1. 1. Rohit, Manojkumar and Krishnappa, Darshan and Selvaraj, Raja J.. Wide to narrow complex tachycardia: What is the diagnosis? 2018;29:487--488. DOI link.

  2. 2. Selvaraj, Raja J.. Demonstration of dual AV nodal physiology - More than one way to skin a cat? Indian Pacing and Electrophysiology Journal 2018;18:47--48. DOI link.

  3. 3. Gupta, Praveen K. and Selvaraj, Raja J.. A young female with cyanosis and clubbing 2018;:. DOI link.

  4. 4. Gupta, Praveen K. and Pillai, Ajith A. and Satheesh, Santhosh and Selvaraj, Raja and Balachander, Jayaram. Honeycomb-like appearance on optical coherence tomography in right coronary artery The International Journal of Cardiovascular Imaging 2018;34:343--344. DOI link.

  1. 1. Vora, A. and Kapoor, A. and Nair, M. and Lokhandwala, Y. and Narsimhan, C. and Ravikishore, A. G. and Dwivedi, S. K. and Namboodiri, N. and Hygriv, R. and Saxena, A. and Nabar, A. and Garg, S. and Bardoloi, N. and Yadav, R. and Nambiar, A. and Pandurangi, U. and Jhala, D. and Naik, A. and Nagmallesh and Rajagopal, S. and Selvaraj, R. and Arora, V. and Thachil, A. and Thomas, J. and Panicker, G.. Clinical presentation, management, and outcomes in the Indian Heart Rhythm Society-Atrial Fibrillation (IHRS-AF) registry Indian Heart Journal 2017;69:43--47. DOI link. Aim A national atrial fibrillation (AF) registry was conducted under the aegis of the Indian Heart Rhythm Society (IHRS), to capture epidemiological data-type of AF, clinical presentation and comorbidities, current treatment practices, and 1-year follow-up outcomes. Methods A total of 1537 patients were enrolled from 24 sites in India in the IHRS-AF registry from July 2011 to August 2012. Their baseline characteristics and follow-up data were recorded in case report forms and subsequently analyzed. Results The average age of Indian AF patients was 54.7 years. There was a marginal female preponderance – 51.5{\%} females and 48.5{\%} males. At baseline, 20.4{\%} had paroxysmal AF; 33{\%} had persistent AF; 35.1{\%} had permanent AF and 11{\%} had first AF episode. At one-year follow-up, 45.6{\%} patients had permanent AF. Rheumatic valvular heart disease (RHD) was present in 47.6{\%} of patients. Hypertension, heart failure, coronary artery disease, and diabetes were seen in 31.4{\%}, 18.7{\%}, 16.2{\%}, and 16.1{\%}, respectively. Rate control was the strategy used in 75.2{\%} patients, digoxin and beta-blockers being the most frequently prescribed rate-control drugs. Oral anticoagulation (OAC) drugs were used in 70{\%} of patients. The annual mortality was 6.5{\%}, hospitalization 8{\%}, and incidence of stroke 1{\%}. Conclusions In India, AF patients are younger and RHD is still the most frequent etiology. Almost two-third of the patients have persistent/permanent AF. At one-year follow-up, there is a significant mortality and morbidity in AF patients in India.

  2. 2. Selvaraj, Raja J. and Sakthivel, R. and Satheesh, Santhosh and Pillai, Ajith Ananthakrishna and Sagnol, Pascal and Jouven, Xavier and Dodinot, Bernard and Balachander, Jayaraman. Reuse of pacemakers, defibrillators and cardiac resynchronisation devices Heart Asia 2017;9:30--33. DOI link. OBJECTIVE Access to pacemakers remains poor among many patients in low/middle-income countries. Reuse of explanted pacemakers is a possible solution, but is still not widespread because of concerns regarding outcomes, especially infection. Our objective was to study early outcomes with implants using reused devices and compare them with those with implants using new devices. METHODS We studied all patients who underwent implantation of a new or reused pacemaker, cardiac resynchronisation therapy (CRT) device or implantable cardioverter defibrillator (ICD) in the last 5 years at a single institution. We analysed outcomes related to infection, device malfunction and device-related death within 6 months after initial implantation. RESULTS During the study period, 887 patients underwent device implant, including 127 CRT devices or ICDs. Of these, 260 devices (29.3{\%}) were reused and the others were new. At 6 months, there were three device-related infections in implants using a new device. There were no infections among patients receiving a reused device. There were no device malfunctions or device-related deaths in either group. CONCLUSIONS We found no difference in rate of infection or device malfunction among patients getting a reused device as compared with those with a new device. This study reinforces the safety of reusing devices for implant including CRT and ICDs.

