2 and 1.32 (0.45) cm2 (P = 0.004), mean left atrial size was 4.27 (0.67) cm and 3.91 (0.5) cm (P = 0.029), mean diastolic pressure gradient was 12.64 (5.69) mm Hg and 10 (5.5) mm Hg (P = 0.049), and absence of mitral regurgitation was seen in 45% and 23% of patients respectively (P = 0.1). Among patients with spontaneous echo contrast, 31% had either left atrial/appendage thrombus or a history of embolism, upsilon 0% in patients without spontaneous echo contrast (P < 0.0001).
There is a high incidence of spontaneous echo contrast in the left atrium in Indian patients with rheumatic mitral stenosis in normal sinus rhythm on multiplane transoesophageal echocardiography. These patients are likely to embolise or form thrombi in the left atrium. The presence of spontaneous echo contrast is also associated with significantly smaller mitral valve area, larger left atrium, and higher mean diastolic mitral pressure gradient.
Heart 10/1995; 74(3):296-9.
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ABSTRACT: Papillary fibroelastoma of the mitral valve diagnosed and treated in life is extremely rare. There have been eight cases documented so far. We report the first case of a mitral valve papillary fibroelastoma associated with severe rheumatic mitral stenosis and tricuspid regurgitation with stenosis. The tumor arose from the posteromedial papillary muscle of the mitral valve. The mitral valve was replaced after excising the valve with the tumor and the tricuspid valve was repaired. The patient did well and remains asymptomatic.
European Journal of Cardio-Thoracic Surgery 02/1995; 9(1):54-5. · 2.55 Impact Factor
