European Journal of Cardiovascular Medicine

Background: The operating room (OR) is a highly complex environment where excessive auditory stimuli may impair concentration, communication, and surgical performance. Human-generated noise and equipment-related sounds are increasingly recognized as important contributors to intraoperative distraction. Objectives: To evaluate the prevalence, common sources, and perceived impact of auditory distractions during different surgical procedures. Methods: This prospective observational study was conducted at N. K. P. Salve Institute of Medical Sciences & Research Centre and Lata Mangeshkar Hospital, Nagpur and included 370 surgical procedures comprising laparoscopic abdominal, open abdominal, breast, thyroid, perineal, hernia, and limb surgeries. Auditory distraction events were recorded in real time and categorized as phone ringtones, verbal conversations, equipment alarms, or background music. Data regarding the number and type of distraction events, personnel affected, and type of surgery were documented. Statistical analysis included descriptive statistics, chi-square testing, logistic regression, and multivariate analysis. Results: A total of 728 auditory distraction events were recorded, with a mean of 1.97 distractions per surgery. Phone ringtones were the most common source (35.2%), followed by verbal conversations (29.1%), equipment alarms (22.5%), and background music (13.2%). Laparoscopic abdominal surgeries demonstrated the highest distraction frequency (2.38 events/case). The primary surgeon was the most affected personnel (39.0%). Elective procedures showed higher distraction rates than emergency procedures (2.23 vs 1.62 events/case). Logistic regression demonstrated that phone ringtones (OR 2.48, p<0.001) and verbal conversations (OR 1.89, p=0.001) significantly increased surgeon distraction risk. Conclusion:  Auditory distractions are common in modern operating rooms and are predominantly caused by modifiable human-generated noise. Targeted noise-reduction strategies may improve concentration, communication, and surgical safety.

Background: • Cardiovascular diseases (CVDs) are the leading cause of global mortality. •Beyond traditional risk factors such as hypertension, dyslipidemia, diabetes, and obesity, the gut microbiota has emerged as a key determinant of cardiovascular health. •The intestinal microbiome influences host metabolism, immunity, and inflammation through microbial metabolites and gut–vascular interactions. Objectives: •To review evidence linking gut microbiota composition and function with cardiovascular health and disease. •To summarize mechanistic pathways by which microbial metabolites and dysbiosis affect vascular physiology. •To highlight emerging therapeutic interventions targeting the gut–heart axis. Methods: •A comprehensive literature review was conducted using PubMed, Scopus, and Google Scholar (2010–2025). •Keywords included gut microbiota, cardiovascular disease, TMAO, SCFA, dysbiosis, atherosclerosis, and hypertension. •Original studies, systematic reviews, and meta-analyses in both human and experimental models were analyzed. Results: • Dysbiosis is associated with hypertension, atherosclerosis, heart failure, and metabolic syndrome. •Key microbial metabolites include: oTMAO – pro-atherogenic, pro-thrombotic effects. oSCFAs – anti-inflammatory and vasoprotective actions. oBile acids & LPS – modulate lipid metabolism and systemic inflammation.•Therapeutic strategies—such as dietary modification, probiotics, prebiotics, synbiotics, FMT, and enzyme inhibition of TMA formation—show promising cardiovascular benefits. Conclusions: • The gut–heart connection represents a novel paradigm in preventive cardiology. • Modulating the gut microbiome offers potential to complement traditional CVD management. • Large-scale, mechanistic, and interventional studies are essential to translate these findings into clinical applications.

Background: Chronic liver disease (CLD) causes thrombocytopenia and coagulation abnormalities that increase the risk of spontaneous bleeding. Ocular hemorrhages may reflect the severity of these systemic changes. Aim: To evaluate the occurrence of spontaneous subconjunctival and retinal hemorrhages in CLD patients and their association with platelet count, INR, and disease severity. Methods: A prospective observational study was conducted on 80 patients with CLD. Comprehensive ophthalmic examinations and laboratory investigations were performed. Disease severity was assessed using the Child–Pugh classification. Results: Subconjunctival hemorrhage was observed in 22.5% and retinal hemorrhage in 15% of patients. The incidence of ocular hemorrhages increased significantly with decreasing platelet count, increasing INR, and worsening Child–Pugh class. Patients with platelet counts below 50,000/µL and INR >2.5 had the highest prevalence of ocular bleeding. Conclusion: Ocular hemorrhages are common in CLD and are significantly associated with thrombocytopenia, coagulopathy, and advanced liver disease. Routine ophthalmic evaluation may help identify patients at increased bleeding risk.

Background: Atherosclerotic cardiovascular disease (ASCVD) remains a major global health burden, and optimal lipid management is critical for secondary prevention. Low‑density lipoprotein cholesterol (LDL‑C) reduction is the cornerstone of therapy, while lipoprotein(a) [Lp(a)] has emerged as an independent, genetically determined risk factor contributing to cardiovascular risk. Despite strong guideline recommendations for achieving lower LDL‑C targets and performing at least once‑in‑a‑lifetime Lp(a) testing, real‑world adoption remains inconsistent. Understanding clinician practices is essential to addressing persistent gaps in ASCVD risk management. Aim and Objective: To assess healthcare professionals’ awareness, perceptions, and clinical practices regarding LDL‑C and Lp(a) in ASCVD management and to identify gaps in risk classification, LDL‑C target adoption, treatment escalation, and Lp(a) testing. Methods: An anonymised, structured, closed‑ended questionnaire was administered during the Cardiological Society of India (CSI) Congress 2025. The survey collected data on clinician demographics, ASCVD risk classification, LDL‑C targets, treatment strategies, Lp(a) awareness, testing patterns, thresholds used, and actions taken when Lp(a) was elevated. Responses were captured digitally and analysed descriptively. Results: A total of 201 clinicians participated, predominantly cardiologists (83%). The perceived ASCVD risk level differed according to how recent the cardiovascular event was. When the event was recent, most respondents classified patients as high risk (64%) or very high risk (20%), which remains discordant with guideline recommendations. However, when the event had occurred 20 years earlier, most clinicians classified the patient as moderate risk (72%), with only 11% identifying them as very high risk—indicating differing perceptions based on the timing of the event rather than guideline‑defined criteria. In very high‑risk patients, 56% targeted LDL‑C <70 mg/dL, while only 20% selected the recommended <55 mg/dL target. Use of injectable lipid‑lowering therapy was low, with most clinicians reporting that fewer than 10% of their patients received these agents; escalation was typically considered only at LDL‑C ≥150 mg/dL (59%). Lp(a) awareness was moderate; however, testing remained limited. Only about half of clinicians reported testing patients routinely or occasionally, despite once‑in‑a‑lifetime testing being recommended. Key barriers included cost, limited awareness, lack of inclusion in standard lipid panels, and the absence of targeted therapies. Conclusion: Significant gaps persist between guideline recommendations and clinical practice in ASCVD risk classification, LDL‑C goal setting, and treatment intensification. Lp(a) testing remains underutilized despite guideline endorsement. Strengthened clinician education and greater implementation of available advanced lipid‑lowering therapies are essential to enhance secondary prevention and reduce residual cardiovascular risk.

