ii

Cardiology Update 2017(CARDIOLOGICAL SOCIETY OF INDIA)

EDITOR-IN-CHIEF

K SARAT CHANDRA, MD, DM FACC FESC FCSIChief CardiologistIndo-US Superspecialty HospitalHyderabad, IndiaFormer Editor – Indian Heart JournalPresident Elect – CSIChairman, Scientifi c Committee, CSICON 2017

CO-EDITOR

MANISH BANSAL, MD, DNB CARDIOLOGY, FACC, FASE, FISCUAssociate Director Cardiology,Medanta- The Medicity, Gurgaon, IndiaJoint Secretary, CSI

EDITORIAL ADVISORSV Dayasagar Rao (Hyderabad) O P Yadava (New Delhi)Gagandeep Singh Wander (Gurgaon)B Hygriv Rao (Hyderabad)Mona Bhatia (New Delhi)Rahul Mehrotra (New Delhi)Vishal Rastogi (New Delhi)Nagendra Bhoopathy (Chennai)A J Swamy (Pune)

Cardiology Update 2017, Edited by K Sarat Chandra, Manish Bansal

© 2017 Cardiological Society of India. Publishing Services by RELX India Private Limited.All rights reserved.

ISBN: 978-81-312-5285-7

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v

A B GOPALAMURUGAN, MBBS, MD, MRCP, CCDS, FRCP, FACC Director of Cardiac Sciences and Senior Interventional Cardiologist SIMS Hospital, Chennai, India

A KUNDU, MBBS, MS, MCH (CVTS) Consultant Cardiac Surgeon National Heart Institute, New Delhi, India

AASHA S GOPAL, MD, MS, FACC Director, Advanced Echocardiography Saint Francis Hospital, Roslyn, New York, and Associate Professor of Medicine, Stony Brook University, New York, USA

ABHIJIT JOSHI, MBBS Junior Surgical Resident Department of Cardiac Surgery, Narayana institute of Cardiac Sciences, Bangalore, India

ABHINAV JAIN, MD DNB Cardiology Fellow Max Superspeciality Hospital, New Delhi, India

AJEET BANA, MS, MCH Chairman Cardiac Sciences Eternal Hospital, Jaipur, India

AK BANERJEE, CONSULTANT AND INTERVENTIONAL CARDIOLOGIST Formerly Institute of Cardiovascular Sciences, Institute of Postgraduate Medical Education and Research, and Memorial Hospital Kolkata, West Bengal, India Past-President Cardiological Society of India, Association of Physicians of India, SAARC Cardiac Society

AK PANCHOLIA, MD, FACC, FESC, FCSI, FISH, FIMSA, MAMS HOD - Clinical & Preventive Cardiology Arihant Hospital & RC, and Gokuldas Heart Center, Indore, India

AKSHYAYA PRADHAN, MD, DM Assistant Professor King George Medical University, Lucknow, India

ALLA GOPALA KRISHNA GOKHALE, MS, MCH, DNB, SMP(IIM-C) Consultant Cardiothoracic and Transplant surgeon Apollo Hospitals, Hyderabad, India

AMIER AHMAD, MD Internal Medicine Resident University of Alabama at Birmingham, Birmingham, AL, USA

AMIT MISRI, MBBS, MD (PEDIATRICS), FELLOW NATIONAL BOARD (PEDIATRIC CARDIOLOGY) Senior Consultant Medanta- The Medicity, Gurgaon, India

ANANDAROOP LAHIRI, MD DM(CARDIOLOGY) Associate Professor Christian Medical College, Vellore, India

ANATOLI KIOTSEKOGLOU, MD, PhD Specialist Cardiologist Örebro University Hospital, Örebro, Sweden

ANIL DHALL, MD, DM, FACC, FESC, FSCAI, FHRS, FCSI Director, Cardiovascular Sciences Venkateshwar Hospital, New Delhi, India

ANIRUDH KOHLI, MD DNB DMRD Chief Radiologist Breach Candy Hospital Trust, Mumbai, India

ANKIT ROY, MBBS Post-graduate trainee (MD-Medicine) Vivekananda Institute of Medical Sciences, Kolkata, India

ARUN SHARMA, MD Senior Resident, Department of Cardiovascular Radiology and Endovascular Interventions All India Institute of Medical Sciences, New Delhi, India

Contributors

vi Contributors

AS NARULA, MD, DM, FACP Director - Department of Nephrology and Transplant Medicine Fortis Escorts Kidney and Urology Institute, Fortis Escorts Hospital, New Delhi, India

ASHA MOORTHY, MD, DM, FCCP, FICP, FIMSA, FICC, FIACM Senior Consultant Cardiologist SIMS (SRM Institutes for Medical Science), SIMS Hospital, Chennai, India

ASHISH KUMAR PRAKASH, MBBS, DTCD, DNB, EUROPEAN DIP IN ADULT RESP MEDICINE Associate Consultant Medanta- The Medicity, Gurgaon, India

AVIRAJ CHAUDHARY, MD(MEDICINE), FELLOW IN CARDIOLOGY SRIII IMS, BHU, Varanasi, India

AYAN KAR, MBBS, DNB (MEDICINE) Senior Registrar and National Board Fellow in Cardiology Narayana Health -Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India

B C SRINIVAS, DM CARDIOLOGY Professor in Cardiology Sri Jayadeva Institute of Cardiovascular Sciences, Bengaluru, India

B VINODKUMAR, MD Physician Billroth Hospital, Chennai, India

B. HYGRIV RAO, MD, DM, FACC Senior Consultant Cardiologist Director, Division of Pacing & Electrophysiology, Krishna Institute of Medical Sciences, Secunderabad, India

BABUREDDY T S, DM CARDIOLOGY Associate Professor in Cardiology Sri Jayadeva Institute of Cardiovascular Sciences, Bengaluru, India

BALAJI LOHIYA, DM (CARDIOLOGY) SSR IMS, BHU, Varanasi, India

BALBIR SINGH, MD DM Chairman, Division of Cardiac Electrophysiology Medanta Heart Institute, Medanta- The Medicity, Gurgaon, India

BHAGAWAN KOIRALA, MS Professor Manmohan Cardiothoracic Vascular and Transplant Center, Tribhuvan University, Kathmandu, Nepal

BHARAT RAWAT, MD , DM, FACC, FSCAI Associate Director - Department of Cardiology Medanta Hospital, Indore, India

BHAWANI SHANKAR, MD, DNB Senior Consultant Cardiology Medanta- The Medicity, Gurgaon, India

BISWA RANJAN MISHRA, MD, DM, FCSI, FIAE, FESC Chief Consultant Cardiologist Max Diagnostic Centre, Cuttack, India

BORNALI DATTA, MBBS, MD, MRCP, CCST(UK) Associate Director Medanta- The Medicity, Gurgaon, India

C M NAGESH, DM CARDIOLOGY Associate Professor in Cardiology Sri Jayadeva Institute of Cardiovascular Sciences, Bengaluru, India

C NARASIMHAN, MD, DM (AB) Sr. Consultant - Cardiologist & Electrophysiologist, HOD of the Department of Cardiology CARE Hospital, Banjara Hills, India

C VENKATA S RAM, MD, MACP, FACC, FASH Director Apollo Institute for Blood Pressure Management World Hypertension League/South Asia Offi ce Apollo Hospitals, and Apollo Medical College, Hyderabad, India

CH. RAVIRAJU, MBBS Registrar in cardiothoracic surgery Apollo Hospitals, Hyderabad, India

CHANDRASEKAR PADMANABHAN, MS, DNB (SURG), DNB (CTVS ), MBA (HM ) Consultant Cardiothoracic Surgeon GKNM Hospital, Coimbatore, India

viiContributors

DAVID CHASE, MD DM(CARD), FELLOWSHIP IN CARDIAC ELECTROPHYSIOLOGY AND PACING (AUSTRALIA) Professor Christian Medical College, Vellore, India

DEBDATTA BHATTACHARYYA, MD, MRCP (UK), CCST (UK) Director Cathlab Services & Senior Interventional Cardiologist Narayana Health -Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India

DEVIPRASAD SHETTY, MBBS, MS (GENERAL SURGERY), Chairman & Executive Director Narayana Institute of Cardiac Sciences, Bangalore, India

DHARMENDRA JAIN, MD, DM(CARDIOLOGY), FNB, FACC, FSCAI, FESC, FISE, FISC, FCSI Associate Professor, Dept of Cardiology IMS, BHU, Varanasi, India

DIPAK RANJAN DAS, MD, DM, FCSI, FIAE, FESC Asst. Prof cardiology S.C.B. Medical college, Cuttack, India

FELIPE KAZMIRCZAK, MD Advanced Cardiac Imaging Fellow Division of Cardiology, Veterans Affairs Health Care System, Minneapolis, MN, USA

G SENGOTTUVELU, MD, DM, DNB, FRCP (GLASGOW), FSCAI, FMMC, FELLOWSHIP IN INTERVENTIONAL CARDIOLOGY (FRANCE) Senior Consultant & Interventional Cardiologist Apollo Hospitals, Chennai, India

GAGANDEEP SINGH, MD, DM, FACC, FSCAI Senior Consultant Cardiology Medanta- The Medicity, Gurgaon, India

GEETESH MANIK, MD, DM, DNB (CARDIOLOGY) Consultant Cardiologist Teerthanker Mahaveer Hospital, Moradabad, India

GEETHA SUBRAMANIAN, MD, DM(CARDIOLOGY), FCSI, FIAE, FISE, FMMC Prof and Head, Dept of Cardiology IMS, BHU, Varanasi, India

GEEVAR ZACHARIAH, MD, DM Senior Cardiologist and HOD Cardiology Mother Heart Care, Mother Hospital, Thrissur, India

GEORGE JOSE VALOORAN, MBBS, MS, MCH Consultant Cardiothoracic Surgeon Rajagiri Hospital, Cochin, India

GN MAHAPATRA, MBBS, DRM (INMA S, DU) FICA (USA) FCCP (USA), DSC, FRSH (UK), INT REG TRAIN NUCL MED (CIAMS, USSR), FCSI (INDIA), SPL TRAIN IN PET-CT (UNIV OF TEXAS), MD (USA) Senior Consultant & Head, Department of Nuclear Medicine Seven Hills Hospital, Mumbai, India

GP CAPT (DR) AJ SWAMY, MD (MED), DNB (MED), DM (CARDIOLOGY) Professor - Cardiology Military Hospital (CTC), Pune, India

GURLEEN WANDER, MBBS, MD Speciality Registrar Queen Charlotte’s and Chelsea Hospital, Imperial College, NHS Trust, London

GURPREET S SANDHU, MD, PhD Chair, Division of Interventional Cardiology Mayo Clinic, Rochester, MN, USA

GURPREET SINGH, MD (MEDICINE), DM (CARDIOLOGY) Professor and Head of Cardiology Hero DMC Heart Institute, Dayanand Medical College & Hospital, Ludhiana, India

HARIKRISHNAN S, DM, DNB, FRCP Professor Cardiology Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India

HARIRAJ TOMAR, MD, DNB Senior Consultant Cardiology Medanta- The Medicity, Gurgaon, India

ISAAC V. MAMMEN, MBBS, MD, DM Assistant Professor, Department of Cardiology Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, India

JABIR A, MD, DM, FSCAI, FESC, FACC, Consultant Cardiologist Lisie Heart Institute, Lisie Hospital, Kochi, India

JAGDISH C MOHAN, MD, DM, FASE Director & HOD - Cardiology Fortis Hospital, New delhi, Inida

viii Contributors

JAIN T KALLARAKKAL, MD, DM Consultamt-Cardiologist Mar Baselios Medical Mission Hospital, Ernakulam, India

JAMES KJ, MD, DM Senior Cardiologist Mother Heart Care, Mother Hospital, Thrissur, India

