Mukund A. Prabhu

Bio: Mukund A. Prabhu is an academic researcher from Sree Chitra Thirunal Institute for Medical Sciences and Technology. The author has contributed to research in topics: Medicine & Cardiology. The author has an hindex of 4, co-authored 14 publications receiving 63 citations.

Left sympathetic cardiac denervation in managing electrical storm: acute outcome and long term follow up

Abstract: Left sympathetic cardiac denervation (LSCD) may be beneficial in treating electrical storm (ES) of varied aetiologies. The present study analyse the outcome and long term follow up of LSCD in treating ES. This is a retrospective study of patients with ES who underwent LSCD. Nine patients (majority males (88.89 %), median age 52 years, IQR 50.5–56.5) underwent LSCD. Coronary artery disease was the commonest substrate (7 (77.78 %)). Five patients, who had hypotension and unstable hemodynamics, underwent percutaneous stellate ganglion blockade. Three of the survivors subsequently underwent surgical sympathectomy. In the remaining four, video assisted thoracoscopy (VATS) guided sympathectomy was performed. Five (55 %) and seven (77.78 %) had a >90 and 80 % reduction in ventricular arrhythmias (VA), respectively. LSCD was ineffective in one patient, who succumbed to ES. There was no difference in outcome between patients with monomorphic versus polymorphic VA (60 vs 70 %, respectively, p = 0.82). One (11.1 %) patient had sudden death on the fifth day after LSCD. The median hospital stay was 13 days (IQR 11–16). During median 34 months of (IQR 18–46) follow up, one patient died of heart failure, and another had recurrence of ES. There was sustained reduction in VA burden in others. LSCD is effective in controlling ES and continues to reduce the incidence of VAs during long term follow up. Pharmacological LSCD needs particular emphasis, as it can be performed at bedside, and can be a bail-out procedure in centres where sophisticated procedures like VATS-guided LSCD or radiofrequency ablation are not readily available.

Flecainide challenge test: Predictors of unmasking of type 1 Brugada ECG pattern among those with non-type 1 Brugada ECG pattern.

Abstract: Background Many subjects in community have non-type 1 Brugada pattern ECG with atypical symptoms, relevance of which is not clear. Provocative tests to unmask type 1 Brugada pattern in these patients would help in diagnosing Brugada Syndrome. However sensitivity and specificity of provocating drugs are variable. Methods We studied 29 patients referred to our institute with clinical presentation suggestive but not diagnostic of Brugada or with non-Type 1 Brugada pattern ECG. Flecainide Challenge Test (FCT) was done in these patients (IV Flecainide test in 4 patients and Oral Flecainide in 25 patients). Resting 12-lead ECG with standard precordial leads and ECG with precordial leads placed 1 Intercostal space above were performed after flecainide administration every 5 min for first 30 min and every 30 min thereafter until ECG became normal or upto 6 h. The positivity was defined as inducible Type 1 Brugada pattern in atleast 2 right sided leads. Result Median age was 35(range = 5–65) years. In 16 (55%) patients the Type 1 Brugada pattern was unmasked. There were no episodes of major AV block, atrial or ventricular tachyarrhythmia. Three groups were considered for analysis: Group 1(n = 9) – FCT Positive among patients with non-type 1 Brugada ECG pattern, Group 2(n = 4) – FCT Negative among the patients with non-type 1 Brugada ECG pattern, and Group 3(n = 7) – FCT Positive among patients with no spontaneous Brugada ECG pattern. Binary logistic regression analysis found that family h/o SCD was predictive of FCT positivity in Group 1 (Odd’s ratio 21, 95% Confidence interval 1.04 to 698.83, p = 0.004). Conclusion Oral flecainide is useful and safe for unmasking of Type I Brugada pattern. In our study, among the many variables studied, family history of sudden cardiac death was the only predictor of flecainide test positivity among those with non-Type 1 Brugada pattern.

An unusual cause for unruptured sinus of valsalva aneurysm.

Abstract: Sinus of valsalva aneurysm is considered to be one of the rarest complications of inflammatory aortitis. Herewith, we are reporting a young male patient who presented to us with severe aortic regurgitation. On evaluation, he was found to have unruptured sinus of valsalva aneurysm. CT angiography and magnetic resonance imaging have shown value in the diagnosis of sinus of valsalva aneurysm.

Classical response of antidromic atriofascicular tachycardia to premature atrial extrastimulus delivered during septal refractoriness.

Abstract: A 23-year-old gentleman presented with a history of palpitations. The 12-lead electrocardiogram showed no manifest ventricular pre-excitation. Echocardiogram was within normal limits. A retrograde study showed concentric activation of the atrium with decremental conduction. Atrial pacing from right atrial free wall showed progressive pre-excitation. No anterograde nodal duality was documented.