Background: Rheumatic mitral valvular disease remains a common cause of cardiovascular morbidity and mortality in Bangladesh. Accordingly, the present study was undertaken to compare early postoperative outcomes of right mini-thoracotomy versus standard median sternotomy in patients undergoing isolated mitral valve replacement, to better understand the safety and effectiveness of these surgical approaches. Methods: This prospective observational comparative study was conducted at the Department of Cardiac Surgery, National Heart Foundation Hospital and Research Institute (NHFH & RI), Mirpur, Dhaka, Bangladesh (July 2013–June 2015) to compare early outcomes of right mini thoracotomy versus median sternotomy in isolated mitral valve replacement; 44 first time isolated MVR patients were equally allocated (n = 22 each), with defined exclusions, and clinical, echocardiographic, operative, and 1 month follow up data were prospectively analyzed using SPSS version 16 (p < 0.05). Results: A total of 44 patients were equally divided into right mini-thoracotomy (n = 22) and median sternotomy (n = 22). Baseline and echocardiographic variables were comparable (p > 0.05). Mini-thoracotomy had longer operative times but smaller incisions (p < 0.05). It also showed shorter ventilation time, reduced hospital stay, lower pain scores, and less blood loss (p < 0.05), while ICU stay, complications, mortality, and postoperative echocardiographic outcomes were similar between groups. Conclusion: Right mini-thoracotomy for mitral valve replacement is a safe alternative to median sternotomy and is associated with reduced surgical trauma and improved early postoperative recovery.

Background: The aortic valve is a tricuspid structure forming the left ventricular outflow tract, and its most common pathology is aortic stenosis. Aortic valve replacement has evolved from median sternotomy to minimally invasive approaches such as ministernotomy. This study compares early outcomes of ministernotomy versus conventional median sternotomy in isolated aortic valve replacement. Methods: This quasi-experimental comparative study was conducted in the Department of Cardiac Surgery at the National Heart Foundation Hospital and Research Institute (NHFH & RI), Mirpur, Dhaka, Bangladesh, from January 2012 to December 2013 among 44 patients undergoing isolated aortic valve replacement (AVR), equally divided into ministernotomy and conventional median sternotomy groups. Perioperative and follow-up outcomes were compared, and statistical analysis was performed using SPSS version 17 with p <0.05 considered significant. Results: Forty-four patients were equally allocated to ministernotomy (n = 22) and median sternotomy (n = 22). Baseline variables were comparable (all p > 0.05). Ministernotomy had longer CPB time (122.45 vs 104.50 min, p = 0.025) and shorter incision (9.45 vs 21.72 cm, p = 0.001). Transfusion was higher (86.4% vs 31.8%, p = 0.001), with similar blood loss and drainage. Recovery was better with ministernotomy, including shorter ventilation, ICU stay, lower inotrope use, and less pain (all p ≤ 0.003), while hospital stay was similar. Wound infection, mortality, and LVEF outcomes were comparable (all p > 0.05). Conclusion: Ministernotomy for isolated aortic valve replacement is a safe alternative to median sternotomy with comparable outcomes and several advantages in early postoperative recovery.

Background: Sudden cardiac death (SCD) is a major global public health problem and constitutes a large proportion of medicolegal autopsies. In India, data from semi-rural regions remain limited, and many cardiovascular pathologies go undiagnosed during life. Objectives: To evaluate the histopathological spectrum of cardiac lesions in sudden deaths, assess age- and sex-wise distribution, and correlate gross and microscopic cardiac findings. Methods: This autopsy-based observational study was conducted on sudden death cases received at a tertiary care center in the Mahakaushal region of Madhya Pradesh, India. Hearts were examined grossly and sampled systematically from the left ventricle, interventricular septum, right ventricle, and coronary arteries. Histopathological evaluation was performed using hematoxylin and eosin staining. Results: Cardiovascular pathology was identified in the majority of sudden deaths, with ischemic heart disease and coronary atherosclerosis being the predominant findings. The left anterior descending artery was most frequently involved. Acute myocardial infarction showed coagulative necrosis, wavy fibers, edema, and neutrophilic infiltration, while chronic ischemic injury was characterized by fibrosis and collagen scar formation. Males in the 41–60-year age group were most commonly affected. Gross findings such as cardiomegaly, left ventricular hypertrophy, and coronary stenosis showed strong correlation with histopathological abnormalities. Conclusion: Coronary atherosclerosis and myocardial ischemic injury are the leading histopathological substrates of sudden cardiac death in the Mahakaushal region. Autopsy with detailed microscopic examination remains indispensable for accurate cause-of-death determination and for identifying silent cardiovascular disease in the community.

