Milind Hote | All India Institute of Medical Sciences, New Delhi (original) (raw)

Papers by Milind Hote

Journal of the Practice of Cardiovascular Sciences, 2021

Objective: The objective is to assess the clinical course and outcomes of heart transplant (HTx) ... more Objective: The objective is to assess the clinical course and outcomes of heart transplant (HTx) recipients affected by COVID-19 disease in a tertiary care health care institution. Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) is a contagious illness with alarming morbidity and mortality. The HTx recipients are chronically immunosuppressed and thus COVID-19 infection in them may result in an unpredictable clinical course. Materials and Methods: HTx recipients in a tertiary care transplant center in North India were retrospectively reviewed from January 2020 to January 2021. Case records of 28 patients of HTx were reviewed, and four (14%) were found to have developed Covid-19 infection. Clinical parameters and outcomes of these four HTx recipients with confirmed SARS-CoV-2 infection are described. Results: Fourteen percent of our HTx patients (4 out of 28 patients under follow-up) developed COVID-19 in the first infection wave. The study population consisted of 3 males and 1 female patient with a median age of 28 years (range 15–39). The most common presenting symptoms were fever (100%), myalgia (100%) and cough (75%). There was no mortality observed in this study. None required intensive care admission or mechanical ventilatory support. Three were managed with hospital admission while one was subjected to home isolation. The mean hospital stay was 13.5 days (12–17 days). Immunosuppressants were modified by reducing tacrolimus and mycophenolate, however, corticosteroids were continued. Conclusion: The dose modification rather than discontinuation of immunomodulatory agents should be established as standard of care for transplant recipients. Steroids may provide added benefit and should be continued. The morbidity and mortality in such cases may be lower than anticipated; however, this needs to be substantiated with larger multicentric studies.

Journal of Cardiac Critical Care TSS, 2021

Background Patients undergoing on-pump coronary artery bypass grafting (CABG) are at increased ri... more Background Patients undergoing on-pump coronary artery bypass grafting (CABG) are at increased risk of perioperative bleeding and morbidity associated with transfusion as a result of acquired and pharmacologically induced impaired platelet function. Settings and Design In this a prospective observational study where 52 patients underwent on-pump CABG were analyzed with ROTEM platelet aggregometry. Materials and Methods Patients were assigned to the “nonexcessive” and “excessive” postoperative bleeding groups according to the postoperative chest tube drainage over 24 hours. Platelet function was assessed by ROTEM platelet using three different activators (arachidonic acid, adenosine diphosphate, and thrombin receptor-activating peptide), at two perioperative time points (T1, before heparinization and T2, 5–10 minutes after protamine administration). Results There were no differences regarding demographic, pre–cardiopulmonary bypass (CPB) platelet count and antiplatelet therapy. Plate...

Journal of clinical trials, 2016

Background: Oxygen saturation and the PaO2 are the direct risk factors for post -operative respir... more Background: Oxygen saturation and the PaO2 are the direct risk factors for post -operative respiratory outcome in patients undergoing prolonged surgery under general anaesthesia. However the effect of preoperative PaO2 and PaO2 /FiO2 ratio on the postoperative course of the patient undergoing coronary artery bypass grafting is not known. Hypothesis: Pre-operative PaO2 and PaO2 /FiO2 ratio have a significant effect on the postoperative outcome among the patients undergoing coronary artery bypass grafting. Study design: Prospective clinical study Setting: Tertiary health care centre Materials and Methods: One hundred and fifty eight consecutive patients with a EURO Score of <6 undergoing routine first time coronary artery bypass grafting were selected for this study. Patients with ventricular dysfunction, Chronic Obstructive Pulmonary Disease (COPD), renal or hepatic dysfunction, patients on mechanical ventilation, on preoperative Intra Aortic Ballon Pump (IABP) and those who had t...

Journal of Perioperative Echocardiography, 2016

Major vessel injury is a possible complication during pericardiectomy for chronic constrictive pe... more Major vessel injury is a possible complication during pericardiectomy for chronic constrictive pericarditis (CCP). We present a case of CCP, who while undergoing radical pericardiectomy incurred an iatrogenic injury of a major vessel with profuse bleeding. A rent in main pulmonary artery (MPA) was detected by the surgical team and simultaneously confirmed on transesophageal echocardiography (TEE), and a timely intervention was done. Importance of monitoring TEE in a patient undergoing pericardiectomy for CCP is highlighted. How to cite this article Makhija N, Narula J, Kumar S, Taneja S, Hote MP. Pulmonary Artery Perforation: Rare reported Complication of Pericardiectomy for Chronic Constrictive Pericarditis recorded on Transesophageal Echocardiography. J Perioper Echocardiogr 2016;4(1):17-18.

