PROFORMA FOR REGISTRATION OF



PROFORMA FOR REGISTRATION OF

SUBJECT FOR DISSERTATION

DISSERTATION PROPOSAL

“A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON THE KNOWLEDGE REGARDING CARDIAC RESYNCHRONIZATION THERAPY AMONG THE STAFF NURSES IN A SELECTED HOSPITAL,TUMKUR.”

SUBMITTED BY:

Ms.JENCY MARY JOHN

1st YEAR M.Sc.NURSING

MEDICAL SURGICAL NURSING,

SHRIDEVI COLLEGE OF NURSING,

TUMKUR.

(2009-2011)

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE,KARNATAKA.

ANNEXURE-II

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT

FOR DISSERTATION

| | | |

|1. |NAME OF THE CANDIDATE AND |Ms.JENCY MARY JOHN |

| |ADDRESS |1st YEAR MSc. NURSING |

| | |SHRIDEVI COLLEGE OF NURSING |

| | |SIRA ROAD. |

| | |TUMKUR |

| | |SIRA ROAD.TUMKUR. |

| | | |

|2. |NAME OF THE INSTITUTION |SHRIDEVI COLLEGE OF NURSING |

| | | |

|3. |COURSE STUDY AND SUBJECT |1ST YEAR M.Sc. NURSING |

| | |MEDICAL SURGICAL NURSING. |

| | | |

|4. |DATE OF ADMISSION TO |01-06-2009 |

| |COURSE | |

| | | |

|5. |TITLE OF THE STUDY |A STUDY TO EVALUATE THE |

| | |EFFECTIVENESS OF |

| | |STRUCTURED TEACHING PROGRAMME |

| | |ON THE KNOWLEDGE REGARDING |

| | |CARDIAC RESYNCHRONIZATION |

| | |THERAPY AMONG THE STAFF NURSES |

| | |IN A SELECTED HOSPITAL,TUMKUR. |

6. BRIEF RESUME OF INTENDED WORK

INTRODUCION

“If you have health,

you probably will be happy,

and if you have health

and happiness,

you have all the wealth you need,

even if it is not all you want.”

~Elbert

Hubbard

More than 22 million people worldwide suffer from various kinds of cardiac diseases,which are potentially debilitating diseases.Cardiac dysynchrony results in a decrease in stroke volume,facilitation of mitral regurgitation,increased wall stress,and delayed relaxation.Until recently,lifestyle changes,medication and, sometimes,heart surgery were the only treatment options.Patients with severe symptoms,however,received little,if any,relief from such approaches.Conduction delay,as manifested by a prolonged QRS complex duration,is common among patients with systolic dysfunction and heart failure and is associated with an increased prevalence of mechanical dyssynchrony, as opposed to patients with a narrow QRS complex.1

Cardiac resynchronization therapy (CRT) is a relatively new therapy

for patients with symptomatic heart failure resulting from systolic dysfunction.Cardiac resynchronization refers to pacing techniques that change the degree of atrial and ventricular electromechanical asynchrony in patients with major atrial and ventricular conduction disorders.2

Cardiac resynchronization therapy (CRT) is achieved by simultaneously pacing both the left and right ventricles.Biventricular pacing resynchronizes the timing of global left ventricular depolarization and improves mechanical contractility and mitral regurgitation. Resynchronization produces beneficial hemodynamic and antiarrhythmic effects by providing a more physiologic pattern of depolarization. Atrial resynchronization may prevent atrial fibrillation in selected patients with underlying bradycardia or interatrial block.1

The idea of biventricular pacing (BiV), or cardiac resynchronization therapy (CRT) as it is more commonly known today, most likely came out of a variety of animal studies performed in the late 1980s and early 1990s. Most notable among these studies was the 1986 study of canine pacing in which Burkhoff and colleagues noted that left ventricular pressure decreased linearly as the QRS duration increased.It was noted in further studies that there was a high prevalence of left bundle branch block (LBBB) or intraventricular conduction delay in chronic heart failure.Interventricular dyssynchrony tends to occur as a result. This leads to a prolonged delay between the onset of left ventricular (LV) and right ventricular (RV) contraction as well as a decrease in the duration of LV diastole and a prolonged isovolumetric relaxation with a shortened LV filling period.The hemodynamic effects of LBBB in chronic heart failure include a reduced left ventricular ejection fraction, reduced cardiac output,and reduced mean arterial pressure.Following the Burkhoff study, Lattuca and colleagues hypothesized that by simultaneously pacing the LV along with the RV, a more synchronous ventricular activation (QRS) plus a resultant more synchronous ventricular contraction pattern could be achieved with a reduction in QRS and thereby a reduction in intraventricular asynchrony.3

A recent study published by Boriani G;et al in Nov2009 states that cardiac resynchronization therapy is treatment of proven efficacy for selected patients with heart failure and associated conduction disturbances.As a whole,cost-effectiveness and cost-utility estimates of cardiac resynchronization therapy is improved even in India.4