Cis-atracurium is a preferred intermediate-acting neuromuscular blocker for routine tracheal intubation, valued for its organ-independent elimination and cardiovascular safety profile. This study evaluates and compares three different doses of cis-atracurium to determine the ideal dose for achieving optimal intubating conditions, onset speed, and hemodynamic stability during general anesthesia. Methods: A randomized, prospective, double-blind clinical trial was conducted on 45 adult patients (ASA status 1 and 2, aged 18–60 years) scheduled for elective surgeries. Patients were equally distributed into three groups (n=15 each) to receive intravenous cis-atracurium at doses of 0.2 mg/kg (Group A), 0.3 mg/kg (Group B), or 0.4 mg/kg (Group C). Neuromuscular blockade onset and clinical duration were evaluated objectively using a Train-of-Four (TOF) watch. Endotracheal intubating conditions, perioperative hemodynamic variables, and potential adverse effects were monitored and recorded for statistical analysis. Results: The 0.4 mg/kg dose (Group C) demonstrated the fastest neuromuscular blockade, with a mean onset time of 166.5 ± 26.6 seconds, compared to 231.0 ± 45.9 seconds in Group B and 264.6 ± 69.9 seconds in Group A (p < 0.001). The clinical duration of action was significantly prolonged with increasing doses, measuring 49.4 ± 7.9 minutes in Group A, 59.3 ± 8.8 minutes in Group B, and 65.8 ± 7.8 minutes in Group C (p < 0.001). Excellent intubating conditions were successfully achieved across all three groups. Cardiovascular parameters remained stable throughout the study periods, and no drug-related adverse events or histamine-release symptoms were observed. Conclusion: Cis-atracurium in the dose range of 0.2–0.4 mg/kg provides consistently excellent and safe intubating conditions with high hemodynamic stability. However, a dose of 0.4 mg/kg is optimal for routine clinical anesthesia because it delivers the fastest onset of action and a prolonged surgical block without inducing adverse side effects. 

Background: Heart failure (HF) presents with varied clinical features, where albuminuria might indicate a poorer outcome. This research investigates the link between albuminuria and HF patient characteristics. Methods: We conducted a retrospective study of data from May to November 2025 at a medical college in rural Bihar, analyzing records of 120 patients with HF across preserved, midrange, and reduced ejection fractions. Albuminuria was evaluated via urine albumin/creatinine ratio, classifying patients as normoalbuminuric (<30 mg/g), microalbuminuric (30-299 mg/g), or macroalbuminuric (≥300 mg/g). Results: Of the 120 HF patients,48 (40%) presented with new-onset HF and 72 (60%) with worsening HF. Ejection fraction distribution showed 20% reduced, 40% midrange, and 40% preserved. Microalbuminuria affected 46.7% and macroalbuminuria 45.0%. Preserved EF strongly correlated with macroalbuminuria (p=0.0014), while midrange EF linked significantly to microalbuminuria (p=0.0018). NYHA class IV patients showed elevated macroalbuminuria (62.7%, p=0.0231). Albuminuria was significantly tied to histories of diabetes mellitus, hypertension, and myocardial infarction (p<0.05). Macroalbuminuria patients more often showed clinical symptoms such as basilar crepitations(p=0.0003), lower limb pitting (peripheral) edema (p=0.0012), hepatic enlargement (hepatomegaly)(p=0.0039), recumbent dyspnea (orthopnea)(p=0.0021), and jugular venous distension (p=0.0019). Conclusion: Albuminuria could signal congestion and HF severity, underscoring its value in routine HF evaluation and management.

Background: Calcific aortic stenosis (AS) is the most prevalent primary valvular heart disease in developed nations, frequently requiring transcatheter aortic valve implantation (TAVI) in elderly or high-risk populations. Precise anatomical measurement via multimodal imaging is crucial for procedural success and minimizing complications like paravalvular leak or conduction disturbances. Case Presentation: We present a comprehensive imaging and clinical analysis of a 74-year-old male diagnosed with severe degenerative valvular heart disease and hostile bilateral peripheral vasculature. Multidetector Computed Tomography (MDCT) and two-dimensional echocardiography (2D ECHO) were cross-evaluated pre- and post-intervention to assess structural parameters and guide procedural planning. Results: Pre-procedural 2D ECHO revealed severe AS with moderate aortic regurgitation (AR) and moderate concentric left ventricular hypertrophy (LVH), demonstrating an aortic valve area (AVA) of 0.6 cm² and a peak gradient of 92 mmHg. MDCT confirmed a tricuspid aortic valve configuration with moderate calcification extending into the LVOT. Annular average diameter was 22.5 mm (area: 413.6 mm²) with severe bilateral common iliac calcification. Post-TAVI echocardiography demonstrated a reduction in transvalvular gradient (PG/MG: 15/8 mmHg) with maintained LV systolic function (EF: 55%). Conclusion: This report highlights the synergy of quantitative MDCT planning and echocardiographic assessment in ensuring favorable hemodynamic outcomes for complex TAVI procedures when standard transfemoral access is not feasible.

Background: Community-acquired pneumonia (CAP) is a significant childhood morbidity across the globe, and antibiotics are regularly prescribed in outpatient practices. Nevertheless, it is still unclear what the best length of antibiotic treatment in simple paediatric CAP should be. Short-course therapy could provide similar clinical benefit, and less antimicrobial exposure and resistance pressure. Objective: To evaluate the clinical effectiveness and safety of short-course (3-5 days) and conventional-course (7-10 days) outpatient antibiotic therapy in children with uncomplicated CAP. Methods: This meta-analysis and systematic review was prepared based on PRISMA 2020 guidelines. Search in PubMed/MEDLINE, Scopus, Web of Science, and Cochrane Library (until December 2023) identified randomized controlled trials and high-quality comparative studies that evaluated the duration of oral antibiotics in children aged 1 month to 18 years. They were extracted into clinical cure, treatment failure, relapse, hospitalization, adverse drug reactions, and antibiotic re-treatment. They were pooled risk ratios (RRs) calculated by random-effects models using a 95% confidence interval (CI). Sensitivity and subgroup and publication bias were done. Results: The quantitative synthesis involved twelve studies. Pooled analysis demonstrated that there was no significant difference on clinical cure in short-course versus standard-course therapy (RR = 1.01, 95% CI 0.98-1.03) and low heterogeneity (I²= 12%). There were no significant differences on treatment failure, relapse, hospitalization or antibiotic re-treatment. Adverse drug reactions were reported in a narrative fashion and because of heterogeneous reporting, most studies reported similar or fewer events in short-term groups. Sensitivity and subgroup analyses provided similar results and there was no indication of publication bias. Conclusion: Antibiotic therapy in short course is clinically effective, safe, and consistent with antimicrobial stewardship principles. These results justify its application as the desirable timeframe of uncomplicated outpatient paediatric CAP.