Journal of the Practice of Cardiovascular Sciences, 2017

Introduction: Heart Transplant in India started in 1994. We were initially doing 1-2 per year but... more Introduction: Heart Transplant in India started in 1994. We were initially doing 1-2 per year but the numbers have picked up since 2014 and we have done 25 in the past 3 years. We describe our experience of the last 4 years in this paper. Results: Initially, we experienced a relatively higher rate of rejections, fungal infections and graft failure. As we changed protocols, stopped using induction therapy except in high risk, maintained higher levels of immune suppression and tapered steroids faster in the first year, the complications reduced. All patients who had rejections and all the later transplants were maintained on a regime of tacrolimus, mycophenolate mofetil and steroids along with six months of valgancyclovir, voriconazole and co-trimoxazole. Steroids were tapered by six months to 0.1 mg/kg per day in all patients. Conclusions: In our recent patients, infection was the most common adverse event followed by rejection and PGD. In the latter half of our experience, we found that the complications reduced, suggesting that experience leads to less complications.

Molecular and cellular biochemistry, Jan 14, 2018

Pulmonary hypertension (PH) is a morbid complication of cardiopulmonary as well as several system... more Pulmonary hypertension (PH) is a morbid complication of cardiopulmonary as well as several systemic diseases in humans. It is rapidly progressive and fatal if left untreated. In the present study, we investigated the effect of PPARα agonist fenofibrate (FF) on monocrotaline (MCT)-induced PH in rats. FF, because of its pleiotropic property, could be helpful in reducing inflammation, oxidative stress, and reactive oxygen species. On day 1, MCT (50 mg/kg, s.c.) was given to all the rats in MCT, sildenafil, and FF group except normal control rats. After 3 days of giving MCT, sildenafil (175 µg/kg, orally) and FF (120 mg/kg, orally) were given for 25 days. Echocardiography, hemodynamic parameters, fulton's index, histopathology, oxidative stress parameters, inflammatory markers, Bcl2/Bax gene expression ratio in the right ventricle, and protein expression for NOX-1 in lungs were studied in all the groups. FF has shown to prevent decrease in ratio of pulmonary artery acceleration time...

Medicines (Basel, Switzerland), Jan 17, 2018

The study was designed to explore any beneficial effect of Ocimum sanctum (Linn) (OS) in experime... more The study was designed to explore any beneficial effect of Ocimum sanctum (Linn) (OS) in experimental pulmonary hypertension (PH) in rats. OS is commonly known as “holy basil” and “Tulsi” and is used in the Indian System of Medicine as antidiabetic, antioxidant, hepatoprotective, adaptogenic, and cardioprotective. Monocrotaline (MCT) administration caused development of PH in rats after 28 days and rats were observed for 42 days. Treatments (sildenafil; 175 µg/kg, OS; 200 mg/kg) were started from day 29 after the development of PH and continued for 14 days. Parameters to assess the disease development and effectiveness of interventions were echocardiography, right and left ventricular systolic pressures, and right ventricular end diastolic pressure, percentage medial wall thickness (%MWT) of pulmonary artery, oxidative stress markers in lung tissue, NADPH oxidase (Nox-1) protein expression in lung, and mRNA expression of Bcl2 and Bax in right ventricula...

Annals of Cardiac Anaesthesia, 2017

Background: The mechanism of development of atrial fibrillation (AF) in patients undergoing coron... more Background: The mechanism of development of atrial fibrillation (AF) in patients undergoing coronary artery bypass grafting (CABG) has not been clearly defined, and the involvement of multiple factors such as advanced age, withdrawal of β-blockers, inadequate atrial protection, and electrolyte imbalance, particularly hypomagnesemia has been documented by several authors. Despite all the available pharmacologic prophylaxis, incidence of AF still remains high in this group of patients. This unexplained cause could be genetic inheritance of endothelin-1 (ET-1) gene which is thought to have a pro-arrhythmogenic effect. Aim: This study aims to investigate the relationship between plasma ET-1 concentrations, ET-1 gene polymorphisms in loci-1370 T/G,-134 (3A/4A) Ins/del, Lys198Asn (G/T), and occurrence of AF in patients undergoing CABG. Methodology: Ninety-eight nonrelated, nondiabetic patients over a period of 4 years undergoing routine CABG were selected for the present study. All patients were genotyped for three single nucleotide polymorphisms (SNPs) in loci-1370 T/G,-134 (3A/4A) Ins/del, and Lys198Asn (G/T) in the ET-1 gene by gene sequencing. The plasma ET-1 concentrations were measured using an ET immunoassay. Results: Plasma ET-1 concentrations were higher in AF+ group (P = 0.001) as compared to AF− group. The allele frequencies between AF+ and AF− group were significantly different only with respect to the Lys198Asn (G/T) SNP of the ET-1 gene. Conclusion: The study described the possible correlation of polymorphism of ET gene in CABG population from India. The ET-1 gene might play a disease-modifying role in atrial fibrillation.

Annals of cardiac anaesthesia

Poor sleep quality is emerging as high prevalence among the patients suffering from cardiometabol... more Poor sleep quality is emerging as high prevalence among the patients suffering from cardiometabolic disturbances. The vascular polypeptide endothelin 1 (ET-1) is involved in many of the health disorders. However, its potential involvement in patients having poor sleep quality along with cardiovascular problem is limited. The present study was formulated to conduct a prospective analysis of the relationship between ET-1 and in hospital outcome in sleep disorder patients undergoing routine coronary artery bypass grafting (CABG). A total of 156 patients were enrolled and divided into two groups based on the Pittsburg Sleep Quality Index (PSQI) of ≤5 (Group I, n = 101) or >5 (Group II, n = 55). Blood sample was collected before anesthesia induction (ET-1a) and at 48 h (ET-1b) to analyze the plasma ET-1 and blood sugar level. The patients were monitored for any intraoperative adverse events and postoperative complications during their hospital stay. Both groups were comparable in rela...