JAMSHED J DALAL, MD, DM, PhD, FESC, FRCP Director- Centre for Cardiac Sciences Kokilaben Hospital, Mumbai, India

JAYAGOPAL PB, MD, DM, DNB, FACC, FICC, FCSI, FESC, FSCAI Senior Interventional Cardiologist & Director of Cardiology Lakshmi Hospital, Palakkad, India

JAYANTA SAHA, MD, DM Associate Professor Medical College, Kolkata, India

JAYAPRAKASH SHENTHAR, MD (MED), DNB (MED), DM (CARD), FACC, FRCP (LONDON) Professor - Electrophysiology Unit Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India

JIMMY GEORGE, MD, DM Consultant Cardiologist Lisie Heart Institute, Lisie Hospital, Kochi, India

JOHANN CHRISTOPHER, MD, DNB Consultant Cardiologist Director of Cardiac Imaging, CARE Hospitals, Hyderabad, India

JOHN ROSHAN, MD DM(CARD), CCDS, CEPS, FELLOWSHIPS IN ADULT AND PEADIATRIC ELECTROPHYSIOLOGY (TORONTO) Professor Christian Medical College, Vellore, India

JOHNSON FRANCIS, MBBS, MD, DM, FCSI, FACC, FRCP EDIN, FRCP LONDON Senior Consultant Cardiologist Baby Memorial Hospital Ltd, Kozhikode, India

JOSHUA C VOGT, MD Instructor in Medicine, Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA

JPS SAWHNEY, DM, FESC, FACC Chairperson - Department of Cardiology Dharma Vira Heart Center, Sir Ganga Ram Hospital, New Delhi, India

JS HIREMATH, DM (CARDIOLOGY), DNB (CARDIOLOGY), FACC Interventional Cardiologist, Director- Cath Lab Ruby Hall Clinic, Pune, India

K SARAT CHANDRA, MD, DM, FACC, FESC, FCSI Consultant Cardiologist Indo-US Superspeciality Hospital, Hyderabad, India

K SHETH, DNB (CARDIOLOGY) Interventional Cardiologist Ruby Hall Clinic, Pune, India

K SIVAKUMAR, MD DNB(PED) DM DNB(CARDIOLOGY) Head, Department of Pediatric Cardiology Madras Medical Mission, Chennai, India

K VENUGOPAL, MBBS, MD, DM Professor and Head, Department of Cardiology Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, India

KAMALES KUMAR SAHA, MBBS, MS, DNB, MCH (AIIMS) C801/802 Raheja Sherwood, Mumbai, India

KARTIK GANGA, MD Senior Resident, Department of Cardiovascular Radiology and Endovascular Interventions All India Institute of Medical Sciences, New Delhi, India

KARTIKEYA BHARGAVA, MD, DNB CARDIOLOGY, FHRS, FISHNE, FCSI Associate Director, Cardiology Medanta- The Medicity, Gurgaon, India

KESAVA MOORTHY BHOOPALAN, MD, DM Consultant Intervention Cardiologist Meenakshi Hospital, Thanjavur, India

KEWAL C GOSWAMI, MBBS, MD, DM Professor - Cardiology All India Institute of Medical Sciences, New Delhi, India

ixContributors

KODURU VENKATA RAMANA, MS, MCH Consultant Cardiothoracic surgeon Apollo Hospitals, Hyderabad, India

KOMARAKSHI BALAKRISHNAN, MS, MCH Director - Cardiac sciences Fortis Malar Hospital, Chennai, India

KUNAL SARKAR, FRCS (GLAS), FRCS (EDIN) MNMS Senior Consultant Cardiac Surgeon and Head of MICS Medica Super Specialty Hospital, Kolkata, India

KUSHAGRA MAHANSARIA, MD, MPH, MBA Senior Resident Cardiology Medanta- The Medicity, Gurgaon, India

KUSHAL MADAN, PhD, FAHA Cardiac Rehabilitation Consultant Dharma Vira Heart Center, Sir Ganga Ram Hospital, New Delhi, India

M JAWAHAR FAROOK, DNB, DNB, MNAMS Fellow in Interventional Cardiology Institute of Cardiovascular Diseases, The Madras Medical Mission, Chennai, India

MAHIM SARAN, MD, DM Senior Resident King George Medical University, Lucknow, India

MANISH BANSAL, MD, DNB CARDIOLOGY, FACC, FASE Associate Director Cardiology Medanta- The Medicity, Gurgaon, India

MEGHNA GUPTA, MBBS Resident Kishori Ram Hospital and Diabetes Care Centre, Bathinda, India

MOHAMMED SADIQ AZAM, MD DNB Cardiology Resident Department of Cardiology, Krishna Institute of Medical Sciences, Secunderabad, India.

MOHAN BHARGAVA, DM (CARD), FACC, FASCI, FESC Principal consultant, Interventional Cardiology Max Superspeciality Hospital, New Delhi, India

MOHAN NAIR, MD; DM Coordinator and Head, Department of Cardiology Holy Family Hospital, New Delhi, India

MONA BHATIA, MD, FRCR, FSSCT Head of Department, Radiology and Imaging Fortis Escorts Heart Institute, New Delhi, India

MR ROY MATHEW, BSC (NURSING) Transplant Coordinator, Heart Failure Nurse Practitioner Fortis Escorts Heart Institute, New Delhi, India

MRINAL KANTI DAS, MBBS, MD, DM (CARDIO), FICP, FICC, FCSI Consultant & Interventional Cardiologist B.M. Birla Heart Research Centre, Kolkata, India

MS (SHIRISH) HIREMATH, MD (MEDICINE), DM (CARDIOLOGY), MNAMS Director - Cath lab Ruby Hall Clinic, Pune, India

MUKTA TIWARI, CCP, PhD Director Clinical Perfusion & DMS Cardiac Surgery Eternal Hospital, Jaipur, India

MULLASARI S AJIT, MD, DM, FRCP Senior Consultant Institute of Cardio-Vascular Diseases, The Madras Medical Mission, Chennai, India

MUNESH TOMAR, MD, FNB PEDIATRIC CARDIOLOGY Director Sri SathyaSai Sanjeevani International Center for Child Heart Care and Research, Baghola, India

N AGGARWAL, MD (MED), DM (CARDIOLOGY) Consultant Cardiology Army Hospital (Research & Referral), Delhi Cant, India

N V DESHPANDE, MD, DM, DNB, FACC, FESC Director Cath –Lab Spandan Heart Institute & Research Center, Nagpur, India

NAGENDRA BOOPATHY S, MD, DM, FACC Consultant General and Interventional Cardiologist (Assistant Professor of Cardiology) Sri Ramachandra Medical Centre, Sri Ramachandra University, Chennai, India

NAGESHWAR RAO, MD, DM Chief Pediatric Cardiologist CARE Hospital, Hyderabad, India

x Contributors

NANDHAKUMAR VASU, MD, DNB Associate Consultant Institute of Cardio-Vascular Diseases, The Madras Medical Mission, Chennai, India

NAVIN NANDA, MD, DSC(HON), DSC(MED)(HON), FACC, FAHA, FISCU(D) Distinguished Professor of Medicine and Cardiovascular Disease University of Alabama at Birmingham, Birmingham, AL, USA

NEHA GUPTA, MD MEDICINE, FNB INFECTIOUS DISEASES Consultant- Infectious Diseases Department of Infectious Diseases & Division of Internal Medicine, Medanta- The Medicity, Gurgaon, India

NILKANTH CHANDRAKANT PATIL, MBBS, MD, DM (CARDIOLOGY) Consultant Interventional Cardiologist Care Hospitals, Hyderabad, India

NITIN J BURKULE, MD, DM, DNB, FACC, FASE Consultant Cardiologist Jupiter Hospital, Thane, India

NITIN KUMAR, MBBS, MRCP(UK), FHEA (UK), CCT—CARDIOLOGY(UK) Consultant Cardiology Venkateshwar Hospital, New Delhi, India

NN KHANNA, MD, DM, FRCP (LONDON), FRCP (EDIN.), FRCP (GLASG.), FACC, FESC, FSCAI, FCCP, FAPSIC, FIMSA, FEISI, FICC, FIAMS, FCSI, FICP Senior Consultant & Coordinator – Cardiology & Vascular Sciences Indraprastha Apollo Hospital, New Delhi, India

ONKAR AUTI, MBBS, DNB Consultant Radiologist Ruby Hall Clinic, Pune, India

OP YADAVA, MBBS, MS, DNB (CARDIAC SURGERY) CEO & Chief Cardiac Surgeon National Heart Institute, New Delhi, India

P BHARADWAJ, VSM*, MD (MED), DM (CARDIOLOGY) Consultant Cardiology Military Hospital (CTC), Pune, India

PANKAJ M KOLHE, DNB RADIOLOGY Department of Radiology Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India

PANNIYAMMAKAL JEEMON, PhD (GLASGOW), MPH, FRSPH (LONDON) Assistant Professor, Epidemiology Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India

PARNEESH ARORA, DNB, DM, MNAMS, FSCAI, MD Additional Director Fortis Hospital, Noida, India

PARTHO P SENGUPTA, MD, DM, FACC, FASE Director, Cardiovascular Imaging Heart & Vascular Institute, West Virginia University, Morgantown, WV, USA

POOJA TANDON, MD (GYNAE) Associate Professor of Obstetrics and Gynaecology Dayanand Medical College & Hospital, Ludhiana, India

PP MOHANAN, MD, DM Director and Head of the Department, Cardiology Westfort Hi-Tech Hospital Ltd, Trissur, India

PRABHAT KHAKURAL, MCH Lecturer Manmohan Cardiothoracic Vascular and Transplant Center, Tribhuvan University, Kathmandu, Nepal

PRACHAL BHARGAVA, MBBS, MEM Emergency Medicine Fellow Aster Hopsital, Bengaluru, India

PRADEEP NARAYAN, FRCS (GLAS), FRCS (EDIN), FRCS (CTH), MD (UNIVERSIY OF BRISTOL) Senior Consultant Cardiac Surgeon NH Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India

PRAGYA KUMARI, MBBS, PGDCC (CARDIOLOGY) Consultant Heart Failure Program Fortis Escorts Heart Institute, New Delhi, India

PRASANNA SIMHA MOHAN RAO, MBBS, MS, DIPNB (GEN SURGERY) MCH, DIPNB (CVTS), PGDHHM Professor Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India

xiContributors

PRASANT KR. SAHOO, MD; DM ; FRCP (LOND. & GLASG.); FACC; FSCAI; FESC; FAPSIC; FICC; FCSI Sr. Consultant Cardiologist; Director, Interventional Cardiology APOLLO HOSPITAL, Bhubaneswar, India

PREM RATAN DEGAWAT, MD, DM Consultant, Interventional Cardiology Eternal Heart Care Centre & Research Institute, Mount Sinai New York Affi liate, Jaipur, India

PREMCHAND RAJENDRA KUMAR, MD, DM (CARDIOLOGY), DIU (PARIS) Director & Senior Consultant Interventional Cardiologist Krishna Institute of Medical Sciences, Secunderabad, India

PRITAM PAL, MBBS, MS Sr. Registrar Fortis Escorts Heart Institute & Research Centre, New Delhi, India

PRIYA JAGIA, MD, DNB Professor, Department of Cardiovascular Radiology and Endovascular Interventions All India Institute of Medical Sciences, New Delhi, India

PRIYABRATA SAHU, MD; DM Cardiologist APOLLO HOSPITAL, Bhubaneswar, Inida

RAGHAV BANSAL, MBBS, MD Senior Resident, Department of Cardiology All India Institute of Medical Sciences, New Delhi, India

RAGHUL GANESAPANDI, MD, DM Associate Consultant - Department of Cardiology Apollo Hospitals, Chennai, India