Background: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) represents one of the most technically demanding subsets of coronary interventions. With advances in devices and techniques, procedural success and safety have improved; however, the clinical benefits of CTO PCI continue to be debated. Objectives: To evaluate demographic characteristics, angiographic complexity, procedural details, and 12‑month clinical outcomes of patients undergoing CTO PCI, and to contextualize these findings with contemporary evidence. Methods: This single‑center observational study included 78 consecutive patients undergoing CTO PCI. Baseline clinical and angiographic data were collected. Lesion complexity was assessed using the J‑CTO score. Clinical follow‑up at 12 months evaluated left ventricular ejection fraction (LVEF), angina status, and major adverse cardiac events (MACE). Results: Mean age was 57.1 ± 8.9 years, with male predominance (85.9%). Hypertension (78.2%) and hypercholesterolemia (82.1%) were common. Multivessel disease was present in 52.6%, and mean J‑CTO score was 1.8 ± 1.0. At 12 months, LVEF improved from 40.5 ± 6.5% to 45.5 ± 4.5%. Angina relief was achieved in 91.0% of patients. MACE occurred in 5.1%. Conclusions: CTO PCI was associated with significant improvement in symptoms and left ventricular function with low adverse event rates at 12 months, supporting its role in selected patients.

Background: Epicardial adipose tissue (EAT) is a metabolically active visceral fat depot implicated in coronary inflammation and atherosclerosis. Increasing evidence suggests a significant relationship between epicardial fat volume (EFV) and coronary artery disease (CAD) severity. Objective: To evaluate the association between epicardial fat volume (EFV) and severity of coronary artery disease assessed using CAD-RADS classification on CT coronary angiography (CTCA). Methods: This prospective observational study included 92 patients undergoing CT coronary angiography for suspected CAD. EFV was quantified using semiautomated volumetric CT analysis with attenuation thresholds of −200 to −30 Hounsfield units. Results: Mean EFV was 118.97 ± 32.63 cm³. EFV increased progressively across CAD-RADS categories from 72.43 ± 15.61 cm³ in CAD-RADS 0 to 162.87 ± 28.39 cm³ in CAD-RADS 5 (p < 0.001). Conclusion: Epicardial fat volume demonstrated significant association with coronary artery disease severity and multiple cardiometabolic risk factors.

Background: Epicardial adipose tissue (EAT) is a metabolically active visceral fat depot implicated in coronary inflammation and atherosclerosis. Increasing evidence suggests a significant relationship between epicardial fat volume (EFV) and coronary artery disease (CAD) severity. Objective: To evaluate the association between epicardial fat volume (EFV) and severity of coronary artery disease assessed using CAD-RADS classification on CT coronary angiography (CTCA). Methods: This prospective observational study included 92 patients undergoing CT coronary angiography for suspected CAD. EFV was quantified using semiautomated volumetric CT analysis with attenuation thresholds of −200 to −30 Hounsfield units. Results: Mean EFV was 118.97 ± 32.63 cm³. EFV increased progressively across CAD-RADS categories from 72.43 ± 15.61 cm³ in CAD-RADS 0 to 162.87 ± 28.39 cm³ in CAD-RADS 5 (p < 0.001). Conclusion: Epicardial fat volume demonstrated significant association with coronary artery disease severity and multiple cardiometabolic risk factors.

Background: Metabolic syndrome (MetS) is a cluster of metabolic abnormalities including central obesity, hypertension, hyperglycemia, hypertriglyceridemia, and low HDL cholesterol, which increase the risk of cardiovascular disease and type 2 diabetes mellitus. Serum ferritin, an indicator of body iron stores and inflammation, has been increasingly associated with insulin resistance and metabolic disturbances. Aims and Objectives: To evaluate serum ferritin levels in patients with metabolic syndrome and determine its association with various components of metabolic syndrome. Materials and Methods: A cross-sectional observational study was conducted in the Department of General Medicine, RIMS Hospital ,RIMS ,Raichur  involving 100 patients diagnosed with metabolic syndrome. Clinical history, anthropometric measurements, and laboratory investigations including fasting plasma glucose, HbA1c, lipid profile, renal function tests, complete blood count, and serum ferritin were performed. Statistical analysis was carried out using appropriate correlation tests, and a p-value <0.05 was considered statistically significant. Results: The mean age of the study population was 49.67±11.96 years with male predominance (58%). Mean serum ferritin level was 196.15±97.58 ng/mL. Significant positive correlation was observed between serum ferritin and waist circumference (r=0.456, p<0.001) as well as triglyceride levels (r=0.398, p<0.001). Serum ferritin showed a significant inverse correlation with HDL cholesterol (r=−0.229, p=0.022). No significant association was observed between serum ferritin and diabetes mellitus, hypertension, or number of metabolic syndrome components. Conclusion: Serum ferritin levels are elevated in patients with metabolic syndrome and are significantly associated with central obesity and dyslipidemia. Serum ferritin may serve as a useful biomarker for metabolic risk assessment.

Background: Metabolic syndrome (MetS) is a cluster of metabolic abnormalities including central obesity, hypertension, hyperglycemia, hypertriglyceridemia, and low HDL cholesterol, which increase the risk of cardiovascular disease and type 2 diabetes mellitus. Serum ferritin, an indicator of body iron stores and inflammation, has been increasingly associated with insulin resistance and metabolic disturbances. Aims and Objectives: To evaluate serum ferritin levels in patients with metabolic syndrome and determine its association with various components of metabolic syndrome. Materials and Methods: A cross-sectional observational study was conducted in the Department of General Medicine, RIMS Hospital ,RIMS ,Raichur  involving 100 patients diagnosed with metabolic syndrome. Clinical history, anthropometric measurements, and laboratory investigations including fasting plasma glucose, HbA1c, lipid profile, renal function tests, complete blood count, and serum ferritin were performed. Statistical analysis was carried out using appropriate correlation tests, and a p-value <0.05 was considered statistically significant. Results: The mean age of the study population was 49.67±11.96 years with male predominance (58%). Mean serum ferritin level was 196.15±97.58 ng/mL. Significant positive correlation was observed between serum ferritin and waist circumference (r=0.456, p<0.001) as well as triglyceride levels (r=0.398, p<0.001). Serum ferritin showed a significant inverse correlation with HDL cholesterol (r=−0.229, p=0.022). No significant association was observed between serum ferritin and diabetes mellitus, hypertension, or number of metabolic syndrome components. Conclusion: Serum ferritin levels are elevated in patients with metabolic syndrome and are significantly associated with central obesity and dyslipidemia. Serum ferritin may serve as a useful biomarker for metabolic risk assessment.