  3. 3. Senthilnathan, Sengottuvel and Selvaraj, Raja J. and Patel, Rajesh and Satheesh, Santhosh and Katholil, Gireesan and Janawadkar, Madhukar P. and Radhakrishnan, Thimmakudy S.. Noninvasive Determination of HV Interval Using Magnetocardiography PACE - Pacing and Clinical Electrophysiology 2017;40:568--577. DOI link. {\textcopyright} 2017 Wiley Periodicals, Inc. Background: The His-ventricular (HV) interval is an important index of atrioventricular conduction, but at present can be reliably measured only during an invasive electrophysiology (EP) study. Magnetocardiography (MCG) is a noninvasive measurement of weak magnetic fields generated by the heart. We compared HV interval noninvasively assessed using MCG with the corresponding values measured directly in an EP study. Methods: MCG was measured using a 37-channel system inside a magnetically shielded room in patients who had previously undergone an EP study. His-bundle potential was identified in the PR segment after signal averaging. Magnetic field maps representing the spatial distribution of ramp-like signals in the PR segment generated at various instants of time were used to identify His-bundle signals in cases where the deflection representing the His was ambiguous. Results: The study included 23 patients (14 male, nine female) with a wide range of HV intervals measured during EP study (49 ± 17 ms, range 35–120 ms). In 21 (91{\%}) subjects, discernible His-bundle signals are observed in the PR segment of MCG traces. HV intervals measured between the two methods showed a correlation (r 2 = 0.87, P {\textless} 0.0001) with a mean difference of 5.4 ± 3.2 ms. Conclusion: With the use of new criteria to identify the His-bundle deflection in signal-averaged MCG signals, we report a high success rate in noninvasive HV interval measurement and a good agreement with those from EP study. The results encourage the use of MCG as a noninvasive method for measurement of the HV interval.

  4. 4. Selvaraj, Raja J. and Kumar, Binay and Rangasamy, Sasinthar. Infra-His Block during Atrial Pacing—Functional or Pathological? PACE - Pacing and Clinical Electrophysiology 2017;40:69--71. DOI link. {\textcopyright} 2016 Wiley Periodicals, Inc. The significance of infra-His conduction abnormalities observed in the electrophysiology lab can be difficult to assess. In this report we show infra-His conduction block during programmed atrial stimulation in a patient and discuss if this should be considered functional or pathological.

  5. 5. Selvaraj, Raja J. and Sarin, Krishna and Veeramani, Raveendranath. Which side are you on? – Deducing the chamber of origin of atrial tachycardia Indian Pacing and Electrophysiology Journal 2017;17:54--57. DOI link. Atrial arrhythmias rising from the regions of the atria that are in close proximity to each other may pose a challenge in identifying the chamber to map and ablate in. In this report, we discuss a patient with left atrial tachycardia which initially mimicked right atrial tachycardia. We discuss the origins of the abnormal electrograms in the right atrium and how this provides a general understanding of the mechanism of double potentials.

  6. 6. Jagadheesan, K.S. and Rangasamy, S. and Selvaraj, R.J.. A deadly mix - rheumatic mitral stenosis, preexcited atrial fibrillation, left atrial appendage thrombus and left atrial appendage accessory pathway Indian Pacing and Electrophysiology Journal 2017;:. DOI link.