RAHUL MEHROTRA, MBBS, MD (MEDICINE), DNB (CARDIOLOGY) Principal Consultant and HOD, Non Invasive Cardiology Max Superspeciality Hospital, New Delhi, India

RAJ KUMAR, MD, PGDCC Consultant, Non Invasive Cardiology Max Superspeciality Hospital, Delhi, India

RAJEEV GUPTA, MD, PhD Chairman, Preventive Cardiology & Internal Medicine Eternal Heart Care Centre & Research Institute, Mount Sinai New York Affi liate, Jaipur, India

RAJIV AGARWAL, MD, DM Senior Director, Department of Cardiology Max Smart Super Speciality Hospital, New Delhi, India

RAJIV G BHAGWAT, MD, DNB CARDIOLOGY Consultant Cardiologist Nanavati Super Speciality Hospital, Shushrusha Hospital, Breach Candy Hospital, Mumbai, India

RAKESH NAIK LACHMA, MBBS, MS, MCH (CVTS) Assistant Professor Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India

RAMPRAKASH BALASUNDARAM, MD, DM Cardiologist and Electrophysiologist G.Kuppuswamy Naidu Memorial Hospital, Coimbatore, India

RANJAN SHETTY, MBBS, MD (AIIMS), DM (PGIMER), FESC, FACC Consultant interventional cardiologist Department of Cardiac Sciences, Manipal Hospitals, Bangalore, India

RAVI R KASLIWAL, MD, DM Chairman, Clinical and Preventive Cardiology Medanta- The Medicity, Gurgaon, India

RAVINDRAN RAJENDRAN, MD, DM Assistant Professor & Consultant Cardiologist Chennai Medical College Hospital & Research, Trichy, India

RICHA KOTHARI, MBBS, DNB Fellow in Cardiothoracic Imaging Narayana Institute of Cardiac Sciences, Narayana Health City, Bangalore, India

RINETT SEBASTIAN, MBBS, MS, MCH, DNB Consultant Cardiothoracic Surgeon Rajagiri Hospital, Cochin, Kerala, India

RISHI SETHI, DM, MNAMS, FACC, FESC, FSCAI, FAPSIC, FCSI Professor King George Medical University, Lucknow, India

xii Contributors

RONAK V RUPARELIA, DNB (GEN. MED), DNB CARDIOLOGY FELLOW DNB Cardiology Fellow Nanavati Super Speciality Hospital, Mumbai, India

RONY MATHEW, MD, DM, DNB(MED), DNB(CARD), FCSI, FSCAI, FACC, FESC, FRCP Head of Department Lisie Heart Institute, Lisie Hospital, Kochi, India

S RAMAKRISHNAN, MD, DM, FACC Professor, Department of Cardiology All India Institute of Medical Sciences, New Delhi, India

S SHANMUGASUNDARAM, MD, DM Emeritus Professor of Cardiology, Tamilnadu Medical University Billroth Hospital, Chennai, India

SALIL GARG, MD, DNB, FACC, FSCAI Senior Adviser (Medicine & Cardiology), Professor of Cardiology Army Hospital (Research & Referral), Delhi Cant, India

SAMIR K SAHA, MD, PhD, FASE, FACC, FESC Senior Consultant - Cardiac Centre Umeå University Hospital, Umeå, Sweden

SAMUEL MCELWEE, MD Cardiology Fellow University of Alabama at Birmingham, Birmingham, AL, USA

SANGEETHA IYER, DOCTOR OF PHARMACY Intern – Cardiovascular Sciences, Member – CCNAP (ESC) Department of Pharmacy Practice, MCOPS, Manipal University, Manipal, India

SANJAYA VISWAMITRA, MD HOD and Sr. Consultant, Department of Radiology Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India

SANJIV KAUL, MD, FRCP, FACC, FAHA CEO - Knight Cardiovascular Institute Oregon Health & Science University, Portland, Oregon, USA

SANKAR NEELAKANTAN, MD RADIOLOGY Staff Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India

SANTOSH JAIN PASSI, PhD Honorary Consultant Nutrition Foundation of India, New Delhi, India

SATISH C GOVIND, MD, PhD, FASE Chief of Non Invasive Cardiology Fortis Hospitals, Bengaluru, India

SATYA NARAYAN ROUTRAY, MD, DM, FACC, FICC, FCSI, FIAE, FESC Professor & HOD, Cardiology SCB Medical College, Cuttack, India

SATYAJEET N SURYAWANSHI, DNB (CARDIOLOGY), MNAMS, FCPS(MEDICINE) Fellowship in Cardiac Interventions and Electrophysiology, Consultant Interventional Cardiologist Ruby Hall Clinic, Pune, India

SATYENDRA NATH DUTTA, MD PDT Medical College, Kolkata, India

SAUMITRA RAY, MD, FRCP, FCSI, FICP, FACC, FESC Professor Vivekananda Institute of Medical Sciences, Kolkata, India

SAURABH BAGGA, MD, DM Senior Resident (Department of Cardiology) GB Pant hospital, New Delhi, India

SHANMUGAM KRISHNAN, MBBS MD Senior Resident - Cardiology All India Institute of Medical Sciences, New Delhi, India

SHARATH KUMAR, MD, DM Consultant - Cardiac Electrophysiologist CARE Hospital, Banjara Hills, India

SHASHANK R JOSHI, MD, DM, FICP, FACP (USA), FACE (USA), FRCP (LOND, GLSG. & EDIN.) Endocrinologist Joshi Clinic, Lilavati & Bhatia Hospital, Mumbai, India

SHISHU SHANKAR MISHRA, MD, FAIMS, DOCM, MCAM, FCCP, FIAE, FICC, FCSI Prof. & Director Hi-tech Medical College , Bhubaneswar Med’ N’ Heart Clinic, Cuttack, India

xiiiContributors

SHIV KUMAR NAIR, MBBS, MS(PGI), MCH, FIACS Senior Consultant & HOD Rajagiri Hospital, Cochin, India

SHIVANESAN PITCHAI, MS, MCH Assistant Professor, Vascular Surgery Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India

SIMRAN SAWHNEY, MBBS Postgraduate student (Department of Medicine) St. Stephen’s hospital, New Delhi, India

SIRISH CHANDRA SRINATH, MD DM(CARDIOLOGY) Assistant Professor Christian Medical College, Vellore, India

SKM SARJUN BASHA, MD, DNB (CARDIOLOGY) Interventional Cardiologist Lakshmi Hospital, Palakkad, India

SMIT SHRIVASTAVA, MD PGDHHM DM CARDIOLOGY FACC FICP FISE FIMSA FIACM Associate Professor and Head, Department of Cardiology Pt J N M Medical College & Dr B R A M Hospital, Raipur, India

SOUMITRA KUMAR, MBBS, MD, DM (CARDIOLOGY) Professor and Head, Department of Cardiology Vivekananda Institute of Medical Sciences, Kolkata, India

SRIKANTH SOLA, MD Senior Consultant, Department of Cradiology Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India

SS IYENGAR, DM (CARDIOLOGY), FRCP (E) Consultant, Cardiac Sciences Manipal Hospital, Bengaluru, India

SUBHASH CHANDER MANCHANDA, DM Senior Consultant Cardiology Dharma Vira Heart Center, Sir Ganga Ram Hospital, New Delhi, India

SULTHAN RASLIN SALIH, MBBS, MD (GENERAL MEDICINE) Senior Resident, Department of Cardiology Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, India

SUMIT AGARWAL, MBBS, MD (MEDICINE), DM (CARDIOLOGY) Interventional Cardiologist, Member – SCAI & CSI Sapphire hospital, Agra, India

SUNDEEP MISHRA, DM CARDIOLOGY, FACC, FSCAI, FAPSIC Professor - Department of Cardiology All India Institute of Medical Sciences, New Delhi, India

SUPARNA RAO, MBBS, MRCP (UK) Clinical Associate Indraprastha Apollo Hospital, New Delhi, India

SURESH CHANDRAVANSHI, MD MEDICINE Associate Professor Department of Medicine Pt J N M Medical College & Dr B R A M Hospital, Raipur, India

TAPAN SINHA, MBBS, DIP. CARD., MRCP Consultant Cardiologist Kothari Medical College, Kolkata, India

THOMAS BARTEL, MD Section Head of Invasive Cardiology Heart & Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates

U ILAYARAJA, MD, DM Consultant Cardiologist Billroth Hospital, Chennai, India

ULHAS M. PANDURANGI, MD., DM (CARDIOLOGY) Chief – Cardiac Electrophysiology & Pacing Arrhythmia Heart Failure Academy, The Madras Medical Mission, Chennai, India

UMESH C SAMAL, MD, FICC, FIACM, FACC, FIAE, FISE, FISC, FAPVS National Convener, CSI-Heart Failure Council Director, Asmita Imaging & Cardiac Care, Patna, India

UNNIKRISHNAN MADATHIPAT, MS, MCH, FIACS, FVSIHead Department of Vascular SurgerySree Uthradom Thirunal Hospital, Pattom, Thiruvananthapuram, Kerala; Sree Chitra Institute, Kerala, India

xiv Contributors

UPENDRA KAUL, MD, DM, FCSI, FACC, FAMS, FSCAI Chairman - Batra Heart Centre Batra Hospital & Medical Research Centre, New Delhi, India

V DAYASAGAR RAO, DM (CARDIOLOGY), FRCP (CANADA), FRCP (EDINBURGH) Senior Consultant Interventional Cardiologist Department of Cardiology, Krishna Institute of Medical Sciences, Secunderabad, India

V.V.K.BHARADWAJA, MS, MCH Consultant Cardiothoracic surgeon Apollo Hospitals, Hyderabad, India

VANITA ARORA, MD, DNB (CARDIOLOGY) Director & Head - Cardiac Electrophysiology lab & Arrhythmia Services Max Healthcare Super Speciality Hospital, New Delhi, India

VARUN GUPTA, MBBS International Fellow Thoracic and Cardiovascular Surgery, Bundang Hospital, Seoul, South Korea

VARUN SHETTY, MBBS, DNB (CVTS) Consultant Cardiac Surgeon Department of Cardiac Surgery, Narayana institute of Cardiac Sciences, Bangalore, India

VIJAY BOHRA, MD, DM Classifi ed Specialist (Medicine) & Cardiologist Army Hospital (Research & Referral), Delhi Cant, India

VIJAY KHER, MD, DM, FAMS, FISN, FRCPE Chairman - Department of Nephrology and Transplant Medicine Fortis Escorts Kidney and Urology Institute, Fortis Escorts Hospital, New Delhi, India

VIJAY KUMAR, MD (MEDICINE), DNB (CARDIOLOGY) Principal Consultant Interventional Cardiologist Fortis Escorts Heart Institute, New Delhi, India

VIJAYAKUMAR S, MD, DM, FNB Senior Consultant Institute of Cardiovascular Diseases, The Madras Medical Mission, Chennai, India

VIJAYAKUMAR SUBBAN, MD, DM, FNB Senior Consultant Institute of Cardio-Vascular Diseases, The Madras Medical Mission, Chennai, India

VIJAYKUMAR J R, DM CARDIOLOGY Assistant Professor in Cardiology Sri Jayadeva Institute of Cardiovascular Sciences, Bengaluru, India

VIKAS KATARIA, MD; DM Senior Consultant, Cardiology and Electrophysiology Holy Family Hospital, New Delhi, India

VIMAL RAJ, MBBS, FRCR, CCT, EDM Consultant Cardiothoracic Radiologist Narayana Institute of Cardiac Sciences, Narayana Health City, Bangalore, India

VINEET BHATIA, DNB, MD, DM Senior Consultant Fortis Hospital, Noida, India

VISHAL RASTOGI, MD (MEDICINE), DM (CARDIOLOGY) Head Advanced Heart Failure Program Fortis Escorts Heart Institute, New Delhi, India

VISHWAS MOHAN, MBBS, DIPLOMA IN CARDIOLOGY (LONDON) Department of Cardiac Sciences Fortis Hospital, New Delhi, India

VITULL K. GUPTA, MD (MEDICINE), FICP, FCSI Consultant Physician, Kishori Ram Hospital and Diabetes Care Centre and Professor and Unit Head, Dept of Medicine, AIMSR Bhatinda, India

VIVEKANAND GUPTA, MD, DNB Associate Consultant, Department of Cardiology Max Smart Super Speciality Hospital, New Delhi, India

Y CHANDRASHEKHAR, MD Professor of Medicine University of Minnesota, Mail Code VAMC IIIc, 1, Veterans Drive, Minneapolis, MN, USA

YOGESH SATHE, MD, FNB PEDIATRIC CARDIOLOGY Consultant Sri SathyaSai Sanjeevani International Center for Child Heart Care and Research, Baghola, India

YUGAL K MISHRA, MBBS, MS, PH.D, FCSI, D.SC (HONORIS CAUSA) Director, Department of Cardiovascular Surgery Fortis Escorts Heart Institute & Research Centre, New Delhi, India

xv

Preface

The annual conference of the Cardiological Society of India is incomplete without Cardiology Update. The book is much sought after, not only by the practicing cardiologists but also by the fellows and students pursuing Cardiology and General Medicine. This book serves as a valuable resource containing the latest updates in the fi eld of Cardiology; this is a must-have, year after year!