Background: Cardiac power output (CPO) has significant prognostic utility in patients with heart failure [1-3], cardiogenic shock [4], patients undergoing transcatheter aortic valve replacement (TAVR) [5,6]. CPO, however, has been evaluated scarcely in the perioperative period of cardiac surgical patients. CPO values in severe mitral stenosis (MS) patients undergoing mitral valve replacement (MVR) surgery is not known. This study aimed to find out the value of in severe MS patients undergoing MVR in comparison with patients with no known cardiac disease undergoing non-cardiac surgery. Methods: Transthoracic echocardiography (TTE) was performed to measure cardiac output (CO) prior to induction of anaesthesia in 50 patients with severe MS undergoing MVR (MS group) and 50 patients with no known cardiac disease undergoing major non-cardiac surgery (Non cardiac group). Mean arterial pressure (MAP) readings were simultaneously obtained from invasive arterial pressure monitor. CPO was calculated and compared between the two groups. Correlation between CPO and EuroSCORE 2 predicted mortality risk was evaluated in the MS group. Results: The median (IQR) CPO found in the MS group 0.62 (0.49-0.77) W was significantly less (p 0.000) than the CPO of 1.03 (0.80-1.24) W obtained in the non-cardiac group. CPO in the MS group had a moderately strong inverse correlation (Spearman’s rho -0.345, p= 0.014) with EuroSCORE 2 predicted mortality risk. Conclusion: CPO in severe MS patients undergoing MVR is significantly lower than that in adult patients with no known cardiac disease undergoing major non-cardiac surgery. CPO in severe MS patients undergoing MVR has moderately strong inverse correlation with EuroSCORE 2 predicted perioperative mortality risk.

Background: Gynaecomastia is a benign proliferation of male breast glandular tissue caused by an imbalance between estrogen and androgen activity.[1] Although commonly physiological during adolescence, persistent or symptomatic cases often require medical or surgical intervention. Limited Indian data exist regarding the clinical profile and treatment outcomes of gynaecomastia. Objectives: To evaluate the demographic profile, etiological spectrum, clinical characteristics, and therapeutic outcomes of gynaecomastia in Indian males presenting to a tertiary care centre. Methods: This hospital-based cross-sectional study was conducted over 24 months at a tertiary care centre in Bangalore and included 100 male patients with clinically or ultrasonographically confirmed gynaecomastia. Patients with lipomastia, suspected malignancy, or non-consenting individuals were excluded. Clinical evaluation included history, physical examination using Simon’s grading, and selective hormonal investigations. Management modalities included observation, tamoxifen therapy, and surgical intervention using liposuction with subcutaneous mastectomy. Data were analysed using descriptive statistics and chi-square tests, with p <0.05 considered statistically significant. Results: Adolescents aged 13–20 years constituted the largest group (52%), followed by young adults aged 21–40 years (34%). Bilateral gynaecomastia was observed in 84% of patients, while 70% presented primarily with cosmetic concerns. Grade IIa disease was the most common presentation (42%). Idiopathic gynaecomastia accounted for 62% of cases, followed by pubertal (22%) and drug-induced causes (8%). A significant association was observed between anabolic steroid use and younger adults (χ² = 7.21, p = 0.02). Observation resulted in spontaneous regression in 72% of selected cases. Tamoxifen significantly relieved mastalgia (p = 0.01) but showed limited effect on gland size reduction. Surgical management achieved the highest patient satisfaction rate (92%), which was statistically significant compared to non-surgical modalities (χ² = 14.52, p <0.001). Conclusion: Gynaecomastia predominantly affects adolescents and young adults in the Indian population, with idiopathic and pubertal forms being the most common. Early recognition and stage-based management are essential for optimal outcomes. While conservative and medical therapies are effective in selected early cases, surgical management provides the most definitive treatment and highest patient satisfaction in persistent or advanced disease.

Introduction: Cardiac hemangiomas are rare benign vascular tumors accounting for nearly 2% of all benign cardiac neoplasms. They may remain asymptomatic or present with varied clinical manifestations depending on their size and anatomical location. Presentation as acute coronary syndrome (ACS) is extremely uncommon and poses significant diagnostic challenges. Case Presentation: A 58-year-old chronic smoker presented with sudden onset typical anginal chest pain associated with retrosternal heaviness and diaphoresis. Electrocardiography showed pathological Q waves in the inferior leads, and high-sensitivity troponin-I levels were elevated more than three times the upper limit of normal. Transthoracic echocardiography revealed a 3.5 × 3.2 cm heterogeneous echogenic mass within the mid-apical interventricular septum protruding into the right ventricular cavity with both arterial and venous flow on color Doppler imaging. Coronary angiography demonstrated non-critical left circumflex artery disease and a highly vascular lesion supplied by feeder vessels arising from the right coronary artery and septal branches of the left anterior descending artery, suggestive of cardiac hemangioma. Cardiac magnetic resonance imaging confirmed a vascular mass in the interventricular septum with characteristic progressive post-contrast enhancement along with ischemic changes in the inferior and inferolateral left ventricular walls. The patient was managed conservatively with beta-blockers, antiplatelet agents, and antianginal therapy, with surgical excision planned if symptoms persisted during follow-up. Conclusion: Cardiac hemangioma presenting as acute coronary syndrome is exceedingly rare. Multimodality imaging including echocardiography, coronary angiography, and cardiac magnetic resonance imaging plays a pivotal role in diagnosis and treatment planning. Early recognition of this rare entity is important to differentiate it from other cardiac tumors and to guide appropriate management.

Introduction: Peripheral nerve blocks are effective for postoperative pain management in lower limb surgeries. The addition of adjuvants to local anesthetics can enhance the quality and duration of analgesia. Aim: This study aimed to compare the efficacy and safety of clonidine versus dexmedetomidine as adjuvants to levobupivacaine in ultrasound-guided femoro-sciatic nerve blocks for lower limb surgeries. Materials and Methods: In this prospective, randomized, double-blind study, 90 ASA I-II patients scheduled for lower limb surgeries were randomly allocated into two groups. Group A (n=45) received levobupivacaine with clonidine (1 μg/kg), and Group B (n=45) received levobupivacaine with dexmedetomidine (1 μg/kg) for ultrasound-guided femoro-sciatic nerve blocks. Postoperative pain was assessed using Visual Analog Scale (VAS) scores at 0, 2, 4, 8, 12, and 24 hours. Secondary outcomes included hemodynamic parameters (heart rate, blood pressure), motor blockade (Bromage score), and side effects (bradycardia, hypotension, nausea/vomiting). Results: Demographic parameters were comparable between the groups. VAS scores were significantly lower in the dexmedetomidine group compared to the clonidine group at all time points (p<0.001). Bromage scores, indicating motor blockade, were significantly higher in the clonidine group at 2, 4, and 8 hours (p<0.001). The dexmedetomidine group had a significantly higher incidence of bradycardia (33.3% vs. 15.6%, p=0.050) and hypotension (26.7% vs. 4.4%, p=0.004). Systolic blood pressure was significantly lower in the dexmedetomidine group at 4 and 8 hours (p=0.009 and p=0.026, respectively). Mean arterial pressure showed significant differences at multiple time points with variable patterns. Conclusion: Dexmedetomidine provides superior analgesia compared to clonidine when used as an adjuvant to levobupivacaine in femoro-sciatic nerve blocks but is associated with a higher incidence of cardiovascular side effects. Clonidine results in more intense motor blockade with a more favorable cardiovascular profile. The choice between these adjuvants should be individualized based on patient characteristics and surgical requirements.