  7. 7. Pillai, Ajith Ananthakrishna and {Gousy. V}, Saranya and Kottyath, Harichandrakumar and Satheesh, Santhosh and Selvaraj, Raja and Jayaraman, Balachander. Long-term outcomes following left main bifurcation stenting in Indian population-Analysis based on SYNTAX I and II scores Indian Heart Journal 2017;:. DOI link. Background: Syntax 1 and recently Syntax 2(SS2) scores are validated risk prediction models in coronary disease. Objectives: To find out the long term outcomes following stenting for unprotected left main bifurcation disease (LMD) and to validate and compare the performance of the SYNTAX scores 1 and 2(SS1 and SS2 PCI) for predicting major adverse cardiac events (MACE) in Indian population. Methods: Single-center, retrospective, observational study involving patients who underwent percutaneous coronary intervention (PCI) with at least one stent implanted for the LMD. Discrimination and calibration models were assessed by ROC curve and the Hosmer-Lemeshow test. Results: Data of 103 patients were analyzed. The mean SS1 and SS2 scores were 27.9 and 30.7 and MACE was 16.5{\%} at 4 years. The target lesion revascularization (TLR) rate at 4 years was 11(10.7{\%}). There were 4 deaths (3.8{\%}). The mean left ventricular ejection fraction (LV EF) was the only variable in SS2, which predicted cardiac events. ROC curve analysis showed both models to be accurate in predicting TLR and mortality following LM PCI. SS2 score showed a better risk prediction than SSI with AUC for TLR (SSI 0.560 and SS2PCI 0.625) and AUC for mortality (SS1 0.674 and SS2PCI 0.833). Hosmer-Lemeshow test validated the accuracy of both the risk models in predicting the events. Conclusions: Both risk models were applicable for Indian patients. The SS2 score was a better predictor for mortality and TLR. In the SS2 score, the LV EF was the most useful predictor of events after LM PCI.

  1. 1. Selvaraj, Raja J. and Sarin, Krishna and Singh, Vivek Raj and Satheesh, Santhosh and Pillai, Ajith Ananthakrishna and Kumar, Mahesh and Balachander, Jayaraman. Radiofrequency ablation of posteroseptal accessory pathways associated with coronary sinus diverticula Journal of Interventional Cardiac Electrophysiology 2016;47:253--259. DOI link. Pubmed. PURPOSE: Posteroseptal accessory pathways may be associated with a coronary sinus (CS) diverticulum. Our purpose was to describe the clinical characteristics, mapping and ablation of these pathways. METHODS: This was a retrospective study of all patients who underwent ablation of posteroseptal accessory pathways in a single centre. Patients with a diverticulum of the CS or one of its tributaries were included in group I, while the other patients formed group II. Clinical presentation, ablation procedure and outcome were compared between the two groups. RESULTS: A total of 51 patients were included, 16 in group I and 35 in group II. There were no significant differences in age or sex distribution. Atrial fibrillation (AF) and previous unsuccessful ablation were more common in group I. A negative delta wave in lead II was the ECG finding with best sensitivity and specificity for the presence of a diverticulum. A pathway potential was common at the successful site in group I, and the interval between local ventricular electrogram and delta wave onset was shorter (19.5 +/- 8 vs 33.1 +/- 7.6 ms, p {\textless} 0.001). There was a trend toward lower procedural success rate and higher recurrence rate in group I, although this was not significant. CONCLUSIONS: CS diverticula should be suspected in patients with manifest posteroseptal accessory pathways who have a previous failed ablation, documented AF or typical electrocardiographic signs. A discrete potential is frequently seen at the successful site, but the local ventricular electrogram is not as early as in other accessory pathways.

  2. 2. Selvaraj, Raja and Satheesh, Santhosh and Balachander, Jayaraman. Change of Heart: Altered Atrial Activation Following an Atrial Extrastimulus 2016;27:618--620. DOI link.

  1. 1. Selvaraj, Raja J. and Yerram, Sreekanth and Kumar, Pradeep and Satheesh, Santhosh and Pillai, Ajith Ananthakrishna and Saktheeswaran, Mahesh Kumar and Balachander, Jayaraman. Pace mapping in the atrium using bipolar electrograms from widely spaced electrodes Journal of Arrhythmia 2015;31:274--278. DOI link. Background Pace mapping is a useful tool but is of limited utility for the atrium because of poor spatial resolution. We investigated the use of bipolar electrograms recorded from widely spaced electrodes in order to improve the resolution of pace mapping. Methods This prospective study included patients undergoing a clinical electrophysiology study. Unipolar pacing from either the superior or inferior lateral right atrium was performed to simulate atrial tachycardia. Twelve-lead electrocardiograms were recorded during pacing as a template. In addition, three intracardiac bipolar electrograms from a set of widely spaced electrodes were also recorded. Subsequently, unipolar pacing was performed from electrodes at known distances from the initial pacing site, and the morphology of P waves in the electrocardiogram and bipolar electrograms were compared with that of the template. Morphological comparison was performed by a cardiologist and by automated computerized matching. Spatial resolution was calculated as the minimum distance at which there was no match. Results Fifteen patients participated in the study. Distance at which differences in morphology were noted was smaller in the bipolar electrograms compared to that indicated by P waves in the electrocardiogram, when matched by the cardiologist (6.1±3.8 mm vs. 9.9±5.2 mm, p=0.012) or by automated analysis (4±0 mm vs. 9.9±4 mm, p{\textless}0.001). Conclusions Use of three bipolar electrograms recorded from a set of widely spaced electrodes in the right atrium improves the resolution of pace mapping compared to that using P waves from surface electrocardiograms alone.