2018 ESC Guidelines for the diagnosis and management of syncope

Abstract: Authors/Task Force Members: Michele Brignole* (Chairperson) (Italy), Angel Moya* (Co-chairperson) (Spain), Frederik J. de Lange (The Netherlands), Jean-Claude Deharo (France), Perry M. Elliott (UK), Alessandra Fanciulli (Austria), Artur Fedorowski (Sweden), Raffaello Furlan (Italy), Rose Anne Kenny (Ireland), Alfonso Mart ın (Spain), Vincent Probst (France), Matthew J. Reed (UK), Ciara P. Rice (Ireland), Richard Sutton (Monaco), Andrea Ungar (Italy), and J. Gert van Dijk (The Netherlands)

Progress toward the prevention and treatment of atrial fibrillation: A summary of the Heart Rhythm Society Research Forum on the Treatment and Prevention of Atrial Fibrillation, Washington, DC, December 9-10, 2013.

Abstract: The Heart Rhythm Society convened a research symposium on December 9–10, 2013, in Washington, DC, that focused on the prevention of atrial fibrillation (AF) as well as AF-related stroke and morbidity. Attendees sought to summarize advances in understanding AF since a 2008 National Institutes of Health (NIH) conference on this topic1 and to identify continued knowledge gaps and current research priorities. The research symposium also sought to identify key deficiencies and opportunities in research infrastructure, operations, and methodologies. The committee sought to identify both basic research targets and how clinical AF research could be improved in the current health care environment. This whitepaper summarizes our deliberations in an effort to accelerate progress toward preventing AF and its consequences. Although largely focused on primary prevention of AF, the paper also addresses some aspects of secondary prevention of recurrent AF due to the continuum of risk factors that contribute to arrhythmogenesis, permissive left atrial (LA) substrates, and the emergence of AF.

Diagnostic and prognostic role of electrocardiogram in acute myocarditis: A comprehensive review

Abstract: Background Acute myocarditis represents a challenging diagnosis as there is no pathognomonic clinical presentation. In patients with myocarditis, electrocardiogram (ECG) can display a variety of non-specific abnormalities. Nevertheless, ECG is widely used as an initial screening tool for myocarditis. Methods We researched all possible ECG alterations during acute myocarditis evaluating prevalence, physiopathology, correlation with clinical presentation patterns, role in differential diagnosis, and prognostic yield. Results The most common ECG abnormality in myocarditis is sinus tachycardia associated with nonspecific ST/T-wave changes. The presence of PR segment depression both in precordial and limb leads, a PR segment depression in leads with ST segment elevation, a PR segment elevation in aVR lead or a ST elevation with pericarditis pattern favor generally diagnosis of perimyocarditis rather than myocardial infarction. In patients with acute myocarditis, features associated with a poorer prognosis are: pathological Q wave, wide QRS complex, QRS/T angle ≥ 100°, prolonged QT interval, high-degree atrioventricular block and malignant ventricular tachyarrhythmia. On the contrary, ST elevation with a typical early repolarization pattern is associated with a better prognosis. Conclusions ECG alterations in acute myocarditis could be very useful in clinical practice for a patient-tailored approach in order to decide appropriate therapy, length of hospitalization, and frequency of followup.

Contemporary Management of Electrical Storm

Abstract: Cardiac electrical storm (ES) is characterised by three or more discrete episodes of ventricular arrhythmia within 24hours, or incessant ventricular arrhythmia for more than 12hours. ES is a distinct medical emergency that portends a significant increase in mortality risk and often presages progressive heart failure. ES is also associated with psychological morbidity from multiple implanted cardioverter defibrillator (ICD) shocks and exponential health resource utilisation. Up to 30% of ICD recipients may experience storm in follow-up, with the risk higher in patients with a secondary prevention ICD indication. Storm recurs in a high proportion of patients after an initial episode, and multiple storm clusters may occur in follow-up. The mechanism of storm remains elusive but is likely influenced by a complex interplay of inciting triggers (e.g., ischaemia, electrolyte disturbances), with autonomic perturbations acting on a vulnerable structural and electrophysiologic substrate. Triggers can be identified only in a minority of patients. An emergent treatment approach is warranted, if possible with emergent transfer to a high-volume centre for ventricular arrhythmia management with a multi-modality approach including ICD reprogramming, sympathetic blockade (sedation, intubation, ventilation, beta blockers), and anti-arrhythmic drugs, and adjunctive intervention techniques, such as catheter ablation and neuraxial modulation (e.g., thoracic epidural anaesthesia, stellate ganglion block). Outcomes of catheter ablation of ES are excellent with resolution of storm in over 90% of patients at 1year with a low complication rate (∼2%). ES may occur in the absence of structural heart disease in the context of channelopathies, Brugada syndrome, early repolarisation and premature ventricular contraction-induced ventricular fibrillation. There are unique treatment approaches to these conditions that must be recognised. This state-of-the-art review will summarise the incidence, mechanism, and multi-modality treatment of ES in the contemporary era.