Annals of Cardiac Anaesthesia, 2017

Background: There has been a constant emphasis on developing management strategies to improve the... more Background: There has been a constant emphasis on developing management strategies to improve the outcome of high-risk cardiac patients undergoing surgical revascularization. The performance of coronary artery bypass surgery on an off-pump coronary artery bypass (OPCAB) avoids the risks associated with extra-corporeal circulation. The preliminary results of goal-directed therapy (GDT) for hemodynamic management of high-risk cardiac surgical patients are encouraging. The present study was conducted to study the outcome benefits with the combined use of GDT with OPCAB as compared to the conventional hemodynamic management. Material and Method: Patients with the European System for Cardiac Operative Risk Evaluation ≥3 scheduled for OPCAB were randomly divided into two groups; the control and GDT groups. The GDT group included the monitoring and optimization of advanced parameters, including cardiac index (CI), systemic vascular resistance index, oxygen delivery index, stroke volume variation; continuous central venous oxygen saturation (ScVO 2), global end-diastolic volume, and extravascular lung water (EVLW), using FloTrac ™ , PreSep ™ , and EV-1000 ® monitoring panels, in addition to the conventional hemodynamic management in the control group. The hemodynamic parameters were continuously monitored for 48 h in Intensive Care Unit (ICU) and corrected according to GDT protocol. A total of 163 patients consented for the study. Result: Seventy-five patients were assigned to the GDT group and 88 patients were in the control group. In view of 9 exclusions from the GDT group and 12 exclusions from control group, 66 patients in the GDT group and 76 patients in control group completed the study. Conclusion: The length of stay in hospital (LOS-H) (7.42 ± 1.48 vs. 5.61 ± 1.11 days, P < 0.001) and ICU stay (4.2 ± 0.82 vs. 2.53 ± 0.56 days, P < 0.001) were significantly lower in the GDT group as compared to control group. The duration of inotropes (3.24 ± 0.73 vs. 2.89 ± 0.68 h, P = 0.005) was also significantly lower in the GDT group. The two groups did not differ in duration of ventilated hours, mortality, and other complications. The parameters such as ScVO 2 , CI, and EVLW had a strong negative and positive correlation with the LOS-H with r values of − 0.331, −0.319, and 0.798, respectively. The study elucidates the role of a goal-directed hemodynamic optimization for improved outcome in high-risk cardiac patients undergoing OPCAB.

Journal of Ethnopharmacology, 2017

effects of aqueous extract of stem bark of Terminalia arjuna (Roxb.), an Ayurvedic drug in experi... more effects of aqueous extract of stem bark of Terminalia arjuna (Roxb.), an Ayurvedic drug in experimental pulmonary hypertension",

Journal of Cardiothoracic and Vascular Anesthesia, 2017

Objectives: The postoperative course following on-pump coronary artery bypass grafting (CABG) in ... more Objectives: The postoperative course following on-pump coronary artery bypass grafting (CABG) in patients with severe left ventricular (LV) systolic dysfunction is often unpredictable. Therefore, the aim of this study was to identify predictors of poor postoperative outcome in this subset of patients. Design: Prospective observational study Setting: Single university hospital Participants: Forty patients with severe LV systolic dysfunction undergoing isolated on-pump CABG Interventions: None Measurements and Main Results: Comprehensive transesophageal echocardiographic examination was performed to obtain the indices of systolic and diastolic LV function after induction of anesthesia. A poor postoperative outcome was defined as patient death or vasoactive inotropic scoreZ20 for at least 6 hours and/or requiring intra-aortic balloon counterpulsation and/or mechanical ventilation for Z24 hours. Poor postoperative outcome was observed in 40% (16/40) of patients. Patients with poor postoperative outcomes had a significantly higher systolic dyssynchrony index, septal-lateral delay with a significantly lower global longitudinal strain and isovolumic acceleration, end-diastolic volume, end-systolic volume, and lateral and medial mitral annulus systolic velocity. In a binary logistic regression model, global longitudinal strain (odds ratio, 1.5, confidence interval [CI] 95%, 1.19-1.88, p ¼ 0.001), septal-lateral delay (odds ratio, 1.02, 95% CI, 1.01-1.03; p ¼ 0.001) and systolic dyssychrony index (odds ratio, 1.3, 95% CI, 1.13-1.48; p ¼ 0.000) were found to be predictors of poor postoperative outcome. Conclusion: Global longitudinal strain, systolic dyssynchrony index, and septal-lateral delay were reliable and accurate predictors of adverse outcomes in patients with severe LV systolic dysfunction undergoing on-pump CABG.