  2. 2. Keepanasseril, Anish and Maurya, Dilip Kumar and Yavana, Suriya J. and Selvaraj, Raja. Complete atrioventricular block in pregnancy: Report of seven pregnancies in a patient without pacemaker BMJ Case Reports 2015;2015:. DOI link. {\textcopyright} 2015 BMJ Publishing Group. All rights reserved. Obstetric management of a woman with a permanent pacemaker in situ is well reported in the literature; but those who present without pacing are still debatable. The necessity for setting the optimal timing or rate of temporary artificial pacing, specifically for labour, has not been objectively assessed. Temporary pacing in most cases reported in the literature might be to withstand the variations in haemodynamic status during delivery and labour. We report a case of a patient with complete heart block without any pacing who had seven pregnancies without any significant changes in haemodynamic status during labour and delivery. Managing a pregnancy without pacing might be an appropriate alternative for women without any underlying cardiac disorder, as it will not lead to significant changes in the haemodynamic system.

  3. 3. Selvaraj, Raja J. and {Raj Singh}, Vivek and Balachander, Jayaraman. Diagnostic Dilemma in a Narrow Complex Tachycardia PACE - Pacing and Clinical Electrophysiology 2015;38:887--890. DOI link. Pubmed.

  4. 4. Swamy, Mahadeva and Katyal, Deepak and Selvaraj, Raja J.. Jumping across the gap - A series of atrial extrastimuli Indian Pacing and Electrophysiology Journal 2015;15:73--75. DOI link. The ‘gap phenomenon' is an interesting phenomenon in electrophysiology arising from the differences in refractory periods at two or more levels of the atrioventricular (AV) conduction system. We present a patient with dual AV nodal physiology in whom the AH jump mediates the gap phenomenon. We also briefly discuss the other mechanisms of gap phenomenon that have been described in this setting.

  5. 5. Ramasamy, Chandramohan and Satheesh, Santhosh and Selvaraj, Raja. Seckel Syndrome with Severe Sinus Bradycardia Indian Journal of Pediatrics 2015;82:292--293. DOI link. Pubmed. Seckel syndrome is an uncommon form of microcephalic dwarfism. The authors report a young boy with Seckel syndrome who presented with severe sinus bradycardia with symptoms of syncope and presyncope. Implantation of a permanent pacemaker was necessary in view of the severe symptoms. Although uncommon, cardiac abnormalities have been rarely reported in Seckel syndrome. This is the one of the few reports of rhythm abnormalities in this condition.

  6. 6. Ezhumalai, Babu and Ananthakrishnapillai, Ajith and Selvaraj, Raja J. and Satheesh, Santhosh and Jayaraman, Balachander. Cardiac syndrome X: Clinical characteristics revisited Indian Heart Journal 2015;67:328--331. DOI link. Pubmed. Background Cardiac syndrome X includes a heterogenous group of patients with angina but normal epicardial coronaries in angiography. Objective Our objective was to study the clinical characteristics of patients with cardiac syndrome X. Methods Data of patients who underwent coronary angiography over a period of one year was retrospectively analyzed. Those with normal or non-obstructive coronaries in angiography with chest pain were included in this study. Results 1203 patients underwent coronary angiography during the study period. 105 (8.7{\%}) patients fulfilled the inclusion criteria. There were 52 (49.5{\%}) males and 53 (50.5{\%}) females including 31 (29.5{\%}) postmenopausal women. Many patients had atherosclerotic risk factors. Typical angina and atypical chest pain were reported by 63 (60{\%}) and 42 (40{\%}) patients, respectively. ECG was normal in 46 (43.8{\%}) and abnormal in 59 (56.2{\%}) patients. The most common abnormal finding in ECG was ST-T changes seen in 49 (46.7{\%}) patients. Regional wall motion abnormality with mild left ventricular systolic dysfunction was seen in 4 (3.8{\%}) patients while 101 (96.2{\%}) patients had normal ventricular function in echocardiography. TMT was positive for inducible ischemia in 35 (33.3{\%}) patients and inconclusive in 10 (9.5{\%}) patients. Angiography showed normal epicardial coronaries in 85 (80.9{\%}) patients. Conclusions Cardiac syndrome X constitutes a significant subset of patients undergoing coronary angiography. It is essential to identify and treat them specifically for microvascular angina. Many of them have atherosclerotic risk factors but their presentation is different from those with obstructive coronaries.