Keeping the above in mind, we proudly present to you the 2017 edition of Cardiology Update. The focus, this year too, has been on emphasizing the recent developments in the fi eld, which are relevant to clinical practice.

This book encompasses all the important aspects of Cardiology, ranging from preventive cardiology to complex cardiac interventions. Cardiac surgery, as we all know, is indispensable in the management of various cardiac disorders; therefore, no treatise in cardiology can be complete without adequate focus on cardiac surgery. Accordingly, Cardiology Update 2017 includes a separate section on cardiac surgery, which discusses the latest in the fi eld that every cardiologist, aspiring or practicing, must know. The topics in this section encompass the entire gamut, from coronary artery disease to valves and aortic aneurysms.

All the chapters in this book have been authored by carefully chosen, renowned names in the fi eld of Cardiology and allied specialties, with years of experience behind them. They have graciously spent time and energy to give their best for this book. We gratefully thank all of them.

Cardiological Society of India, being a leading academic organization, has the responsibility to uphold the values of intellectual proprietorship. Accordingly, utmost care has been taken to avoid any kind of copyright infringement while compiling this book.

We have also taken great care to maintain the highest publishing standards. However, in a project of this magnitude, involving so many authors, accomplished in a relatively short time-period, some errors are bound to creep in. We sincerely hope the readers will be forgiving on their part.

I am sure the book will live up to its expectations and the readers will fi nd it enriching.Happy reading!

K SARAT CHANDRA

(Editor-in-chief)MANISH BANSAL

(Co-Editor)

xvii

Acknowledgements

We are grateful to the Cardiological Society of India for entrusting us with this enormous responsibility to spearhead this year’s edition of Cardiology Update.

We thank the Mankind Pharma Ltd for their support in bringing out this book.We also thank the editorial team at Elsevier (Division of RELX India Pvt. Ltd.), specifi cally Ms Supriya

Barua Kumar and Ms Sheenam Aggarwal, for their highly professional services and the wonderful support throughout the production of this book.

We gratefully acknowledge the timely help extended by the editorial team of Ms Shveta Dhamija Khera and Mr Tarun Choudhry at Kontent Worx, New Delhi, India, in the manuscript editing and development process.

Finally, we are also thankful to Ms Bharathi Moturi (Hyderabad Offi ce) and Mr Ravinder Singh Negi (Medanta), who worked tirelessly to execute every instruction of ours and helped us materialize this book.

xix

Contents

Are Saturated Fats Bad 21Are Ruminant Trans Fats Equally Bad as Industrial Trans Fatty Acids 22CIS-Unsaturated Fatty Acids 22Selecting Heart-Healthy Edible Oil 22

Fruits and Vegetables 23Nuts 24Whole and Refi ned Grains 24Sugar 24Salt 25Coffee and Tea 25Dairy Products 25

Different Types of Diet 25Other Factors in Nutrition 26Conclusions 27

Chapter 4Does Obesity Paradox Exist 31PREM RATAN DEGAWAT • RAJEEV GUPTA

Introduction 31Epidemiology 31Obesity Pathophysiology 32Obesity Paradox 34Conclusions 37

Chapter 5LDL-C Lowering for Prevention of Cardiovascular Disease: The Changing Concepts 39S.S. IYENGAR

Introduction 39‘Lower the Better’ 39‘Earlier the Better’ 40How Low One Can Go 40Guidelines Recommending Lower LDL Goals 41Legacy Effect 41‘Treat to Target’ or ‘Fire and Forget’ 41LDL-C Hypothesis 41Conclusion 42

Chapter 6Long-Term Cardiovascular Outcomes with PCSK9 Inhibitors 45PREMCHAND RAJENDRA KUMAR • GEETESH MANIK

Introduction 45Limitations of Current Management of Dyslipidaemia 45PCSK9 and Pathophysiology of Cholesterol Metabolism 46Clinical Experience with PCSK9 Inhibitors 47Effect of PCSK9 Inhibitors on Cardiovascular Outcomes 48Long-Term Safety Profi le of PCSK9 Inhibitors 50Newer PCSK9 Inhibitors 51Summary 52

SECTION IINTRODUCTION 1

Chapter 1Physical Examination: A Cost-Effective Investigation 3MOHAMMED SADIQ AZAM • V. DAYASAGAR RAO

Introduction 3Evaluation of Diagnostic Signs 3Importance of the History and Clinical Examination 3

Examination of the CVS 4Pulse 4Jugular Venous Pressure and Pulse 5Point of Maximal Impulse 6Right Ventricular Heave/Hypertrophy 6Other Precordial Pulsations 6Other Palpatory Findings 7Percussion 7Auscultation 7The First Heart Sound 8The Second Heart Sound 9Ventricular Gallop 10Atrial Gallop 10Murmurs 10Innocent Murmurs 11Pericardial Friction Rubs 11Manoeuvres that Affect the Intensity of Murmurs 11Standing 11Squatting 11Squatting to Standing 12Standing to Squatting 12Inspiration 12Valsalva Manoeuvre 12Passive Leg Elevation 12Handgrip 12Transient Arterial Occlusion 12

Conclusion 12

Chapter 2Cardiology Practice in India: The Challenges Ahead 15K. SARAT CHANDRA

The Complaints 15Differential Diagnosis 15The Interventions 17

SECTION IIPREVENTIVE CARDIOLOGY 19

Chapter 3Cardiovascular Disease and Nutrition: Current Controversies 21S.C. MANCHANDA • S.J. PASSI • KUSHAL MADAN

Introduction 21Is Dietary Cholesterol Bad 21

xx Contents

Chapter 7Blood Pressure Goals for the Treatment of Hypertension in Patients with Cardiovascular Disease 55C. VENKATA S. RAM

Overview 55Data Analysis 56Biophysical Considerations 56Hypertension and Congestive Heart Failure 57Conclusion 58

Chapter 8Managing Hypertension in a Patient with Renal Dysfunction: The Double Jeopardy 61KEWAL C. GOSWAMI • SHANMUGAM KRISHNAN

Introduction 61Epidemiology of Chronic Kidney Disease and Hypertension 61Blood Pressure Measurement in Patients with Chronic Kidney Disease 61Guideline Recommendations for Blood Pressure Control 62Pathophysiology of Hypertension in Chronic Kidney Disease 62

Salt and Water Retention 63Renin–Angiotensin–Aldosterone System Activation 63Other Mechanisms 63

Treatment 63Dietary Salt Restriction and Diuretic Use 64ACEI/ARB 64Other Drugs 65

Future Perspectives 65

Chapter 9Which Diuretics for Which Patients with Hypertension 67RAGHAV BANSAL • SIVASUBRAMANIAN RAMAKRISHNAN

Introduction 67Diuretics Used for Treating Hypertension 67

Thiazide and Thiazide-Like Diuretics 67Loop Diuretics 69Potassium-Sparing Diuretics 70

Importance of Differentiating Individual Drugs within the same Class and Subclass 70Place of Diuretics in Different Guidelines 70Conclusion 72

Chapter 10Cardiovascular Risk Algorithms and Their Applicability to Indians 75RAVI R. KASLIWAL • KUSHAGRA MAHANSARIA • MANISH BANSAL

Introduction 75Defi nition of Cardiovascular Risk 75

Absolute and Relative Risks 75Risk Prediction Beyond 10 Years 75Recurrent CVD Risk 76

Clinical Risk Algorithms 76Framingham Risk Score 76ACC/AHA Pooled Cohort Equations 76WHO/ISH Risk Prediction Charts 76Interheart Modifi able Risk Score 78Score 78QRISK2 78JBS3 Risk Score 78

Cardiovascular Risk Algorithms for use in Indians 78

Limitations of Current Risk Prediction Models 81Role of Subclinical Atherosclerosis Imaging 81Conclusion 82

Chapter 11Lipoprotein: Always Relevant for Indians 85ANKIT ROY • SOUMITRA KUMAR

Lipoprotein: Structure and Metabolism 85Lipoprotein as a Mediator of Atherosclerosis 86How is Lipoprotein Different From LDL 86When and in Whom to Measure Lipoprotein Levels 87Existing and Emerging Therapies for Lipoprotein Reduction 87Clinical Evidence Supporting Lipoprotein as a Major Promoter of CVD and CAVS in the Community: The International Scenario 88Current Status of Lipoprotein in India 88Special Relevance of Lipoprotein in Indians all over the World 89Conclusions 90

Chapter 12Exercise for Prevention of Cardiovascular Disease: Neither Too Less Nor Too Much 93KESAVA MOORTHY BHOOPALAN • RAVINDRAN RAJENDRAN • K. NIRANJANA

Introduction 93Exercise and Cardiovascular Diseases 93Molecular Mediators 94Recommendations 95Present Status and Future Perspectives 95

Chapter 13The Impact of Bariatric Surgery on Cardiovascular Disease Prevention and Diabetes 99A.J. SWAMY • NAVEEN AGGARWAL • P. BHARADWAJ

Introduction: Obesity as a Marker of Adverse Cardiovascular Outcomes 99Causality 99Benefi ts of Reversing Obesity 100Management Options for Obesity 100Types of Bariatric Surgery 100Can We Compare the Various Types of Bariatric Surgery 102Obesity Risk Factors and Bariatric Surgery 103

BMI and Weight 103Hypertension 103Dyslipidaemia 103Type 2 Diabetes Mellitus 104

Obesity-Related Cardiovascular End Points 104Heart Failure 104Myocardial Infarction 105

Mechanisms of Benefi t Following Bariatric Surgery 105Conclusion 105

Chapter 14Familial Hypercholesterolaemia in Routine Cardiac Practice: Recognition and Management 109J.P.S. SAWHNEY • SIMRAN SAWHNEY • SAURABH BAGGA

Introduction 109Pathophysiology and Epidemiology 109

Homozygous Familial Hypercholesterolaemia 110Heterozygous FH 110

Diagnosis 110Correction Factor 111

xxiContents

How to Calculate Cholesterol Concentration Adjusting or Cholesterol Medication 111Cascade Screening 111

Treatment 111Conclusion 113

Chapter 15Coronary Calcium Scoring for Individualized, Disease-Guided Management 115GEEVAR ZACHARIAH • JAMES K.J.