Annals of cardiac anaesthesia

Levosimendan a calcium ion sensitizer improves both systolic and diastolic functions. This novel ... more Levosimendan a calcium ion sensitizer improves both systolic and diastolic functions. This novel lusitropic drug has predictable antiischemic properties which are mediated via the opening of mitochondrial adenosine triphosphate-sensitive potassium channels. This action of levosimendan is beneficial in cardiac surgical patients as it improves myocardial contractility, decreases systemic vascular resistance (SVR), and increases cardiac index (CI) and is thought to be cardioprotective. We decided to study whether levosimendan has any impact on the outcomes such as the duration of ventilation, the length of Intensive Care Unit (ICU) stay, and the hospital stay when compared with the nitroglycerine (NTG), which is the current standard of care at our center. Forty-seven patients undergoing elective coronary artery bypass surgery were randomly assigned to two groups receiving either levosimendan or NTG. The medications were started before starting surgery and continued until 24 h in the po...

Journal of the Practice of Cardiovascular Sciences, 2015

We report the successful implant of an external basal annuloplasty device (basal annuloplasty of ... more We report the successful implant of an external basal annuloplasty device (basal annuloplasty of the cardia externally), which is a dimethyl silicone band, slipped around the base of the heart at the atrioventricular groove and the sub-annular myocardium to provide external myocardial support and mitral annuloplasty. The patient had ischemic heart disease with moderate functional mitral regurgitation which was reduced to mild regurgitation. The patient underwent coronary artery bypass during the same surgery.

Journal of the Practice of Cardiovascular Sciences, 2015

After the first successful adult heart transplant in India at All India Institute of Medical Scie... more After the first successful adult heart transplant in India at All India Institute of Medical Sciences, in 1994, we did our first pediatric heart transplant in 2015. An adult heart was successfully transplanted into a 10-year-old child. The steps from planning to the execution of the surgery and successful discharge of the patient are hereby discussed.

Indian Journal of Thoracic and Cardiovascular Surgery, 2006

Indian Journal of Thoracic and Cardiovascular Surgery, 2006

Indian Journal of Thoracic and Cardiovascular Surgery, 2012

ABSTRACT Introduction Advances in technology have spurred innovations in most surgical discipline... more ABSTRACT Introduction Advances in technology have spurred innovations in most surgical disciplines- including cardiac surgery - directed towards minimizing invasiveness without compromising outcomes. We present our initial experience and learning curve difficulties in performing robotically assisted atrial septal defect closure in an adult population. Patients and methods Over a 4 year period between February 2008 to January 2012, we operated upon 52 patients with secundum type of Atrial Septal Defect (ASD), using the daVinci robotic system. All operations were done with peripheral cardiopulmonary bypass and direct transthoracic access to aorta for cardioplegia and aortic cross clamping. Mean age of patients was 26.8 years, mean cross-clamp, cardiopulmonary bypass and operating times were 68.4, 121.6 and 178.44 min respectively. In 4 patients, there was conversion – to sternotomy in three and to thoracotomy in one. In all patients, successful closure was confirmed by Trans Esophageal Echocardiography (TEE). Mean Intensive Care Unit (ICU) stay duration was 22.1 h and hospital stay 3.6 days. There was no mortality. In one patient, there was lung parenchymal bleeding necessitating reexploration followed by persistent air leak for 48 h. Conclusions Robotic telemanipulation enables application of endoscopic technology to performing complex intrathoracic operations safely. Patients with simple lesions like ASD who are not candidates for device closure may be offered this surgeon-friendly technology to avoid possible complications of sternotomy and enable faster recovery. Factors like - adapting to telemanipulation, setting up peripheral cardiopulmonary bypass and restricted visibility prolongs both operating times and surgeons’ learning curve but greatly minimises patient morbidity.

Annals of cardiac anaesthesia

Aneurysm of sinus of Valsalva is a rare congenital cardiac defect that can present with myriad si... more Aneurysm of sinus of Valsalva is a rare congenital cardiac defect that can present with myriad signs and symptoms ranging from trivial to catastrophic events like cardiogenic shock and death. As clinical examination is not entirely reliable and the patient can sometimes be so ill as to preclude cardiac catheterization, echocardiography has become the definitive investigative tool not only to define and diagnose the lesion but also to quantify its severity. The following is a case report of multiple aneurysms of the left aortic sinus of Valsalva rupturing into the left ventricle. Diagnosis is made on multi plane transesophageal echocardiography and color Doppler regarding precise identification of structural anomalies and shunt locations for perioperative assessment and definitive treatment is surgical repair.

Annals of cardiac anaesthesia

Improved cosmetic appearance, reduced pain and duration of post-operative stay have intensified t... more Improved cosmetic appearance, reduced pain and duration of post-operative stay have intensified the popularity of minimally invasive cardiac surgery (MICS); however, the increased risk of stroke remains a concern. In conventional cardiac surgery, surgeons can visualize and feel the cardiac structures directly, which is not possible with MICS. Transesophageal echocardiography (TEE) is essential during MICS in detecting problems that require immediate correction. Comprehensive evaluation of the cardiac structures and function helps in the confirmation of not only the definitive diagnosis, but also the success of surgical treatment. Venous and aortic cannulations are not under the direct vision of the surgeon and appropriate positioning of the cannulae is not possible during MICS without the aid of TEE. Intra-operative TEE helps in the navigation of the guide wire and correct placement of the cannulae and allows real-time assessment of valvular pathologies, ventricular filling, ventric...