  1. 1. Pillai, Ajith Ananthakrishna and Ramasamy, Chandramohan and Saktheeshwaran, Maheshkumar and Selvaraj, Raja and Satheesh, Santhosh and Jayaraman, Balachander. Balloon valvuloplasty in rheumatic aortic valve stenosis: immediate and long-term results Cardiovascular Intervention and Therapeutics 2014;30:45--50. DOI link. To study the immediate and long-term results of balloon aortic valvuloplasty (BAV) in a large cohort of patients with rheumatic valvular aortic stenosis. Single tertiary care center retrospective data analysis of immediate and long-term outcomes in patients following BAV from 2000 to 2008. Ninety-two patients with rheumatic aortic stenosis (AS) were studied who underwent BAV. Mean age of patients was 21.7 years (95 {\%} CI 14.3-28.9) with mean follow-up period of 5.7 years (±SD 1.3). Intervention resulted in successful BAV (more than 50 {\%} reduction in baseline gradient) in 79 (85.9 {\%}) subjects (Group A) and partially successful BPV ({\textless}50 {\%} reduction in baseline gradient) in 8 (8.7 {\%}) subjects (Group B). BAV failed in 5 (5.4 {\%}) subjects (Group C). Concomitant balloon mitral valvuloplasty was done in 23/92 cases. Mean left ventricular systolic pressure decreased from 165.6 (95 {\%} CI 142.7-196.3) to 110.9 mmHg (95 {\%} CI 92.1-129.6), (P {\textless} 0.001) and mean aortic valve (AV) gradient from 50.7 (95 {\%} CI 35.12-66.22) to 27.2 mmHg (95 {\%} CI 25.83-31.23), (P {\textless} 0.001). The mean change in ejection fraction and mean AV gradient were significantly different between success (Groups A and B) and failure groups (P {\textless} 0.001). Different grades of aortic regurgitation were noted in 32 (34.78 {\%}) patients post BAV (severe regurgitation in 2.18 {\%}). Anova post hoc analysis showed sustained gradient reductions at 1- and 5-year follow-up (P {\textgreater} 0.05). The need for surgery was much lower in Group A (2.5 {\%}) compared to Group B (50 {\%}) and C (100 {\%}). BAV is an effective treatment strategy in dominant AS in multi valvular rheumatic disease situations. Combined aortic and mitral valvuloplasty was performed in one-fourth of study patients.

  2. 2. Ananthakrishna, A. and Balasubramonium, V R and Thazhath, H K and Saktheeshwaran, M. and Selvaraj, R. and Satheesh, S. and Jayaraman, B.. Balloon pulmonary valvuloplasty in adults: immediate and long-term outcomes J Heart Valve Dis 2014;23:511--515. Pubmed. BACKGROUND AND AIM OF THE STUDY: The study aim was to determine the immediate and long-term outcomes of balloon pulmonary valvuloplasty (BPV) in a large cohort of adult patients (aged {\textgreater}/= 18 years) with congenital valvular pulmonic stenosis. METHODS: A retrospective data analysis was conducted of the immediate and long-term outcomes of adult patients who had undergone BPV between 2000 and 2012 at a single tertiary care center. RESULTS: A total of 132 patients (mean age 27.7 years; 95{\%} CI 21.12-34.76) underwent BPV, with a mean follow up period of 5.7 years (95{\%} CI 4.37-6.98). Intervention resulted in successful BPV ({\textgreater} 50{\%} reduction in baseline gradient) in 124 patients (94{\%}), and a partially successful BPV (20-50{\%} reduction in baseline gradient) in eight patients (6{\%}). The mean right ventricular (RV) systolic pressure was decreased from 90.6 mmHg (95{\%} CI 84.90-96.33) to 50.9 mmHg (95{\%} CI 47.17-54.61) (p {\textless} 0.001), and the pulmonary valve (PV) gradient was reduced from 70.7 mmHg (95{\%} CI 65.12-76.22) to 29.0 mmHg (95{\%} CI 25.83-32.23) (p {\textless} 0.001). The mean percentage difference in PV gradient in both genders was 60.23{\%} in males and 57.44{\%} in females (95{\%} CI 55.33-65.12 and 55.32-61.56, respectively) (p {\textgreater} 0.05). Pulmonary valve regurgitation was reported in 17.4{\%} of patients, and was not related to either successful outcome or balloon size. The gradient reductions were maintained after five and 10 years of follow up. Two patients (1.5{\%}) developed restenosis that required repeat BPV. There was no referral for urgent surgery. CONCLUSION: BPV in adults produced excellent long-term clinical results, there being no gender-related difference in outcome. In addition, the need for reintervention was very low.