Introduction 115Evolution of CAC Scoring 115CAC and Coronary Artery Stenosis 116CAC and Myocardial Ischaemia 116CAC and Prognosis in Asymptomatic Individuals 116CAC Score and hsCRP 117CAC Score and Carotid Intima-Media Thickness 118Incorporating CAC Scoring into Prevention Guidelines and Recommendation for Statins 118CAC as a Guide to Treatment 118Role of CAC in Treatment Adherence and a Healthy Lifestyle 119Cost-Effectiveness of CAC 119Role of Serial CAC Scanning 120Recommendations for use of CAC Scoring 120Conclusion 120

Chapter 16Cardiovascular Benefi ts of SGLT2 Inhibitors 125JAMSHED J. DALAL

Introduction 125What is an SGLT2 Inhibitor 125SGLT2 Inhibitors and Cardiovascular Mechanisms 126

Improved Arterial Stiffness 126Systolic and Diastolic Blood Pressure Reduction 126Preservation of Renal Function 127Improvement in Left Ventricular Function 127Metabolic Effi ciency Hypothesis 128

Clinical Evidence: EMPA-REG OUTCOME Study 129Presently Available SGLT2 Inhibitors 129

Safety Considerations 131Conclusion 131

Acknowledgement 131

Chapter 17Using Newer Antidiabetic Agents in Patients with Cardiovascular Diseases 135SHASHANK R. JOSHI

Residual Cardiovascular Risk in Diabetes: Surfacing the Body of Iceberg 135Antidiabetic Therapies and Cardiovascular Risk 135Clinical Considerations 136Conclusion 138

Chapter 18Yoga for Cardiovascular Disease Prevention: Science Behind the Art 141ASHA MOORTHY • JAIN T. KALLARAKKAL

Introduction 141Yoga 141

Yoga and the Cardiovascular System 141Stress, Anxiety and Depression 141

Yoga and CHD Risk Factors 142Yoga in CHD Patients 142Post–Myocardial Infarction 143Risks Involved in Practicing Yoga 143

Conclusion 143

SECTION IIICORONARY ARTERY DISEASE 145

Chapter 19Angiotensin-Converting Enzyme Inhibitors in Postmyocardial Infarction Patients: How Relevant are they in the Present Era 147A.K. PANCHOLIA • BHARAT RAWAT

Introduction 147Mechanism of Cardioprotective Effects of ACE-I 147ACE-I in Acute Myocardial Infarction: Clinical Evidence 149

Early in Anterior Wall MI 150Class Differences 151Comparison to ARBs 151

How Relevant is the use of ACE-I in the Present ERA 151Safety of ACE-I Therapy During Acute MI 152Conclusion 152

Chapter 20Metabolic Management of Coronary Artery Disease 157B.C. SRINIVAS • VIJAYKUMAR J.R. • C.M. NAGESH • BABUREDDY T.S. • C.N. MANJUNATH

Introduction 157Concept of Metabolic Management in CAD 157Metabolic Management in CAD 158

Glucose, Insulin and Potassium Infusion 158CPT-I Inhibitors 158Trimetazidine 159Ranolazine 159Activators of Glucose Oxidation 160

Conclusion 160

Chapter 21Micro RNAs for Prediction of Clinical Outcomes in CAD 163JAYAGOPAL P.B. • S.K.M. SARJUN BASHA

miRNA 163miRNA and Atherosclerosis 163Smoking, Endothelial Function and miRNA 164Platelets and miRNA 164miRNA in CAD 164miRNA in Acute Coronary Syndrome 164Conclusion 164

Chapter 22High-Sensitivity Troponin I:Does it Lead us or Mislead us 167MRINAL KANTI DAS • TAPAN SINHA

Introduction 167Problematizing the Assay Development 168Potential Challenges in Clinical use of High-Sensitive Troponin I 168Biological Variability 169High-Sensitivity Troponin I in Clinical Use 169Troponin Autoantibodies 169

xxii Contents

Role of hs-Tn-I in Diagnosis of Acute Coronary Syndrome 170Hs-Tn-I and Risk Stratifi cation 170Hs-Tn-I in Asymptomatic Population 170Hs-Tn-I for Screening 171Future Directions 171Conclusion 171

Chapter 23Infl ammatory Cytokines in Atherogenesis: Therapeutic Implications 173K.S. SHETH • J.S. HIREMATH

Development of Atherosclerosis: Receptors on Monocytes 174

Role of Cytokines in Treatment of Atherogenesis 174

Chapter 24Duration of Dual Antiplatelet Therapy: Current Controversies 177VINEET BHATIA • PARNEESH ARORA • UPENDRA KAUL

Second-Generation DES: A Safer lot in Reducing Risk of late and very late Stent Thrombosis 177Bleeding and Mortality after Stenting 178

Studies Looking at Critical Question Number 1 178Studies Looking at Critical Question Number 2 179Studies Looking at Critical Question Number 3 179Ischaemic/Bleeding Risk Dictating the Duration of DAPT and the DAPT Score 179

Controversies of Triple Therapy 180Current Society Guidelines 181Conclusion 181

Chapter 25‘Pharmacological Therapyfor Reducing Infarct Size’ 185SULTHAN RASLIN SALIH • ISAAC V. MAMMEN • K. VENUGOPAL

Introduction 185Statins 185Antiplatelet Agents 186Glycoprotein IIb/IIIa Inhibitors 186Bivalirudin 186Beta Blockers 187ACE Inhibitors/ARB 187Natriuretic Peptides 187Adenosine 187Cyclosporin-A 188Exenatide 188Erythropoietin 188Nicorandil 188Nitric Oxide Donors 188N-Acetyl Cysteine 189Conclusion 189

Chapter 26Surgery in Acute Coronary Syndrome: Technical Considerations and Clinical Outcomes 193PRADEEP NARAYAN • KUNAL SARKAR

Introduction 193Current Status of Surgical Intervention in Acute Coronary Syndrome 193Outcomes Following Surgical Intervention in Acute Coronary Syndrome 194

Timing of Surgery, Outcome and Current Recommendations in UA/NSTEMI 194

Timing of Surgery, Outcome and Current Recommendations in STEMI 195

Technical Considerations of Surgery in ACS and Relation to Outcome 195

OPCAB Versus Conventional CABG 196On-Pump CABG Versus Conventional CABG 196Infl uence of Patient-Specifi c Features on Outcome Following Surgery in ACS 196

SECTION IVINTERVENTIONAL CARDIOLOGY 201

Chapter 27The Archaeology of Intervention Cardiology: First Step by a Reckless, a Giant Leap for the Mankind 203SUNDEEP MISHRA

Introduction 203The Journey 203So What are the Lessons Learned: Eight Golden Rules of Innovation 209

Chapter 28Growth of Interventional Cardiology in India: The Relevance of National Interventional Council 211N.N. KHANNA • SUPARNA RAO

Introduction 211Global Growth Trends 211Growth of Interventional Cardiology in India 211Relevance of NIC in Growth in Interventional Procedures in India 213

Vision of NIC in the Future Growth of Interventional Cardiology in India 217Tapping the True Potential of Coronary Interventions in India in Background of Price Capping of DES 217

Chapter 29Left Main Intervention in the Light of EXCEL and NOBLE Trials 221DEBDATTA BHATTACHARYYA • AYAN KAR

Pre-EXCEL and NOBLE era 221Results of the EXCEL Trial 225Results of the NOBLE Trial 225Conclusion 225

Chapter 30FFR and iFR: Where Is the Future 227NANDHAKUMAR VASU • VIJAYAKUMAR SUBBAN • MULLASARI S. AJIT

Introduction 227Fractional Flow Reserve 227

Defi nition 227Wires 227Special Features of FFR 228FFR Application in Different Subsets 228FFR in Special Situations 235Limitation of FFR 236

Instantaneous Wave-Free Ratio 236Defi nition 236Need for iFR 236Theoretical Basis of iFR 236Hybrid iFR–FFR Approach 237Role of iFR in Multivessel Disease 237

Conclusion 237

xxiiiContents

Chapter 31Salient Practice Changing Trials in 2016–2017 in Interventional Cardiology 243S. NAGENDRA BOOPATHY • NILKANTH C. PATIL

Introduction 243Left Main Intervention 243Bifurcation Interventions 245Acute Coronary Syndrome 246Stents – Biovascular Scaffolds 247Coronary Physiology 247Chronic Total Occlusion 248

Decision CTO Trial 248Coronary Imaging 249Transcatheter Aortic Valve Replacement 250

Chapter 32Protect Yourself before Saving Others: Radiation Hazards in the Catheterization Laboratory 253M. JAWAHAR FAROOK • VIJAYAKUMAR S.

Radiation Risk 253Biological Basis of Radiation Injury 253Stochastic Effects 253Deterministic Effects 254

Fluoroscopic Equipment 254Radiation Metrics 255

Radiation Management Strategies in Catheterization Laboratory 255

Patient Radiation Safety 256Operator and Laboratory Personnel Safety 257Radiation Exposure for Pregnant Patient and Employee 258

Newer Developments to Reduce Radiation Exposure 258Newer Fluoroscopic Technologies 258Robotic Assisted Cardiovascular Interventions 258Real-Time Dose Tracking Systems 258Zero-Gravity Radiation Protection System 259

Conclusion 259

Chapter 33Role of Iso-osmolar Contrast Media in Reducing Contrast-Induced Acute Kidney Injury 261A.S. NARULA • VIJAY KHER

Introduction 261Defi nition 261Pathogenesis 261Role of Iso-osmolar Contrast Agents 262

Chapter 34Access Site Closure Devices – What We Need to Know 267SATYAJEET SURYAWANSHI • SHIRISH (M.S.) HIREMATH

Recent Literature 268Types of VCDs Based on their Mechanisms of Action 268

Active Approximators 269Passive Approximators 269External Haemostatic Devices 272

The Future 272

Chapter 35Handling Bifurcation, Trifurcationand Quadrifi cation Lesions 275RAJIV G. BHAGWAT • RONAK V. RUPARELIA

Introduction 275Historical Aspect 275

Anatomical Consideration 276Physiological Consideration 276Classifi cation 276Our Approach for Handling a Bifurcation Lesion 278Technical Aspects 279

Main Branch Stenting Only 279Provisional Side Branch Technique 280

Newer Concepts 280Two-Stent Strategy as Intention to Treat 281Approach to a Trifurcation Lesion 285Approach to Quadrifi cation Lesion 287

Conclusion 287

Chapter 36IVUS versus OCT: Relative Merits and Drawbacks 291GAGANDEEP SINGH • HARI RAJ TOMAR • BHAWANI SHANKAR

Advantage of Intracoronary Imaging 291Advantages of IVUS 291

Assessment of Intermediate Left Main Coronary Artery Lesion and LMCA Stenting 291Assessment of Aorto-Ostial Lesions 292Pre-PCI Assessment of Calcifi ed Lesions 292IVUS-Guided CTO-PCI 292IVUS-Guided Stent Placement and the Supportive Evidence 292IVUS Predictors of Early Stent Thrombosis or of in-Stent Restenosis 292

Drawbacks of IVUS 292Advantages of OCT 292

Plaque Characterization 293Plaque Vulnerability 293Pathophysiology of Acute Coronary Syndrome 293PCI Planning 294Calcifi ed Lesions 295Bifurcation Lesions 295Bioresorbable Scaffold Implantation 295Poststent Assessment 295Assessment of Neointimal Hyperplasia and Causes of Stent Failure 296

Drawbacks of OCT Versus IVUS 297Conclusion 297

Chapter 37IVUS in Detecting Complications Post-PCI 301PRASANT KR. SAHOO • PRIYABRATA SAHOO

Coronary Dissections 301Edge Dissection 302Angiographic Haziness after Stenting 302Intramural Haematoma 304Coronary Perforation and Rupture 304Identify the True From False Channels 304Strut Malapposition and Stent Underexpansion 304Strut Fracture 307Restenosis 307