Journal of the Practice of Cardiovascular Sciences, 2021

Objective: The objective is to assess the clinical course and outcomes of heart transplant (HTx) ... more Objective: The objective is to assess the clinical course and outcomes of heart transplant (HTx) recipients affected by COVID-19 disease in a tertiary care health care institution. Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) is a contagious illness with alarming morbidity and mortality. The HTx recipients are chronically immunosuppressed and thus COVID-19 infection in them may result in an unpredictable clinical course. Materials and Methods: HTx recipients in a tertiary care transplant center in North India were retrospectively reviewed from January 2020 to January 2021. Case records of 28 patients of HTx were reviewed, and four (14%) were found to have developed Covid-19 infection. Clinical parameters and outcomes of these four HTx recipients with confirmed SARS-CoV-2 infection are described. Results: Fourteen percent of our HTx patients (4 out of 28 patients under follow-up) developed COVID-19 in the first infection wave. The study population consisted of 3 males and 1 female patient with a median age of 28 years (range 15–39). The most common presenting symptoms were fever (100%), myalgia (100%) and cough (75%). There was no mortality observed in this study. None required intensive care admission or mechanical ventilatory support. Three were managed with hospital admission while one was subjected to home isolation. The mean hospital stay was 13.5 days (12–17 days). Immunosuppressants were modified by reducing tacrolimus and mycophenolate, however, corticosteroids were continued. Conclusion: The dose modification rather than discontinuation of immunomodulatory agents should be established as standard of care for transplant recipients. Steroids may provide added benefit and should be continued. The morbidity and mortality in such cases may be lower than anticipated; however, this needs to be substantiated with larger multicentric studies.

Journal of Cardiac Critical Care TSS, 2021

Background Patients undergoing on-pump coronary artery bypass grafting (CABG) are at increased ri... more Background Patients undergoing on-pump coronary artery bypass grafting (CABG) are at increased risk of perioperative bleeding and morbidity associated with transfusion as a result of acquired and pharmacologically induced impaired platelet function. Settings and Design In this a prospective observational study where 52 patients underwent on-pump CABG were analyzed with ROTEM platelet aggregometry. Materials and Methods Patients were assigned to the “nonexcessive” and “excessive” postoperative bleeding groups according to the postoperative chest tube drainage over 24 hours. Platelet function was assessed by ROTEM platelet using three different activators (arachidonic acid, adenosine diphosphate, and thrombin receptor-activating peptide), at two perioperative time points (T1, before heparinization and T2, 5–10 minutes after protamine administration). Results There were no differences regarding demographic, pre–cardiopulmonary bypass (CPB) platelet count and antiplatelet therapy. Plate...

Journal of clinical trials, 2016

Background: Oxygen saturation and the PaO2 are the direct risk factors for post -operative respir... more Background: Oxygen saturation and the PaO2 are the direct risk factors for post -operative respiratory outcome in patients undergoing prolonged surgery under general anaesthesia. However the effect of preoperative PaO2 and PaO2 /FiO2 ratio on the postoperative course of the patient undergoing coronary artery bypass grafting is not known. Hypothesis: Pre-operative PaO2 and PaO2 /FiO2 ratio have a significant effect on the postoperative outcome among the patients undergoing coronary artery bypass grafting. Study design: Prospective clinical study Setting: Tertiary health care centre Materials and Methods: One hundred and fifty eight consecutive patients with a EURO Score of <6 undergoing routine first time coronary artery bypass grafting were selected for this study. Patients with ventricular dysfunction, Chronic Obstructive Pulmonary Disease (COPD), renal or hepatic dysfunction, patients on mechanical ventilation, on preoperative Intra Aortic Ballon Pump (IABP) and those who had t...

Journal of Perioperative Echocardiography, 2016

Major vessel injury is a possible complication during pericardiectomy for chronic constrictive pe... more Major vessel injury is a possible complication during pericardiectomy for chronic constrictive pericarditis (CCP). We present a case of CCP, who while undergoing radical pericardiectomy incurred an iatrogenic injury of a major vessel with profuse bleeding. A rent in main pulmonary artery (MPA) was detected by the surgical team and simultaneously confirmed on transesophageal echocardiography (TEE), and a timely intervention was done. Importance of monitoring TEE in a patient undergoing pericardiectomy for CCP is highlighted. How to cite this article Makhija N, Narula J, Kumar S, Taneja S, Hote MP. Pulmonary Artery Perforation: Rare reported Complication of Pericardiectomy for Chronic Constrictive Pericarditis recorded on Transesophageal Echocardiography. J Perioper Echocardiogr 2016;4(1):17-18.

Journal of the Practice of Cardiovascular Sciences, 2017

Introduction: Heart Transplant in India started in 1994. We were initially doing 1-2 per year but... more Introduction: Heart Transplant in India started in 1994. We were initially doing 1-2 per year but the numbers have picked up since 2014 and we have done 25 in the past 3 years. We describe our experience of the last 4 years in this paper. Results: Initially, we experienced a relatively higher rate of rejections, fungal infections and graft failure. As we changed protocols, stopped using induction therapy except in high risk, maintained higher levels of immune suppression and tapered steroids faster in the first year, the complications reduced. All patients who had rejections and all the later transplants were maintained on a regime of tacrolimus, mycophenolate mofetil and steroids along with six months of valgancyclovir, voriconazole and co-trimoxazole. Steroids were tapered by six months to 0.1 mg/kg per day in all patients. Conclusions: In our recent patients, infection was the most common adverse event followed by rejection and PGD. In the latter half of our experience, we found that the complications reduced, suggesting that experience leads to less complications.