  3. 3. Ezhumalai, Babu and Satheesh, Santhosh and Anantha, Ajith and Pakkirisamy, Gobu and Balachander, Jayaraman and Selvaraj, Raja J.. Coronary sinus diameter by echocardiography to differentiate atrioventricular nodal reentrant tachycardia from atrioventricular reentrant tachycardia Cardiology Journal 2014;21:273--278. DOI link. Pubmed. BACKGROUND: Coronary sinus (CS) has been shown to be larger in patients with atrioventricular nodal reentrant tachycardia (AVNRT). We sought to determine if echocardiographically measured CS diameter can help identify the mechanism of tachycardia in patients with narrow complex tachycardia without preexcitation before the invasive electrophysiology study. METHODS: Forty four patients with documented narrow complex, short RP tachycardia who were scheduled for an electrophysiology study were included. Based on the electrophysiology study, patients were divided into those with AVNRT and those with a concealed accessory pathway and atrioventricular reentrant tachycardia (AVRT). Proximal CS diameter (CSp) measured at the ostium and mid CS diameter (CSm) 1 cm distal to the ostium using transthoracic echocardiography. RESULTS: CSp was significantly larger in patients with AVNRT than AVRT (14.1 +/- 5 vs. 9.9 +/- 2 mm, p {\textless} 0.0001). CSm diameter was not significantly different between the two groups. A cut-off of CSp {\textgreater} 11.2 mm identified AVNRT with a sensitivity of 92.6{\%} and specificity of 76.9{\%}. CSp was a better discriminant (AUC 0.89, 95{\%} CI 0.75-0.97) compared to age (AUC 0.74, 95{\%} CI 0.58-0.87) or tachycardia rate (AUC 0.60, 95{\%} CI 0.44-0.76). CONCLUSIONS: Echocardiographic measurement of the diameter of CS ostium can help in identifying the mechanism of the tachycardia before the invasive electrophysiology study.

  4. 4. Pillai, Ajith Ananthakrishna and Satheesh, Santhosh and Pakkirisamy, Gobu and Selvaraj, Raja and Jayaraman, Balachander. Techniques and outcomes of transcatheter closure of complex atrial septal defects-Single center experience Indian Heart Journal 2014;66:38--44. DOI link. Objective To prospectively study the techniques and outcomes of transcatheter closure of complex Atrial septal defects (ASD). Study design and settings Prospective single center study with experience in catheter closure of ASD. All patients with complex ASD suitable for device closure. Objective Analysis of outcomes of transcatheter closure of complex ASD in JIPMER Hospital over the past 5-year period. Methods Complex ASD was predefined and patients satisfying inclusion and exclusion criteria are included. All the patients had meticulous Transesophageal echocardiography (TEE) imaging beforehand. Modifications of the conventional techniques were allowed on a case per case basis according to operator preference. Successfully intervened patients were followed up clinically. Results Out of the 75 patients enrolled, 69 patients had successful device closure (success rate 92{\%}) despite challenging anatomy. Fifty-six (74{\%}) patients had ASD ≥25 mm. Fifteen patients (20{\%}) had defect size ≥35 mm and 20 patients (26.6{\%}) had devices implanted with ≥35 mm waist size. Fifty percent of patients had complete absence of aortic rim and 25{\%} had deficient posterior rim. Twenty percent of patients had malaligned septum. Mean follow up period was 3.2 years. Conclusions Trans catheter closure is feasible in anatomically complex substrates of Secundum ASD. Careful case selection, scrupulous imaging protocol, and expertise in modified techniques are mandatory for successful outcomes. Copyright {\textcopyright} 2013, Cardiological Society of India. All rights reserved.

  5. 5. Kumar, Senthil and Subramanian, Anandaraja and Selvaraj, Raja J.. Peritricuspid reentrant ventricular tachycardia in Ebstein's anomaly 2014;16:1633. DOI link.