Chapter 38TAVR: The Patient Selection and Technical Considerations 311A B GOPALAMURUGAN

Indications for TAVR 311Patient Selection 311Landing Zone 312

Relevant Technical Consideration 313Aortic Valve Type 313

Relevant Technical Consideration 314

xxiv Contents

Coronaries 314Relevant Technical Consideration 314

Left Ventricle 315Relevant Technical Consideration 315

Conduction System 315Relevant Technical Consideration 315

Access Route 316Relevant Technical Consideration 316

Cerebral Protection 317Relevant Technical Consideration 317

Renal Protection 318Relevant Technical Considerations 318

Management of Anticipated Complications 318Relevant Technical Considerations 318

Chapter 39Transcatheter Aortic Valves: Types of Available Valves 321G. SENGOTTUVELU • RAGHUL GANESAPANDI

Introduction 321TAVR in Guidelines 321

2017 AHA/ACC Focused Update of Valvular Heart Disease Guideline Aortic Stenosis 321

TAVR Evolution 321TAVR Valves Balloon Expandable Valves vs Self Expandable Valves 321

Balloon-Expandable Valve 322Self-Expanding Valves 322

Summary 330Conclusion 331

SECTION VCARDIAC IMAGING 333

Chapter 40Stress Perfusion CT Coronary Angiography: Expanding the Horizons 335SRIKANTH SOLA • PANKAJ M. KOLHE • SANJAYA VISWAMITRA

Introduction 335Indications for ASP CTCA 335Image Acquisition 336Image Postprocesing 337Image Interpretation 338Conclusion 338

Chapter 41Late Gadolinium Enhancement on Cardiac MRI: A Beginner’s Guide 341JOHANN CHRISTOPHER

Pattern of Gadolinium Enhancement in Coronary Artery Disease 341Risk Prediction 341Infarct Detection and Sizing 341Microvascular Obstruction 342Prediction of Post-MI Mortality 343Pattern of Gadolinium Enhancement in Nonischaemic Cardiomyopathy 343

Dilated Cardiomyopathy 343Hypertrophic Cardiomyopathy 343Cardiac Sarcoidosis 344Amyloidosis 344Myocarditis 345Endomyocardial Fibrosis 345

Pattern of Gadolinium Enhancement in Valvular Heart Disease 345

Regurgitant Valve Disease 345Stenotic Valve Disease 345

Pattern of Gadolinium Enhancement in Pericardial Disease 346Pattern of Gadolinium Enhancement in Thrombi 346Summary 347

Chapter 42When do I Order CT Coronary Angiography 349PRIYA JAGIA • ARUN SHARMA • KARTIK GANGA

Introduction 349CT Coronary Angiography – Technical Advancements 349Patient Selection for CTCA 349

Technical Considerations 349Clinical Considerations 351

Conclusion 357

Chapter 43Noninvasive Coronary Plaque Imaging 361ANIRUDH KOHLI

Chapter 44CT for Pre-TAVR Evaluation 367MONA BHATIA

Aortic Root Anatomy 367Pre-TAVR CT Scan 367CT Evaluation of the Aortic Annulus 368CT Evaluation of Valvular and Landing Zone Calcium Burden 368CT Evaluation of the Aortic Root 368CT-Based Prediction of Angiographic Projection Angles for TAVR 370Access Route Assessment 370Concomitant Cardiac Disease 372Conclusion 372

Chapter 45Utility of Computed Tomographic Coronary Angiography Post Coronary Revascularization 375SANKAR NEELAKANTAN • SANJAYA VISWAMITRA • SRIKANTH SOLA

Background 375Coronary Artery Bypass Grafting 375Coronary Stenting 376Future Considerations 378Conclusion 379

Chapter 46Cardiac MRI in Post-TOF Repair Adults 381RICHA KOTHARI • ONKAR AUTI • VIMAL RAJ

Introduction 381Preoperative Assessment Prior to TOF Surgery 381Surgical Options in TOF 381Cardiac MRI in Patients with Previous TOF Surgery 382

Technical Considerations 382Indications for Cardiac MRI 383

xxvContents

Chapter 47Noncoronary Applications of Nuclear Imaging in Cardiology 389G.N. MAHAPATRA

Nonischaemic Cardiomyopathy 389Various Nuclear Imaging Methods 389Clinical Application of MIBG Imaging 391

Role of Nuclear Imaging in Cardiac Sarcoidosis 392Diagnostic Nuclear Imaging Tests 393

Role of Nuclear Imaging in Cardiac Amyloidosis 394Newer Radiotracer F-18 Sodium Fluoride in Cardiac Amyloidosis 394

Role of Nuclear Imaging in Patients with Infective Endocarditis 395

Role of Nuclear Medicine in Diagnosis of Prosthetic Valve Endocarditis 395

Role of Nuclear Imaging in Left Ventricular Dyssynchrony Assessment Using Myocardial Single-Photon Emission CT 395Conclusion 396

Chapter 48Strain Imaging in Valvular Heart Disease 399JAGDISH C. MOHAN • VISHWAS MOHAN

Overview 399Introduction 399Concept and Fundamentals of Myocardial Strain 401Strain Imaging in Asymptomatic Aortic Stenosis 402Strain Imaging in Aortic Valve Regurgitation 403Strain in Chronic Organic Mitral Regurgitation 405Strain Metrics in Mitral Stenosis 406Conclusion 407

Chapter 49Echocardiography in the Evaluation of Patients with Ischaemic Stroke 411NITIN J. BURKULE

Types of Ischaemic Stroke 411Cardiac Source of Embolism 411Approach to a Suspected Cardioembolic Stroke 411Echocardiographic Imaging 411

TTE Versus TEE 412Individual Pathologies of CV Source of Embolism 413

Chapter 50Clinical Innovations in Cardiac Ultrasound Imaging: The Shape of the Things to Come 423PARTHO P. SENGUPTA

Cardiac Ultrasound–Integrated Clinics in Communities 423Cloud-Based Imaging Platforms 423Robotic Cardiac Ultrasound 424Echo-Imaging ‘Big Data’ and Precision Medicine 424New Technology for Structural Intervention 425

Chapter 51Ultrasound Theranostics for Ischaemia 427SANJIV KAUL

Chapter 52Diastolic Stress Echocardiography 431SATISH C. GOVIND • AASHA S. GOPAL • ANATOLI KIOTSEKOGLOU • SAMIR K. SAHA

Physiology of Diastole 431Left Ventricular Filling Pressures 431Diastolic Stress Echocardiography 432

Defi nition 432Pathophysiology 433Rationale for Using E/e� 433Indications and Contraindications 434Procedure 434NT-ProBNP 436Diastolic Stress Test and Heart Failure with Preserved Ejection Fraction 436Limitations 436

Future Directions 437Conclusions 437

Chapter 53Echocardiographic Evaluation in a Patient Undergoing Ventricular Assist Device Implantation 439RAHUL MEHROTRA • RAJ KUMAR

Introduction 439Mechanical Circulatory Support Devices 439

LVAD 440Role of Echocardiography in Assessment of LVAD 440

Preimplantation Echocardiography 441Perioperative Echocardiography 443Echocardiography after LVAD Implantation 445

Conclusion 448

SECTION VI VALVULAR HEART DISEASE 451

Chapter 54New Guidelines for Management of Valvular Heart Disease: What has Changed 453SAUMITRA RAY • JAYANTA SAHA • SATYENDRA NATH DUTTA

Introduction 453Infective Endocarditis Prophylaxis 453Anticoagulation for Atrial Fibrillation 454Aortic Stenosis 454Primary Mitral Regurgitation 455Secondary MR 455Prosthetic Valve Selection 456Prosthetic Valve Antithrombotic Therapy 457Prosthetic Valve Thrombosis 457Infective Endocarditis 458Conclusion 458

Chapter 55Haemodynamic Subsets of Severe Aortic Stenosis: Implications for Management 461S. SHANMUGASUNDARAM • U. ILAYARAJA • B. VINODKUMAR

Why Revisit Haemodynamics of Aortic Stenosis 461Defi ning Severe Aortic Stenosis 461

Listen to the Patient and Look at the Valve 462Valvuloarterial Impedance – The Double Jeopardy 463Haemodynamics Beyond Valve Orifi ce Size 464

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Before Defi ning Haemodynamics, Stage the Disease! 464Defi ning Haemodynamics 464

Conclusion 469

Chapter 56Decision-Making in Bicuspid Aortic Valve Aortopathy 473FELIPE KAZMIRCZAK • Y. CHANDRASHEKHAR

Introduction 473Bicuspid Aortopathy: General Characteristics 473Patterns of Bicuspid Aortopathy 473Pathophysiology 474Natural History 475Evidence for Decision-Making and Management 475

Medical Management 476Indications for Elective Surgical Repair in Asymptomatic Patients 476Other Factors That Affect Decision-Making in BAV Aortopathy 477

Aortic Aneurysm Surveillance 477Conclusion 477

Chapter 57Tricuspid Regurgitation: Time to Change How We Treat It 481SHIV KUMAR NAIR • RINETT SEBASTIAN • GEORGE JOSE VALOORAN

Introduction 481Pathophysiology of Tricuspid Incompetence 481Anatomical Considerations in FTR – Surgeon’s Challenges 482Assessment of Valve Apparatus and Incompetence 482

3D Echocardiography 483Cardiac MRI 484

Management of fTR 484Medical Therapy 484Surgical Management of fTR 484Percutaneous Approaches and Future Directions to fTR Management 486

Conclusions 486

SECTION VIIHEART FAILURE 489

Chapter 58Moving Beyond Natriuretic Peptides: Newer Biomarkers in Heart Failure 491UMESH C. SAMAL • S. HARIKRISHNAN

Newer Biomarkers 491Soluble ST2 491Troponins 492Galectin-3 492Mid-Regional Pro-Adrenomedullin 493Copeptin 493

Biomarker Panels 493Conclusion 493

Chapter 59Management of Heart Failure with Preserved Ejection Fraction: Current Concepts 497JOHNSON FRANCIS

Defi nition of HFpEF 497Clinical Settings of HFpEF 497

Clinical Trials on Management of HFpEF 497Conclusion 498

Chapter 60High-Output Heart Failure: Diagnosis and Management 501DHARMENDRA JAIN • GEETHA SUBRAMANIAN • AVIRAJ C. • BALAJI V.L.

Introduction 501Pathophysiology of Heart Failure 501Diagnosis 502

Symptoms and Signs 502Aetiology 502Investigations 502Specifi c Conditions Associated with High-Output Heart Failure 503

Anaemia 503Systemic Arteriovenous Fistula 503Skeletal Disorders and Paget Disease 503Chronic Hypercapnia 504Hyperthyroidism 504Sepsis 504Beriberi Heart Disease 504Obesity 504Renal Disease 504Cirrhosis 505Miscellaneous Causes 505

Treatment 505Conclusion 505

Chapter 61Reversible Cardiomyopathies 509VISHAL RASTOGI • PRAGYA KUMARI • ROY MATHEW • VIJAY KUMAR

Peripartum Cardiomyopathy 509Arrhythmia-Induced Cardiomyopathy 510Infl ammatory/Infective Cardiomyopathy 510Takotsubo Cardiomyopathy 511Metabolic Cardiomyopathy 512Cardiomyopathy of Chronic Diseases 512Conclusion 513

Chapter 62Evaluation and Management of Acute Myocarditis: A Status Update 517ANIL DHALL • SALIL GARG • NITIN KUMAR • VIJAY BOHRA

Incidence in India 517Infectious Presentations of Myocarditis 518Pathophysiology of Myocarditis 518

Natural History of the Disease 518Infl ammation in Myocarditis 518

Classifi cation of Myocarditis 519Clinical Features of Myocarditis 520Diagnosis of Acute Myocarditis: Recommendations of European Society of Cardiology 520

Diagnostic Criteria for Clinically Suspected Myocarditis 520Re-Emergence of Endomyocardial Biopsy 521Differential Diagnosis 522

Prognosis 522Management 522

Clinical Management 523Immunosuppressive and Immunomodulatory Therapy in Myocarditis 523

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Specifi c Forms of Myocarditis Common in Indian Population 527

Tuberculous Myocarditis 527Echinococcal Heart Disease 527

Chapter 63Spironolactone: A Grossly Undervalued and Underutilized Drug 531VIVEKANAND GUPTA • JOSHUA C. VOGT • GURPREET S. SANDHU • RAJIV AGARWAL

Introduction 531Physiology 531Clinical Evidence for the use of Spironolactone 532

Heart Failure with Reduced Ejection Fraction 532Heart Failure with Preserved Ejection Fraction 532Resistant Hypertension 533

Spironolactone Underuse 533Measures to Improve the Use of Spironolactone 534Conclusion 534

Chapter 64Heart Rate Modulation in Heart Failure 537RONY MATHEW • JIMMY GEORGE • JABIR A.