Background: Brachial plexus blocks are widely used for upper limb surgeries, with various adjuvants being employed to enhance block quality and prolong postoperative analgesia. This study compared the efficacy of clonidine versus dexmedetomidine as adjuvants to ropivacaine in ultrasound-guided supraclavicular brachial plexus block for patients undergoing upper limb surgeries.  Methods: This prospective, randomized, double-blind study included 106 ASA I-II patients aged 18-60 years undergoing upper limb surgeries. Patients were randomly allocated into two groups (n=53 each): Group A received 30 ml of 0.5% ropivacaine with clonidine 2 μg/kg, and Group B received 30 ml of 0.5% ropivacaine with dexmedetomidine 1 μg/kg. Primary outcomes measured included onset and duration of sensory and motor blockade, time to first rescue analgesia, pain scores, and adverse effects. Results: Demographic profiles were comparable between groups. The dexmedetomidine group demonstrated significantly faster onset of sensory block (6.95±1.47 vs 9.28±1.80 min, p<0.001) and motor block (8.70±2.00 vs 12.08±2.40 min, p<0.001). Block duration was also superior with dexmedetomidine for both sensory (668.26±41.65 vs 551.81±43.93 min, p<0.001) and motor components (595.06±42.37 vs 497.94±46.61 min, p<0.001). The dexmedetomidine group exhibited prolonged time to first rescue analgesia (716.45±76.88 vs 579.15±57.30 min, p<0.001), lower pain scores at rescue (3.28±1.10 vs 4.51±1.09, p<0.001), and reduced analgesic requirements (1.92±0.85 vs 3.51±1.15 doses, p<0.001). Hemodynamic parameters remained stable in both groups, with no significant differences in the incidence of adverse effects. Conclusion: Dexmedetomidine is superior to clonidine as an adjuvant to ropivacaine in ultrasound-guided supraclavicular brachial plexus block, providing faster onset, prolonged duration of blockade, extended postoperative analgesia, and a favourable safety profile for patients undergoing upper limb surgeries.

Background and Aims: Accurate assessment of fluid responsiveness remains challenging in surgical patients, with approximately 50% of haemodynamically unstable patients not responding adequately to fluid therapy. The internal jugular vein distensibility index (IJV-DI) has emerged as a potential non-invasive alternative for predicting fluid responsiveness. This study aims to evaluate the accuracy of IJV-DI measurement compared with transthoracic echocardiography in predicting fluid responsiveness in patients undergoing elective surgery. Methods: This prospective cross-sectional study enrolled 33 adult patients (aged 18-65 years) with ASA physical status I-III undergoing elective surgery under general anaesthesia. Following anaesthesia induction and mechanical ventilation, baseline IJV-DI and stroke volume (SV) measurements were performed using ultrasonography and transthoracic echocardiography respectively. After administering 250 mL crystalloid fluid challenge, measurements were repeated. Patients with >10% increase in stroke volume were classified as fluid responders. The primary outcome was diagnostic accuracy of IJV-DI in predicting fluid responsiveness. Data were analyzed using receiver operating characteristic (ROC) curve analysis, Youden index for optimal cut-off determination, and Spearman's correlation test. Results: Of 33 patients, 19 (57.6%) were fluid responders. The ROC analysis revealed an area under the curve (AUC) of 0.863 (95% CI: 0.731, 0.995). The optimal cut-off value was IJV-DI >13.45% with sensitivity of 84.2% and specificity of 78.6%. Positive predictive value was 0.84 (95% CI: 0.64, 0.95) and negative predictive value was 0.79 (95% CI: 0.54, 0.94). A moderate positive correlation existed between IJV-DI and stroke volume increase (r = 0.542, P < 0.001). Conclusion: IJV-DI assessment demonstrates good diagnostic accuracy in predicting fluid responsiveness in elective surgery patients and is comparable with transthoracic echocardiography stroke volume measurement. This simple, non-invasive bedside tool may help optimize intraoperative fluid management.

Background: Shock index (SI) is calculated as heart rate divided by systolic blood pressure. In the obstetric population, SI of ≥0.9 is associated with maternal adverse outcomes. Our primary aim was to investigate the association between preoperative SI and post-spinal hypotension in non-elective cesarean section. Methods: In this prospective, cross-sectional study, term parturient of ASA physical status I and II, undergoing non-elective cesarean section with spinal anesthesia were enrolled. We performed univariable and multivariable logistic regression to explore the association between baseline SI (categorized as <0.9 and ≥0.9) and hypotension after spinal anesthesia. The diagnostic ability of the baseline SI to predict post-spinal hypotension was assessed using ROC (receiver operating characteristics) curves. Results: Ninety-six parturients were enrolled and analyzed. Forty-five (46.88%) parturients developed post-spinal hypotension, and thirty-three (34.38%) reported post-delivery hypotension. Preoperative SI (adjusted odds ratio [AOR], 2.84; 95% CI, 1.08–7.46; p=0.034) and thoracic sensory block height >T4 (AOR, 2.41; 95% CI, 1.02–5.68; p=0.045) were associated with post-spinal hypotension. Preoperative SI (AOR, 4.52; 95% CI, 1.58–12.91; p=0.005) was significantly associated with post-delivery hypotension. Area under the ROC curve for SI alone in predicting hypotension before and after delivery was 0.54 (95% CI 0.43–0.65) and 0.57 (95% CI 0.46–0.68) respectively. However, the model performance as reflected by ROC curve for the multivariable logistic regression analysis was 0.638 for post-spinal hypotension and 0.692 for post-delivery hypotension, respectively. Conclusion: In parturients undergoing non-elective cesarean section, baseline SI ≥0.9 was associated with post-spinal and post-delivery hypotension. While the SI alone showed limited predictive power for post-spinal and post-delivery hypotension, integrating it with other risk factors improved the model's predictive ability.