Molecular and cellular biochemistry, Jan 14, 2018

Pulmonary hypertension (PH) is a morbid complication of cardiopulmonary as well as several system... more Pulmonary hypertension (PH) is a morbid complication of cardiopulmonary as well as several systemic diseases in humans. It is rapidly progressive and fatal if left untreated. In the present study, we investigated the effect of PPARα agonist fenofibrate (FF) on monocrotaline (MCT)-induced PH in rats. FF, because of its pleiotropic property, could be helpful in reducing inflammation, oxidative stress, and reactive oxygen species. On day 1, MCT (50 mg/kg, s.c.) was given to all the rats in MCT, sildenafil, and FF group except normal control rats. After 3 days of giving MCT, sildenafil (175 µg/kg, orally) and FF (120 mg/kg, orally) were given for 25 days. Echocardiography, hemodynamic parameters, fulton's index, histopathology, oxidative stress parameters, inflammatory markers, Bcl2/Bax gene expression ratio in the right ventricle, and protein expression for NOX-1 in lungs were studied in all the groups. FF has shown to prevent decrease in ratio of pulmonary artery acceleration time...

Medicines (Basel, Switzerland), Jan 17, 2018

The study was designed to explore any beneficial effect of Ocimum sanctum (Linn) (OS) in experime... more The study was designed to explore any beneficial effect of Ocimum sanctum (Linn) (OS) in experimental pulmonary hypertension (PH) in rats. OS is commonly known as “holy basil” and “Tulsi” and is used in the Indian System of Medicine as antidiabetic, antioxidant, hepatoprotective, adaptogenic, and cardioprotective. Monocrotaline (MCT) administration caused development of PH in rats after 28 days and rats were observed for 42 days. Treatments (sildenafil; 175 µg/kg, OS; 200 mg/kg) were started from day 29 after the development of PH and continued for 14 days. Parameters to assess the disease development and effectiveness of interventions were echocardiography, right and left ventricular systolic pressures, and right ventricular end diastolic pressure, percentage medial wall thickness (%MWT) of pulmonary artery, oxidative stress markers in lung tissue, NADPH oxidase (Nox-1) protein expression in lung, and mRNA expression of Bcl2 and Bax in right ventricula...

Annals of Cardiac Anaesthesia, 2017

Background: The mechanism of development of atrial fibrillation (AF) in patients undergoing coron... more Background: The mechanism of development of atrial fibrillation (AF) in patients undergoing coronary artery bypass grafting (CABG) has not been clearly defined, and the involvement of multiple factors such as advanced age, withdrawal of β-blockers, inadequate atrial protection, and electrolyte imbalance, particularly hypomagnesemia has been documented by several authors. Despite all the available pharmacologic prophylaxis, incidence of AF still remains high in this group of patients. This unexplained cause could be genetic inheritance of endothelin-1 (ET-1) gene which is thought to have a pro-arrhythmogenic effect. Aim: This study aims to investigate the relationship between plasma ET-1 concentrations, ET-1 gene polymorphisms in loci-1370 T/G,-134 (3A/4A) Ins/del, Lys198Asn (G/T), and occurrence of AF in patients undergoing CABG. Methodology: Ninety-eight nonrelated, nondiabetic patients over a period of 4 years undergoing routine CABG were selected for the present study. All patients were genotyped for three single nucleotide polymorphisms (SNPs) in loci-1370 T/G,-134 (3A/4A) Ins/del, and Lys198Asn (G/T) in the ET-1 gene by gene sequencing. The plasma ET-1 concentrations were measured using an ET immunoassay. Results: Plasma ET-1 concentrations were higher in AF+ group (P = 0.001) as compared to AF− group. The allele frequencies between AF+ and AF− group were significantly different only with respect to the Lys198Asn (G/T) SNP of the ET-1 gene. Conclusion: The study described the possible correlation of polymorphism of ET gene in CABG population from India. The ET-1 gene might play a disease-modifying role in atrial fibrillation.

Annals of cardiac anaesthesia

Poor sleep quality is emerging as high prevalence among the patients suffering from cardiometabol... more Poor sleep quality is emerging as high prevalence among the patients suffering from cardiometabolic disturbances. The vascular polypeptide endothelin 1 (ET-1) is involved in many of the health disorders. However, its potential involvement in patients having poor sleep quality along with cardiovascular problem is limited. The present study was formulated to conduct a prospective analysis of the relationship between ET-1 and in hospital outcome in sleep disorder patients undergoing routine coronary artery bypass grafting (CABG). A total of 156 patients were enrolled and divided into two groups based on the Pittsburg Sleep Quality Index (PSQI) of ≤5 (Group I, n = 101) or >5 (Group II, n = 55). Blood sample was collected before anesthesia induction (ET-1a) and at 48 h (ET-1b) to analyze the plasma ET-1 and blood sugar level. The patients were monitored for any intraoperative adverse events and postoperative complications during their hospital stay. Both groups were comparable in rela...