  6. 6. Kumar, Pradeep and Balachander, Jayaraman and Selvaraj, Raja J.. Submitral aneurysm: A rare cause of ventricular tachycardia 2014;4:112--113. DOI link. Pubmed.

  7. 7. Kandaswamy, Pradeep Kumar and Anantha, Ajith and Balachander, Jayaraman and Selvaraj, Raja J.. Heart failure and pulsus alternans an unusual presentation of first-degree heart block 2014;7:227--228. DOI link. Pubmed.

  8. 8. Ramasamy, Chandramohan and Kumar, Senthil and Selvaraj, Raja J.. Parasystole in a mahaim accessory pathway Indian Pacing and Electrophysiology Journal 2014;14:223--226. DOI link. Pubmed. Automaticity has been described in Mahaim pathways, both spontaneously and during radiofrequency ablation. We describe an unusual case of automatic rhythm from a Mahaim pathway presenting as parasystole. The parasystolic beats were also found to initiate tachycardia, resulting in initial presentation with incessant tachycardia and tachycardia induced cardiomyopathy.

  9. 9. Selvaraj, Raja J. and Shankar, Bhima and Subramanian, Anandaraja and Nair, Krishnakumar. Chasing red herrings: Making sense of the colors while mapping 2014;7:553--556. DOI link. Pubmed.

  10. 10. Yerram, Sreekanth and Ramasamy, Chandramohan and Balachander, Jayaraman and Selvaraj, Raja J.. A curious alliance: Sinus nodal dysfunction precipitating atrioventricular block Journal of Arrhythmia 2014;30:208--210. DOI link. An elderly woman presented with recurrent syncope. Sinus bradycardia and sinoatrial block were seen on the electrocardiogram; however, PR interval prolongation after sinus pauses suggested atrioventricular conduction system disease. The occurrence of complete atrioventricular block after a pause during the electrophysiological study confirmed a diagnosis of paroxysmal atrioventricular block precipitated by sinus pauses secondary to sinus nodal disease.

  1. 1. Sharma, S. and Nair, P.P. and Murgai, A. and Selvaraj, R.J.. Transient bradycardia induced by thiopentone sodium: A unique challenge in the management of refractory status epilepticus BMJ Case Reports 2013;:. DOI link. Thiopentone sodium is one of the important drugs in the armamentarium for terminating refractory status epilepticus, a neurological emergency. We report a case of thiopentone-related bradycardia during the management of the new onset refractory status epilepticus in a young man, which was circumvented by prophylactic insertion of temporary pacemaker while thiopentone infusion was continued. A systematic approach was employed to manage the status epilepticus, including infusion of thiamine and glucose followed by antiepileptic drugs. The patient was ventilated and infused with lorazepam, phenytoin, sodium valproate, levetiracetam and midazolam followed by thiopentone sodium. With the introduction of thiopentone the seizures could be controlled but the patient developed severe bradycardia and junctional rhythm. The bradycardia disappeared when thiopentone was withdrawn and reappeared when the drug was reintroduced. Propofol infusion was tried with no respite in seizures. Later thiopentone sodium was reintroduced after inserting temporary cardiac pacemaker. Seizure was controlled and patient was weaned off the ventilator. {\textcopyright} 2013 BMJ Publishing Group. All rights reserved.

  2. 2. Ramasamy, Chandramohan and Ramteke, Rahul and Balachander, Jayaraman and Selvaraj, Raja J.. Sequential anterograde and retrograde conduction block during radiofrequency ablation of an accessory pathway Indian Pacing and Electrophysiology Journal 2013;13:148--150. DOI link. We present an interesting image showing sequential loss of anterograde, and subsequently, retrograde conduction during radiofrequency ablation of an accessory pathway. We discuss the possible mechanisms and prior literature concerning this interesting finding.

  3. 3. Selvaraj, Raja J and Yerram, Sreekanth and Ramasamy, Chandramohan and Balachander, Jayaraman. An unusual response to para-Hisian pacing: what is the explanation? Heart rhythm 2013;10:1586--8. DOI link. Pubmed.