Background: Medication administration errors continue to pose a significant perioperative safety problem in that anaesthesia is a risky environment that requires high-pressure, rapid drug preparation and delivery. Self-reported errors in administering drugs are a known problem of anaesthesia providers, but there are no resident-based findings on knowledge attitude and practice across training years. Methods: A cross-sectional questionnaire study in anaesthesia residents of tertiary care teaching hospitals was carried out within 1 month. Knowledge, attitude, and practice were assessed medication administration errors for with Likert-scale items and close-ended items using a 20-item online instrument with convenience sampling (validated by two senior faculty). The domain scores were assigned to poor (<50%), moderate (50–74%), and good (≥75%). The categorical correlations were computed with chi-square/Fisher’s exact tests, and ordinal was subjected to nonparametric tests for comparison across training years; p<0.05 was considered statistically significant. Results: There were 236 residents who participated in the study (mean age 27.4±2.1 years; 52.1% female). Knowledge about medication administration errors was good in 41.1%, moderate in 45.8%, and poor in 13.1%. The positive attitude towards safe medication behaviours was higher (good: 52.5%) and safe practices were lower (good: 34.3%). Knowledge and practice scores increased with seniority: senior residents showed a median practice score that was larger than those of the first year (p<0.001). Look-alike/sound-alike drugs, syringe swaps, fatigue, and interruptions were frequent (self-reported) causes of medication administration errors factors aligned with perioperative human-factors literature. Conclusion: Anaesthesia residents showed moderate overall knowledge and generally favorable attitudes, but practice gaps were evident–especially amongst junior trainees. Structured resident-focused medication safety training, standardized labeling/workflow, and low-barrier incident reporting systems may improve safe practices as well as reduce preventable harm.

Background: Unexpected difficult airway is still one of the most challenging problems in anaesthetic practice and has a major contribution to perioperative morbidity and mortality. Typical bedside airway assessment tests, including the Modified Mallampati classification, thyromental distance, and inter-incisor gap, have limited sensitivity and specificity in predicting difficult intubation. Ultrasonography (USG) has recently become a non-invasive tool with the ability to assess airway anatomy in real time. We aimed to assess the role of preoperative airway ultrasonographic parameters in predicting difficult intubation and to compare their diagnostic accuracy with Cormack–Lehane (CL) grading obtained using direct laryngoscopy. Methods: A prospective cross-sectional study of 185 adults 18–60 years old with ASA physical status I–II undergoing elective surgery under general anaesthesia with endotracheal intubation in a tertiary care teaching hospital. Traditional airway assessment and ultrasonographic measurements of hyomental distance in neutral and extended positions (HMDn, HMDe), hyomental distance ratio (HMDR), pre-epiglottic space (PreE), epiglottis-to-vocal cord distance (E-VC), and the PreE/E-VC ratio were performed for preoperative assessment. Following induction of anaesthesia, direct laryngoscopy was performed and CL grading recorded. Difficult intubation was defined as CL grade III or IV or requirement of three or more intubation attempts. Statistical analysis utilized t-test, chi-square test, correlation analysis, and receiver operating characteristic (ROC) curves. Results: Out of 185 patients, 25 (13.5%) underwent a difficult intubation. Difficult intubation was associated with significantly lower HMDR and greater anterior neck soft tissue thickness at the level of the epiglottis and vocal cords (p<0.05). The best predictive accuracy for difficult airway was found with the PreE/E-VC ratio at AUC 0.86, followed by HMDR (AUC 0.82). Ultrasonographic parameters revealed higher sensitivity than conventional bedside airway tests. Conclusion: Airway ultrasonography provides reliable, objective parameters for predicting difficult intubation. Measurements such as HMDR and PreE/E-VC ratio show promising diagnostic accuracy and may complement conventional airway assessment methods. Integration of airway ultrasonography into routine preoperative evaluation may improve anticipation and management of difficult airways.

Background: Unanticipated difficult laryngoscopy and endotracheal intubation remain important contributors to perioperative airway morbidity. The modified Mallampati test (MMT) is routinely used to screen for difficult airways, but its predictive performance varies across studies, partly due to inconsistent test technique—particularly whether phonation is permitted during assessment. Methods: A hospital-based cross-sectional study was conducted over 3 months among 95 adults (18–65 years) scheduled for elective surgery under general anaesthesia requiring tracheal intubation. Each participant underwent preoperative MMT assessment in the sitting position both without phonation and with phonation (“ah”). Direct laryngoscopy was performed using a Macintosh blade (size 3 or 4). Laryngeal view was graded by the Cormack–Lehane (CL) classification. Difficult laryngoscopy was defined as CL grade III–IV. Difficult intubation was additionally evaluated using the Intubation Difficulty Scale (IDS), with IDS >5 defining difficult intubation. Diagnostic indices (sensitivity, specificity, PPV, NPV, accuracy) were calculated for each MMT approach. Results: There was difficulty in intubation in 11/95 (11.6%) patients. For test positive MMT Class III/IV, MMT without phonation had an increase in sensitivity: 81.8% sensitivity; specificity: 71.4%; PPV: 27.3%; NPV: 96.8%; and accuracy: 72.6%. MMT with phonation displayed sensitivity 63.6%, specificity 86.9%, PPV 38.9%, NPV 94.8%, and accuracy 84.2%. There was a moderate agreement between the two methods (κ ≈ 0.60). Phonation shifted a significant amount of patients toward lower Mallampati classes, reducing false positives but missing some harder cases. Conclusion: In this group, using phonation as an additional step to MMT increased specificity and accuracy, but decreased sensitivity for difficult intubation. Phonated MMT may be helpful to “ruling in” risk when positive, however non-phonated MMT does a better job of “screening” to minimize missed difficult airways. The multivariable assessment is still necessary for further investigation.