Heart Rate and HR Variability in Heart Failure 538HR Reduction in Treatment of HF 538Conclusion 540

Chapter 65Angiotensin Receptor Neprilysin Inhibitor: An update 543BALBIR SINGH

Introduction 543Clinical Evidence Updates with Sacubitril/Valsartan 544

Effi cacy Irrespective of Age 544Effi cacy Irrespective of Ejection Fraction 544Impact on Disease Progression 544Effi cacy Irrespective of Blood Pressure 545Impact on 30-Day Readmission After HFH 545Impact on Mode of Death 545Effi cacy Irrespective of Dose 545Reduced Risk of Hyperkalaemia 545Effi cacy Irrespective of Background Therapy 546

Conclusion 546

Chapter 66Obesity with Severe LV Dysfunction with OSA: How to Manage 549ASHISH KUMAR PRAKASH • BORNALI DATTA

OSA: Historical Background 549Sleep 549Sleep-Related Breathing Disorders 549

Obstructive Sleep Apnoea or Obstructive Sleep Apnoea Syndrome 549Upper Airway Resistance Syndrome 550Central Sleep Apnoea 550Obesity Hypoventilation Syndrome 550

Obesity with Severe LV Dysfunction with OSA 551Pathophysiological Mechanisms Linking OSA with Cardiovascular Risk 551Clinical Features 552Management of Severe LV Dysfunction with OSA 552

Chapter 67Short-Term Ventricular Assist Devices as a Bridge to Decision/Recovery 559ALLA GOPALA KRISHNA GOKHALE • CH. RAVIRAJU • V.V.K. BHARADWAJA • KODURU VENKATA RAMANA

Introduction 559Implant Strategies for using Short-Term Ventricular Assist Devices 559Indications for use of Short-Term Ventricular Support Devices 560Types of Short-Term Ventricular Assist Devices 560

Percutaneous Short-Term Ventricular Assist Devices 560Surgical Short-Term Ventricular Assist Devices 561

Contraindications for Use of Ventricular Assist Devices 561Complications 561Conclusion 562

Chapter 68Left Venrticular Assist Devices as Destination Therapy 565A. JABIR • JIMMY GEORGE

Introduction 565The Journey of LVAD 565Criteria for Implantation of LVAD as DT 567

Intermacs Profi le 567Outcome Data in LVAD as Destination Therapy 568Complications 569LVAD Maintenance 572Current Challenges in LVAD as DT 572Conclusion 572

Chapter 69Extracorporeal Membrane Oxygenation for Heart Failure 575KOMARAKSHI BALAKRISHNAN

Introduction 575Indications for ECMO in Heart Failure 575Contraindications for ECMO 576Technique 576Maintenance 576Complications 577Weaning from ECMO 577Our Experience with ECMO 578Conclusion 578

SECTION VIIICARDIAC ELECTROPHYSIOLOGY 579

Chapter 70Risk Stratifi cation of Inherited Syndromes of Sudden Cardiac Death 581SIRISH C. SRINATH • ANANDAROOP LAHIRI • JOHN ROSHAN

Long QT Syndrome 581Catecholaminergic Polymorphic Ventricular Tachycardia 585Brugada Syndrome 585Hypertrophic Cardiomyopathy 585Arrhythmogenic Right Ventricular Cardiomyopathy 586

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Chapter 71Technological Advances to Treat Nonresponders in CRT 589VANITA ARORA

Introduction 589Historical Methods to Manage Programming of CRT Device 589

Echo-Guided AV and VV Optimization – Aortic Velocity-Time Integral Method 589

Technological Advances to Treat CRT Nonresponders due to the Above Factors 592

Suboptimal AV Timing and Optimization – Adaptive CRT 592Suboptimal LV Lead Positioning 593

Clinical Perspective 596Conclusion 596

Chapter 72Implantable Cardioverter-Defi brillators for Primary Prevention of Sudden Cardiac Death in Heart Failure: Guidelines and Beyond 599SHARATH KUMAR • C. NARASIMHAN

Introduction 599Landmark Trials of Primary Prevention ICDs 599Studies Evaluating Early Implantable Defi brillator Therapy 602ICDs in Nonischaemic Cardiomyopathy 604Study of ICD with Cardiac Resynchronization Therapy 605How to Select Patients 606What Information do We give the Patients before ICD 606Guidelines for ICD Implantation 606

Class I Indications for ICD in Primary Prevention 606Class II Indications for ICD in Primary Prevention 606

Conclusion 606

Chapter 73Electrocardiographic Localization of Idiopathic Monomorphic Ventricular Tachycardia 611JAYAPRAKASH SHENTHAR

Introduction 611Classifi cation 611

Outfl ow Tract Ventricular Tachycardia 611Idiopathic Left Ventricular Tachycardia or Fascicular VT 613VT Arising from the Papillary Muscle 615Annular VTs 615Epicardial VTs and VTs from the Cardiac Veins 616Adrenergic Automatic VTs 616

Conclusion 616

Chapter 74Management of VT Storm in Ischaemic Cardiomyopathy 619MOHAMMED SADIQ AZAM • B. HYGRIV RAO

Introduction 619Defi nition 619Incidence 619Triggers of Electrical Storm 619Management: Protocol-Driven Approach 620

Antiarrhythmic Drugs 620Interventional Therapies 621

Substrate Modifi cation by Radiofrequency Ablation 621Targeting Abnormal Electrograms 622Linear Ablation Lesions 624Ablation of Local Abnormal Ventricular Activities 624Scar Homogenization 624Scar Dechannelling 624Electrical Isolation of the Arrhythmogenic Substrate 625Ablation of Putative Isthmus Sites Defi ned with Pace-Mapping during Sinus Rhythm 625Core Isolation of Critical Substrate Elements 625Epicardial Ablation for ES 625Endocardial Ablation in Presence of LV Thrombus 625

Role of Neuraxial Modulation 626Management of Refractory Cases 627Outcomes 627Conclusion 628

Chapter 75Clinical Features and Treatment of Fascicular Ventricular Tachycardia 631RAMPRAKASH BALASUNDARAM

Introduction 631Clinical Features 631Electrocardiographic Features 631Clinical Differential Diagnosis 631

Long-Term Management 632Anatomic Correlation: Role of False Tendon 632Electrophysiological Characteristics 632

Tachycardia Circuit 633Electrophysiological Differential Diagnosis 634

Medical Management 635Acute Management 635

Radiofrequency Ablation 635Ablation During Tachycardia 635Ablation During Sinus Rhythm 636

Conclusion 637

Chapter 76Left Atrial Appendage Closure: Indication and Technique 641RANJAN SHETTY

Introduction 641Rationale 641Evidence 641Indications 641Technique 641Imaging 643Access and Trans-Septal Puncture Technique 643Angiography 643Technique of ACP Device Implantation 644Checklist before Final Release of the Device 644Watchman Sizing and Implantation Steps 645Postprocedure Treatment and Follow-Up 645Possible Complications 646Our Experience 646

Chapter 77Radiofrequency Catheter Ablation for Rheumatic Atrial Fibrillation 647MOHAN NAIR • VIKAS KATARIA

Technique of Ablation 647Ablation Strategies for Valvular AF 647Success Rates 648

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Chapter 78Balancing Bleeding Risk with Risk of Embolism in AF: The Eternal Dilemma 651RISHI SETHI • AKSHYAYA PRADHAN • MAHIM SARAN

Introduction 651Atrial Fibrillation and Stroke 651Assessing the Risk of Stroke 651Assessing the Risk of Bleeding 652Impact of Anticoagulation 652Balancing the Act 652Dilemma – the Risk Factors For Increased Bleeding are More or less same as those for Thromboembolism 652Mitigating the Bleeding Risk with Oral Anticoagulants 653Vitamin K Antagonists Versus NOACs 654Managing High-Risk Groups 654Antidotes for NOACs 655Conclusion 656

Chapter 79Remote Monitoring of Cardiac Implantable Electronic Devices 659ULHAS M. PANDURANGI

Introduction 659Evolution of Remote Monitoring 659Evidence of Benefi t of Remote Monitoring 660Remote Monitoring: Patients’ Concerns 660Remote Monitoring: Legal Issues 660Guidelines Recommendations for Remote Monitoring 661Remote Monitoring in India 661Conclusion 661

Chapter 80Inappropriate Sinus Tachycardia: Mechanisms and Management 663KARTIKEYA BHARGAVA

Introduction 663Defi nition 663Epidemiology 663Mechanisms 663Clinical Features 663Diagnosis 664Management 664

Radiofrequency Catheter Ablation 664Conclusion 665

SECTION IXRIGHT HEART AND PULMONARY CIRCULATION 667

Chapter 81Combination Therapy in Pulmonary Hypertension: Current Status 669MOHAN BHARGAVA • ABINAV JAIN • PRACHAL BHARGAVA

Introduction 669Haemodynamics 670Epidemiology 671Diagnosis 671Therapy in PH 671

Sequential Drug Combination Therapy 674Initially Combination Therapy 676Upfront Triple Combination Therapy 677

Conclusion 677

Chapter 82Oral Prostaglandins in PH: An Update 681RAHUL MEHROTRA • AMAL KUMAR BANERJEE

Introduction 681Prostaglandins in PAH 681Oral Prostaglandins 682

Oral Treprostinil 683Selexipag 683

Conclusion 684

Chapter 83Pulmonary Thromboendarterectomy: Patient Selection and Clinical Outcomes from a Single Centre Experience 687DEVIPRASAD SHETTY • VARUN SHETTY • ABHIJIT JOSHI

Introduction 687Our Experience with PTE 687

Preoperative and Postoperative Characteristics 687Follow-Up and Clinical Outcome 688

Evaluation of the Patient with CTEPH for PTE 688Patient Selection Criteria for PTE 688Patient Workup 688Operative Technique 688Postoperative Care 689

Challenges in Starting PTE Programme 689Multidisciplinary Team 689ECMO Requirement 689High Mortality Rate and Surgeon Dependent 689

Conclusion 689

SECTION XPEDIATRIC CARDIOLOGY 691

Chapter 84Heart Failure in Paediatric Patients: Causes and Management 693NAGESWARA RAO KONETI

Defi nition 693Epidemiology 693Causes of HF 693Diagnostic Evaluation of HF 694Management of HF 697

Drugs 697Electrophysiological Intervention 699Mechanical Circulatory Support 699Supportive Treatment 699