Annals of Cardiac Anaesthesia, 2017

Background: There has been a constant emphasis on developing management strategies to improve the... more Background: There has been a constant emphasis on developing management strategies to improve the outcome of high-risk cardiac patients undergoing surgical revascularization. The performance of coronary artery bypass surgery on an off-pump coronary artery bypass (OPCAB) avoids the risks associated with extra-corporeal circulation. The preliminary results of goal-directed therapy (GDT) for hemodynamic management of high-risk cardiac surgical patients are encouraging. The present study was conducted to study the outcome benefits with the combined use of GDT with OPCAB as compared to the conventional hemodynamic management. Material and Method: Patients with the European System for Cardiac Operative Risk Evaluation ≥3 scheduled for OPCAB were randomly divided into two groups; the control and GDT groups. The GDT group included the monitoring and optimization of advanced parameters, including cardiac index (CI), systemic vascular resistance index, oxygen delivery index, stroke volume variation; continuous central venous oxygen saturation (ScVO 2), global end-diastolic volume, and extravascular lung water (EVLW), using FloTrac ™ , PreSep ™ , and EV-1000 ® monitoring panels, in addition to the conventional hemodynamic management in the control group. The hemodynamic parameters were continuously monitored for 48 h in Intensive Care Unit (ICU) and corrected according to GDT protocol. A total of 163 patients consented for the study. Result: Seventy-five patients were assigned to the GDT group and 88 patients were in the control group. In view of 9 exclusions from the GDT group and 12 exclusions from control group, 66 patients in the GDT group and 76 patients in control group completed the study. Conclusion: The length of stay in hospital (LOS-H) (7.42 ± 1.48 vs. 5.61 ± 1.11 days, P < 0.001) and ICU stay (4.2 ± 0.82 vs. 2.53 ± 0.56 days, P < 0.001) were significantly lower in the GDT group as compared to control group. The duration of inotropes (3.24 ± 0.73 vs. 2.89 ± 0.68 h, P = 0.005) was also significantly lower in the GDT group. The two groups did not differ in duration of ventilated hours, mortality, and other complications. The parameters such as ScVO 2 , CI, and EVLW had a strong negative and positive correlation with the LOS-H with r values of − 0.331, −0.319, and 0.798, respectively. The study elucidates the role of a goal-directed hemodynamic optimization for improved outcome in high-risk cardiac patients undergoing OPCAB.

Journal of Ethnopharmacology, 2017

effects of aqueous extract of stem bark of Terminalia arjuna (Roxb.), an Ayurvedic drug in experi... more effects of aqueous extract of stem bark of Terminalia arjuna (Roxb.), an Ayurvedic drug in experimental pulmonary hypertension",

Journal of Cardiothoracic and Vascular Anesthesia, 2017

Objectives: The postoperative course following on-pump coronary artery bypass grafting (CABG) in ... more Objectives: The postoperative course following on-pump coronary artery bypass grafting (CABG) in patients with severe left ventricular (LV) systolic dysfunction is often unpredictable. Therefore, the aim of this study was to identify predictors of poor postoperative outcome in this subset of patients. Design: Prospective observational study Setting: Single university hospital Participants: Forty patients with severe LV systolic dysfunction undergoing isolated on-pump CABG Interventions: None Measurements and Main Results: Comprehensive transesophageal echocardiographic examination was performed to obtain the indices of systolic and diastolic LV function after induction of anesthesia. A poor postoperative outcome was defined as patient death or vasoactive inotropic scoreZ20 for at least 6 hours and/or requiring intra-aortic balloon counterpulsation and/or mechanical ventilation for Z24 hours. Poor postoperative outcome was observed in 40% (16/40) of patients. Patients with poor postoperative outcomes had a significantly higher systolic dyssynchrony index, septal-lateral delay with a significantly lower global longitudinal strain and isovolumic acceleration, end-diastolic volume, end-systolic volume, and lateral and medial mitral annulus systolic velocity. In a binary logistic regression model, global longitudinal strain (odds ratio, 1.5, confidence interval [CI] 95%, 1.19-1.88, p ¼ 0.001), septal-lateral delay (odds ratio, 1.02, 95% CI, 1.01-1.03; p ¼ 0.001) and systolic dyssychrony index (odds ratio, 1.3, 95% CI, 1.13-1.48; p ¼ 0.000) were found to be predictors of poor postoperative outcome. Conclusion: Global longitudinal strain, systolic dyssynchrony index, and septal-lateral delay were reliable and accurate predictors of adverse outcomes in patients with severe LV systolic dysfunction undergoing on-pump CABG.