Background and Introduction: Balanced general anaesthesia employing adjuvant drugs allows reduction in primary anaesthetic doses while achieving haemodynamic stability, analgesia, and smooth recovery. Dexmedetomidine, a selective α₂-adrenoceptor agonist, is widely used as an intraoperative adjuvant for its sympatholytic, sedative, and analgesic properties. When combined with ketamine—an NMDA receptor antagonist with sympathomimetic properties—or fentanyl—a potent µ-opioid agonist—distinct haemodynamic and recovery profiles may result. Comparative evidence directly evaluating these two combinations in the intraoperative general anaesthesia setting remains limited, necessitating the present study. Aim: To compare the clinical effects of dexmedetomidine with ketamine versus dexmedetomidine with fentanyl as intraoperative adjuvants during general anaesthesia in terms of haemodynamic parameters, recovery characteristics, anaesthetic requirements, postoperative analgesia, and adverse events. Methods: A prospective randomised controlled study was conducted in 54 ASA I–II adult patients undergoing elective surgery under general anaesthesia. Patients were randomised equally into Group DK (dexmedetomidine + ketamine, n = 27) and Group DF (dexmedetomidine + fentanyl, n = 27). Heart rate, mean arterial pressure, SpO₂, and EtCO₂ were monitored at multiple intraoperative and postoperative time points. VAS pain scores were assessed at the end of surgery and at 2, 4, and 6 hours postoperatively. Muscle relaxant dose, extubation time, Ramsay Sedation Score, PACU stay duration, and adverse events were recorded. Data were analysed using independent samples t-test and chi-square/Fisher's exact test. p < 0.05 was considered statistically significant. Results: Both groups were comparable at baseline for all demographic variables (p > 0.05). Heart rate was comparable up to 40 minutes but was significantly higher in Group DK from 65 minutes onward, at extubation (69.30 ± 6.80 vs 62.11 ± 4.56 bpm; p < 0.001), and at 2 hours postoperatively (70.89 ± 6.38 vs 61.93 ± 4.95 bpm; p < 0.001). MAP was comparable through 125 minutes but significantly higher in Group DK from 140 minutes onward, at extubation (79.56 ± 5.42 vs 74.59 ± 6.70 mmHg; p = 0.004), and at 2 hours postoperatively (82.93 ± 7.99 vs 77.19 ± 9.26 mmHg; p = 0.018). SpO₂ and EtCO₂ were comparable throughout. VAS scores were similar at end of surgery and 2 hours, but significantly lower in Group DK at 4 hours (1.67 ± 0.78 vs 3.89 ± 0.85; p < 0.001) and 6 hours (1.78 ± 0.80 vs 4.44 ± 1.09; p < 0.001). Group DF required a significantly higher muscle relaxant dose (4.07 ± 0.87 vs 3.63 ± 0.69 mg; p = 0.043). Extubation time and Ramsay Sedation Scores were comparable. PACU stay was significantly prolonged in Group DF (p = 0.001). All adverse events were infrequent with no statistically significant intergroup differences. Conclusion: Dexmedetomidine with ketamine provides superior intraoperative haemodynamic stability, reduced muscle relaxant requirement, and significantly better postoperative analgesia at 4 and 6 hours compared to dexmedetomidine with fentanyl, along with a shorter PACU stay. Both combinations demonstrated comparable and acceptable safety profiles. The choice of adjuvant combination should be individualised based on surgical requirements, expected postoperative pain, and recovery logistics.

Background: Radical nephrectomy with inferior vena cava (IVC) thrombectomy is a complex surgical procedure associated with significant hemodynamic instability due to major vascular manipulation. Limited data are available on intraoperative hemodynamic trends and anesthetic implications, particularly in the Indian population. Methods: This retrospective observational study included 23 patients who underwent radical nephrectomy with IVC thrombectomy between January 2015 and December 2025 at a tertiary care center. Hemodynamic parameters including heart rate (HR), mean arterial pressure (MAP), cardiac output (CO), systemic vascular resistance (SVR), and stroke volume variation (SVV) were recorded at six predefined surgical phases. Statistical analysis was performed using repeated measures ANOVA or Friedman test, with p < 0.05 considered significant. Results: Significant hemodynamic variations were observed across surgical phases (p < 0.001). During IVC clamping, MAP decreased (58.9 ± 9.5 mmHg) and CO reduced (4.01 ± 0.85 L/min), while SVR increased (1829 ± 165 dynes·sec/cm⁵) and SVV rose (21.3 ± 5.4%). Following clamp release, MAP (101.9 ± 9.8 mmHg) and CO (6.06 ± 0.75 L/min) increased significantly, while SVR and SVV decreased. Mean blood loss was 1450 ± 520 mL, and 82% patients required transfusion. Two patients developed acute kidney injury, and two deaths occurred due to postoperative pulmonary embolism. Conclusion: IVC thrombectomy is associated with marked hemodynamic fluctuations, particularly during clamping and declamping. Advanced hemodynamic monitoring and vigilant anesthetic management with timely vasopressor support are essential to maintain cardiovascular stability and improve perioperative outcomes.

Background: Hypertension in the elderly is associated with increased cardiovascular risk, and masked hypertension often remains undetected with office blood pressure (BP) measurements alone. This study aimed to evaluate the role of home BP monitoring in identifying hypertension patterns and predicting cardiovascular outcomes in treated elderly patients. Methods: This hospital-based observational study included 106 treated hypertensive patients aged ≥60 years attending OPD and IPD at RKDF Medical College Hospital and Research Centre. Demographic data, cardiovascular risk factors, and BP measurements were recorded. Patients were classified into controlled, masked, sustained, and white coat hypertension based on office and home BP readings. Participants were followed for cardiovascular outcomes, and hazard ratios were calculated to assess risk. Results: The majority of participants were aged 60–69 years, with male predominance (60.4%). Controlled hypertension was observed in 45.3% of patients, while masked hypertension was present in 28.3%. Home BP readings were higher than office measurements. Sedentary lifestyle (41.5%) and dyslipidemia (37.7%) were the most common risk factors. Patients with masked hypertension showed a significantly higher incidence of left ventricular hypertrophy (33.3% vs 12.5%, p=0.01) and coronary artery disease (26.7% vs 12.5%, p=0.04). Masked hypertension was associated with a two-fold increased risk of cardiovascular events (HR 2.05, p=0.01). Increasing home systolic and diastolic BP were significant predictors of cardiovascular risk. Conclusion: Home BP monitoring is essential for detecting masked hypertension and improving cardiovascular risk prediction in elderly hypertensive patients.