Chapter 85Percutaneous Pulmonary Valve Implantation 701K. SIVAKUMAR

Introduction 701Why Pulmonary Valve is Important 701Why not Surgical PVI 701Transcatheter Pulmonary Valves 701Advantages of PPVI 702Native RVOT Provides a Challenge 702Is PPVI the Final Answer for RVOT 702Indications for Pulmonary Valve Implantation 703Contraindications for Balloon-Expandable Valves 703Optimal Timing of PVR 703Recommendations for Surgical PVI 703Preprocedure Assessment 703Prestenting Before PPVI 704

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Preparation of the Valves 704Valve Implantation Procedure 704Complications 704Freedom From Reinterventions 704Self-Expanding Valves 704Venus P-Valve 704

Chapter 86Manifestations and Management of Failing Fontan 709AMIT MISRI

Introduction 709Paradoxical Fontan Physiology 709Fontan Failure 709

Causes of Fontan Failure 710Manifestations of Fontan Failure 710Management of Fontan Failure 711

Conclusion 715

Chapter 87Timing of Cardiac Intervention in Congenital Heart Disease 717YOGESH SATHE • MUNESH TOMAR

Left-to-Right Shunt 717Atrial Septal Defect 717Partial Anomalous Pulmonary Venous Connection 718Atrioventricular Septal Defect 718Ventricular Septal Defects 718Patent Ductus Arteriosus 719Aortopulmonary Window 719

Obstructive Lesions 719Left-Sided Obstructions 719Right Ventricular Outfl ow Tract Obstruction with Intact Ventricular Septum 720

Cyanotic Heart Disease 721Reduced Pulmonary Blood Flow – Tetralogy of Fallot Physiology 721Cyanosis with Increased Pulmonary Blood Flow 721Total Anomalous Pulmonary Venous Connection 722

Other Special Conditions 722Ebstein Anomaly 722Anomalous Origin of Left Coronary Artery From Pulmonary Artery 723Pulmonary Atresia, Intact Interventricular Septum 723Hypoplastic Left Heart Syndrome 723

Conclusion 723

SECTION XICARDIAC SURGERY 725

Chapter 88Surgical Option for the ‘No-Option’ Coronary Artery Disease 727AJEET BANA • MUKTA TIWARI

Introduction 727Transmyocardial Laser Revascularization 727

Technique 727Complications 728Mechanism of Action 728Evidence of Clinical Effi cacy of TMR 728

Coronary Venous Bypass Grafting 728Introduction 728History 729Preclinical Study and Animal Trials 729

Clinical Study 730Procedure of CVBG 730

Temporary Cardiac Sympathectomy 730Spinal Cord Stimulation 731Cell-Based Therapy 732Cardiac Transplantation for Ischaemic Heart Disease 732

Chapter 89Total Arterial Coronary Artery Bypass Grafting: The New Benchmark of Coronary Revascularization 737KAMALESH KUMAR SAHA

Why Total Arterial Revascularization 737Current Status of Total Arterial Revascularization 737Controversies 738Different Techniques of TAR 738Postoperative Therapy 739Successfully Adopting TAR in India 739

Preoperative Assessment 741Learning Curve of TAR 741Extra Time Required for TAR Surgery 741Postoperative Follow-Up 742

Conclusion 742

Chapter 90Hybrid Myocardial Revascularization 745YUGAL K. MISHRA • PRITAM PAL

Introduction 745The Rationale for Hybrid Myocardial Revascularization 745

The Survival Benefi t of a Surgical LIMA-To-LAD Graft 745Surgical Revascularization Outside the LAD Territory – Comparison with PCI 746

Advantages of HMR Procedures 746Indications for Hybrid Myocardial Revascularization 746Contraindications for Hybrid Myocardial Revascularization 747Hybrid Myocardial Revascularization Strategies 747

Staged Hybrid Myocardial Revascularization 748C. Simultaneous CABG and PCI 749

The Individual Components of HMR 749The LIMA–LAD Anastomosis 749Which Type of Stent to Implant 750

Outcomes of Hybrid Myocardial Revascularization 750Conclusion 752

Chapter 91Mitral Valve repair: Technique and Outcomes 757CHANDRASEKAR PADMANABHAN

Introduction 757Evolution 757Functional Anatomy of the Mitral Valve 757Valve Analysis: The Functional Classifi cation 760Techniques of Valve Reconstruction 761

Techniques in Type I Dysfunction 761Techniques in Type II Dysfunction 763Techniques in Type III Dysfunction 766

Outcomes 768Rheumatic Disease 768Degenerative Diseases 769Ischaemic Mitral Regurgitation 769Infective Endocarditis 770

Minimally Invasive Approaches 770Conclusions 770

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Chapter 92Redo Cardiac Surgery: Challenges and Results 773BHAGAWAN KOIRALA • PRABHAT KHAKURAL

Introduction 773General Principles of Redo Cardiac Surgery 773

Preoperative Considerations 773Intraoperative Considerations 774Surgical Approach 774Institution of Cardiopulmonary Bypass and Hypothermia 775Myocardial Protection 775Haemostasis and Chest Closure 775

Specifi c Features of Redo Procedures in Selected Disease Conditions 775

Redo Valve Surgery 775Key Issues and Challenges in Redo Valve Surgery 776Redo Coronary Artery Bypass Grafting 776Combined Valve and Coronary Procedures 776Emergency Redo Cardiac Surgery 776Redo Cardiac Surgery in Paediatric Population 776

Conclusion 777

Chapter 93Aneurysm and Dissection Involving Thoracic Aorta: A Vascular Surgeon’s Experience and Perspective 779MADATHIPAT UNNIKRISHNAN • SHIVANESAN PITCHAI

Incidence 779Aetiology 779Classifi cation 779Presentation 780Investigations 780Threshold for Intervention in Aneurysm 780

Therapeutic Strategies 780Addendum 783

Chapter 94Recent Advances in Valve Surgery 785PRASANNA SIMHA MOHAN RAO • RAKESH NAIK LACHMA

Changing Trends 785Newer Heart Valves 785

Lower Thrombogenicity Mechanical Valve 785Bioprosthetic Valves 785

Percutaneous Valve Placements 786Transcatheter Aortic Valve Replacement 786Transcatherter Mitral Valve Replacement 786

Valve Repairs and Reconstructions 786Mitral Valve Repairs 786

Early Mitral Valve Surgery 787Aortic Valve Reconstruction 787Minimally Invasive Cardiac Surgery 787Hemisternotomy 787Right Thoracotomy 788Robotic Surgery 788

Chapter 95Future Directions in Cardiac Surgery 791O.P. YADAVA • A. KUNDU

Coronary Artery Disease 791Coronary Artery Bypass Surgery 791Hybrid Revascularization 791Robotic and Minimally Invasive CABG 791Anastomotic Devices 792Conduits 792No Option CAD-Coronary Venous Bypass Grafting 792Alternate Therapies to Revascularization 793

Valvular Heart Disease 793Options for Ischaemic MR 794

Heart Failure Therapies 796Ventricular Restraint Therapies 796Ventricular Assist Devices 796Extracorporeal Membrane Oxygenation 798

Aorta 798Gene Therapy in Cardiac Surgery 798

Avoiding Rejection – Immunosuppression 799Paediatric Cardiac Surgery 799

Robotics and Imaging 799Fetal Cardiac Surgery 799

Miscellaneous Issues 799Robotics 799CPB and Intensive Care 799Imaging 800Guidelines and Training 800Research and Innovations 800Gender and Personnel Issues 800

Conclusion 800

SECTION XIIMISCELLANEOUS 805

Chapter 96Vaccination in Cardiac Patients: A Practical Guide 807NEHA GUPTA • VITULL K. GUPTA • MEGHNA GUPTA • VARUN GUPTA

Introduction 807General Principles of Vaccination 807Currently Available Vaccines in India 808

Pneumococcal Vaccine 808Infl uenza Vaccine 809Zoster/Shingles Vaccine 810Hepatitis B Vaccine 810Tetanus, Diphtheria and Acellular Pertussis Vaccine 810Meningococcal Vaccine 810HiB Vaccine 811

Chapter 97Sports-Related Cardiac Deaths Mechanisms and Prevention 813N.V. DESHPANDE

Introduction 813Aetiology of SCD 813Structural Heart Disease 813Electrical Abnormalities 816Acquired Cardiac Abnormalities 816Prevention of SCD in Young Athletes 817Preparticipation Screening 817Conclusion 818

Chapter 98Pregnancy-Induced Hypertension: Newer Concepts, Predictors and Therapy 821GURLEEN WANDER • POOJA TANDON • GURPREET SINGH WANDER

Introduction 821Disease Spectrum 821Diagnosis of Hypertension in Pregnancy 821

Diagnostic Criteria for Hypertensive Disorders in Pregnancy 821

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Symptoms and Signs of Pre-Eclampsia 822Symptoms of Pre-Eclampsia 822Signs of Pre-Eclampsia 822Prediction of Pre-Eclampsia 822

Identifi cation of Risk Factors 823Preventing Pre-Eclampsia and Complications in Women at Increased Risk 823Treatment of Hypertension 823

Antihypertensive Therapy for Severe Hypertension 823Antihypertensive Therapy for Mild Pre-Eclampsia/Gestational Hypertension 824Antihypertensive Therapy for Chronic Hypertension 824

Chapter 99Digital Health Tools in Cardiology: How Useful 825PANNIYAMMAKAL JEEMON • PADINHARE MOHANAN

Introduction 825mhealth in Cardiology 825Mobile Apps for Tracking and Management 827Telemedicine and Telehealth 828Biomedical Sensors 828Digital Imaging Technologies 828Geographical Information Tools and their Applications 829Clinical Research in Cardiology using Digital Health Tools 829Personalized Medicine 829Research Publications on Digital Health Interventions 829Conclusion 829

Chapter 100Cardiac 3D Printing: Redefi ningHow We Manage Cardiac Illnesses 833AMIER AHMAD • NAVIN NANDA • THOMAS BARTEL • SAMUEL MCELWEE

Introduction 8333D Reconstruction 833Cardiovascular Applications 833

Education 833Procedures 833Device Creation 835

Conclusion 835

Chapter 101Peripartum Cardiomyopathy 837SMIT SHRIVASTAVA • SURESH CHANDRAVANSHI

Introduction 837Earlier Names 837History 837Defi nition 837

Incidence 837Normal Changes During Pregnancy 838Risk Factors 839Clinical Presentation 839Aetiopathogenesis 839

Infl ammation and Abnormal Immune Response to Pregnancy 839Angiogenic Imbalance 840Oxidative Stress 840Lymphocytic Myocarditis 840Viral Trigger Mediated 840Environmental and Genetic Factors 841Haemodynamic Stress of Pregnancy 841

Physical Examination 841Diagnosis 841Investigation 841

Laboratory Diagnosis 841ECG 841X-Ray 842Echocardiography 842Cardiac Catheterization 842Endomyocardial Biopsy 842Cardiac Magnetic Resonance Imaging 842

Differential Diagnosis 842Dilated Cardiomyopathy 843Acute Myocarditis 843Preeclampsia with Heart Failure 843Pulmonary Causes 843Cardiac Causes 843

Practical Management of Peripartum Cardiomyopathy 843

Management During Pregnancy 844Management Postpartum 844Management of Decompensated Heart Failure 844

Recurrence 845Prognosis 845Contraception 846Peripartum Cardiomyopathy in India 846Conclusion 846

Chapter 102Endothelial Dysfunction and Atrial Fibrillation 849SHISHU SHANKAR MISHRA • BISWARANJAN MISHRA • SATYANARAYAN ROUTRAY • DIPAK RANJAN DAS

Introduction 849Association of Endothelial Dysfunction and Atrial Fibrillation 849Pathophysiologic Mechanism of Endothelial Dysfunction and Atrial Fibrillation 850Endothelial Dysfunction, A Prognostic Indicator in Atrial Fibrillation 851Therapy in Atrial Fibrillation Directed to Endothelial Dysfunction 851Conclusion 852