Annals of cardiac anaesthesia

Levosimendan a calcium ion sensitizer improves both systolic and diastolic functions. This novel ... more Levosimendan a calcium ion sensitizer improves both systolic and diastolic functions. This novel lusitropic drug has predictable antiischemic properties which are mediated via the opening of mitochondrial adenosine triphosphate-sensitive potassium channels. This action of levosimendan is beneficial in cardiac surgical patients as it improves myocardial contractility, decreases systemic vascular resistance (SVR), and increases cardiac index (CI) and is thought to be cardioprotective. We decided to study whether levosimendan has any impact on the outcomes such as the duration of ventilation, the length of Intensive Care Unit (ICU) stay, and the hospital stay when compared with the nitroglycerine (NTG), which is the current standard of care at our center. Forty-seven patients undergoing elective coronary artery bypass surgery were randomly assigned to two groups receiving either levosimendan or NTG. The medications were started before starting surgery and continued until 24 h in the po...

Journal of the Practice of Cardiovascular Sciences, 2015

We report the successful implant of an external basal annuloplasty device (basal annuloplasty of ... more We report the successful implant of an external basal annuloplasty device (basal annuloplasty of the cardia externally), which is a dimethyl silicone band, slipped around the base of the heart at the atrioventricular groove and the sub-annular myocardium to provide external myocardial support and mitral annuloplasty. The patient had ischemic heart disease with moderate functional mitral regurgitation which was reduced to mild regurgitation. The patient underwent coronary artery bypass during the same surgery.

Journal of the Practice of Cardiovascular Sciences, 2015

After the first successful adult heart transplant in India at All India Institute of Medical Scie... more After the first successful adult heart transplant in India at All India Institute of Medical Sciences, in 1994, we did our first pediatric heart transplant in 2015. An adult heart was successfully transplanted into a 10-year-old child. The steps from planning to the execution of the surgery and successful discharge of the patient are hereby discussed.

Indian Journal of Thoracic and Cardiovascular Surgery, 2006

Indian Journal of Thoracic and Cardiovascular Surgery, 2006

Indian Journal of Thoracic and Cardiovascular Surgery, 2012

ABSTRACT Introduction Advances in technology have spurred innovations in most surgical discipline... more ABSTRACT Introduction Advances in technology have spurred innovations in most surgical disciplines- including cardiac surgery - directed towards minimizing invasiveness without compromising outcomes. We present our initial experience and learning curve difficulties in performing robotically assisted atrial septal defect closure in an adult population. Patients and methods Over a 4 year period between February 2008 to January 2012, we operated upon 52 patients with secundum type of Atrial Septal Defect (ASD), using the daVinci robotic system. All operations were done with peripheral cardiopulmonary bypass and direct transthoracic access to aorta for cardioplegia and aortic cross clamping. Mean age of patients was 26.8 years, mean cross-clamp, cardiopulmonary bypass and operating times were 68.4, 121.6 and 178.44 min respectively. In 4 patients, there was conversion – to sternotomy in three and to thoracotomy in one. In all patients, successful closure was confirmed by Trans Esophageal Echocardiography (TEE). Mean Intensive Care Unit (ICU) stay duration was 22.1 h and hospital stay 3.6 days. There was no mortality. In one patient, there was lung parenchymal bleeding necessitating reexploration followed by persistent air leak for 48 h. Conclusions Robotic telemanipulation enables application of endoscopic technology to performing complex intrathoracic operations safely. Patients with simple lesions like ASD who are not candidates for device closure may be offered this surgeon-friendly technology to avoid possible complications of sternotomy and enable faster recovery. Factors like - adapting to telemanipulation, setting up peripheral cardiopulmonary bypass and restricted visibility prolongs both operating times and surgeons’ learning curve but greatly minimises patient morbidity.

Annals of cardiac anaesthesia

Aneurysm of sinus of Valsalva is a rare congenital cardiac defect that can present with myriad si... more Aneurysm of sinus of Valsalva is a rare congenital cardiac defect that can present with myriad signs and symptoms ranging from trivial to catastrophic events like cardiogenic shock and death. As clinical examination is not entirely reliable and the patient can sometimes be so ill as to preclude cardiac catheterization, echocardiography has become the definitive investigative tool not only to define and diagnose the lesion but also to quantify its severity. The following is a case report of multiple aneurysms of the left aortic sinus of Valsalva rupturing into the left ventricle. Diagnosis is made on multi plane transesophageal echocardiography and color Doppler regarding precise identification of structural anomalies and shunt locations for perioperative assessment and definitive treatment is surgical repair.

Annals of cardiac anaesthesia

Improved cosmetic appearance, reduced pain and duration of post-operative stay have intensified t... more Improved cosmetic appearance, reduced pain and duration of post-operative stay have intensified the popularity of minimally invasive cardiac surgery (MICS); however, the increased risk of stroke remains a concern. In conventional cardiac surgery, surgeons can visualize and feel the cardiac structures directly, which is not possible with MICS. Transesophageal echocardiography (TEE) is essential during MICS in detecting problems that require immediate correction. Comprehensive evaluation of the cardiac structures and function helps in the confirmation of not only the definitive diagnosis, but also the success of surgical treatment. Venous and aortic cannulations are not under the direct vision of the surgeon and appropriate positioning of the cannulae is not possible during MICS without the aid of TEE. Intra-operative TEE helps in the navigation of the guide wire and correct placement of the cannulae and allows real-time assessment of valvular pathologies, ventricular filling, ventric...