  4. 4. George, K. Geofi and Gobu, Pakkirisamy and Selvaraj, Raja and Balachander, Jayaraman. Anomalous left anterior descending artery from pulmonary artery: An extremely rare coronary anomaly Indian Heart Journal 2013;65:88--90. DOI link. We report a rare coronary artery anomaly-anomalous origin of the left anterior descending artery from the pulmonary artery in a 40-year-old woman. The uniqueness of this case is the absence of any significant morbidity from this condition in adulthood which is in contrast to other reported cases where patients present with myocardial infarction, congestive heart failure, and sometimes death during the early infantile period.1 {\textcopyright} 2012, Cardiological Society of India. All rights reserved.

  1. 1. Selvaraj, Raja J. and Gobu, Pakkirisamy and Ashida, Thulaseedharan S. and George, Geofi and Balachander, Jayaraman. Ventricular tachycardia in repaired double chambered right ventricle - identification of the substrate and successful ablation Indian Pacing and Electrophysiology Journal 2012;12:27--31. DOI link. Pubmed. A 35 year old female presented with recurrent ventricular tachycardia 5 years after she had undergone surgical repair of double chambered right ventricle. Electroanatomical mapping showed a localised scar in the apex with double potentials and good pace map. Ablation here resulted in non-inducibility of ventricular tachycardia. We hypothesise that the scarring in the apex is the result of sustained pressure overload and becomes arrhythmogenic similar to the apical scar in patients with mid-ventricular hypertrophic cardiomyopathy.

  2. 2. Vidhyakar, Balasubramanian and Sadasivam, Ravishankar and Balachander, Jayaraman and Selvaraj, Raja J.. Ablation of atrioventricular nodal reentrant tachycardia using the superior approach in a patient with IVC interruption 2012;23:1393--1394. DOI link. Pubmed.

  3. 3. Selvaraj, Raja and Santhosh, Satheesh and Balachander, Jayaraman. Pseudodisappearance of atrial electrogram during accessory pathway ablation 2012;14:993. DOI link. Pubmed.

  1. 1. Selvaraj, Raja and Arunprasath, Palamalai and Babu, Ezhumalai and Balachander, Jayaraman. Termination of a broad complex tachycardia by a premature atrial complex 2011;22:100. DOI link. Pubmed.

  2. 2. Selvaraj, Raja J. and Santhosh, Satheesh and Balachander, Jayaraman. Ablation of ventricular tachycardia arising from the left coronary cusp Heart 2011;97:1720. DOI link. Pubmed.

  3. 3. Babu, Ezhumalai and George, Geofi and Balachander, Jayaraman and Selvaraj, Raja. Multiple inappropriate rate drop responses triggered by ventricular premature beats Europace 2011;13:1046. DOI link. We report the case of a 70-year-old patient presenting with palpitations who was found to have recurrent inappropriate rate drop responses on interrogation of his pacemaker. These were found to be triggered by interpolated premature ventricular complexes (PVCs). We discuss the drop detect algorithm and how interpolated PVCs triggered the rate drop response.

  4. 4. Parasuraman, S. and Raveendran, R. and Selvaraj, R.J.. Effects of cleistanthins A and B on blood pressure and electrocardiogram in Wistar rats Zeitschrift fur Naturforschung - Section C Journal of Biosciences 2011;66:. We have studied the effects of cleistanthin A and cleistanthin B, phytoconstituents isolated from the leaves of Cleistanthus collinus Roxb. (Euphorbiaceae), on blood pressure, electrocardiogram, and barium chloride-induced arrhythmia in Wistar rats. The two compounds were isolated by column chromatography and their identity was confirmed spectroscopically. A healthy, male Wistar rat was used to record the invasive blood pressure and electrocardiograph. The antiarrhythmic effects of cleistanthins A and B were studied using the barium chloride model. Both cleistanthin A and cleistanthin B showed a dosedependent hypotensive effect. Both compounds reduced the mean blood pressure significantly although the dose required for the effect was higher in the case of cleistanthin B. In the electrocardiogram, cleistanthins A and B significantly altered the electrical activity of the heart, the changes were transient and of no further consequence. Intravenous injection of 64 $\mu$g or more of cleistanthins A and B caused a sudden respiratory depression without affecting the electrocardiogram. Cleistanthins A and B did not display any antiarrhythmic effect against barium chloride-induced arrhythmia. In conclusion, both cleistanthin A and cleistanthin B exert a hypotensive effect and have no antiarrhythmic effect against barium chloride-induced arrhythmia in Wistar rats. {\textcopyright} 2011 Verlag der Zeitschrift f{\"{u}}r Naturforschung, T{\"{u}}bingen.