In early studies on CRT, acute improvement in cardiac hemodynamics could be shown. Nowadays it is accepted that cardiopulmonary exercise capacity is also improved in the long term with CRT. In addition, reduction of functional mitral regurgitation and reverse left ventricular remodeling have been demonstrated in the majoriy of patients.The results of the recent studies demonstrate a reduction in mortality and hospitalizations by cardiac resynchronization therapy.These results have led to an accepted indication for cardiac resyncronization therapy as an adjunct treatment in heart failure and other disturbances.This calls out for the contribution of the nurses in knowing about cardiac resynchronization therapy and the areas in which to provide care,thereby reducing the mortality and morbidity seen in cardiac patients.5

6.1.NEED FOR STUDY

“The I in illness is

isolation,

and the crucial letters

in wellness are

WE.”

Heart failure is a chronic progressive syndrome, which impairs quality of life and is associated with frequent hospitalizations and a high mortality rate despite optimal medical therapy. Ventricular dyssynchrony is characteristic of systolic heart failure in some of the patients and is recognized as an interventricular conduction abnormality on the ECG, commonly in the form of left bundle branch block. This contributes to abnormal ventricular contraction pattern, which further reduces cardiac output and exacerbates symptoms.6

Data from clinical trials have demonstrated that by pacing the right and left ventricle simultaneously, as in cardiac resynchronization therapy, ventricular contraction improves with a resultant reduction in symptoms and an improvement in cardiac output and quality of life in the majority of patients.6

Cardiac resynchronization therapy (CRT) is an innovative new therapy that can relieve CHF symptoms by improving the coordination of the heart’s contractions.CRT builds on the technology used in pacemakers and implantable cardioverter devices. CRT devices also can protect the patient from slow and fast heart rhythms.Biventricular (or single-chamber left ventricular) pacing is beneficial for patients with congestive heart failure, severe left ventricular systolic dysfunction, dilated cardiomyopathy (either ischemic or idiopathic), and a major left-sided intraventricular conduction disorder, such as left bundle branch block.1

The primary objective of CRT is restoration of a more normal ventricular activation pattern. Secondarily, CRT allows optimization of the atrioventricular interval for patients in sinus pared with the delayed activation that occurs in the setting of an interventricular conduction delay, CRT depolarizes the left ventricle earlier. CRT is believed to reverse the deleterious effects of dyssynchronous ventricular activation by decreasing the electromechanical delay associated with an interventricular conduction delay and providing near-simultaneous contraction of the ventricular septum and the left ventricular free wall.1

Numerous clinical investigations have demonstrated that in selected patients CRT significantly improves cardiac output, systolic pressure, maximal rate of pressure rise, the magnitude of wall contraction, mitral regurgitation, and left atrial pressure. Furthermore, these acute hemodynamic benefits are achieved while reducing myocardial energy consumption.2

Globally,there are around 4,00,000 new cases of congestive cardiac failure seen annually and India stands with a count of 1,566,280 prevalent cases of congestive cardiac failure.The overall incidence of cardiomyopathy is 1-2 cases per 1,00,000 people.Cardiac resynchronization therapy is proved to be beneficial for patients with congestive heart failure,dilated cardiomyopathy,and major left ventricular conduction disorders.7

A study was conducted by Sunsaneewitayakul B.;et al(2007 July) to assess the feasibility,safety and mid-term efficacy of cardiac resynchronization therapy in patients with severe heart failure and ventricular delay.A sample size of 10 patients with severe heart failure alongwith left ventricular ejection fraction(LVEF) 120ms and left bundle branch block morphology received cardiac resynchronization therapy.At 6 months after the implantation of cardiac resynchronization therapy,all the clinical parameters improved significantly.The QRS duration decreased from 145+/-22ms to 126+6ms;LVEF increased from 21+/-6% to 31+/-12%;N-terminal pro-brain natriuretic peptide(NT-pro BNP) level decreased from 2503+/-1953pg/ml to 767+/-342pg/ml;the 6-minute walking distance increased from 153+/-122m to 278+/-128m;quality of life(QOL) score improved from 66+/-14 to 98+/-25;the number of heart failure visits was reduced from 3.8+/-3.7 per year to 0.7+/-0.8 per year.70% of the patients were free of heart failure visit for 1year after implantation there was no procedure-related mortality.Thus with the study,it was concluded that cardiac resynchronization therapy was safe and effective in improving heart failure symptoms,functional status,LV function and quality of life.Cardiac resynchronization therapy also reduced heart failure hospitalization in the presented patients with severe heart failure and ventricular conduction delay.8

A study conducted by Albert N M(2003 July) focused on cardiac resynchronization therapy in patients with heart failure and ventricular dyssnchrony and the role of nurses.He stated that cardiac resynchronization therapy provides a new adjunct in the armamentarium of therapies available to patients who remain symptomatic despite optimized standard therapies.Substantial data support CRT in reversing left ventricular remodeling,providing hemodynamic benefits and most importantly,imparting clinical benefits related to functional status,symptoms,quality of life and morbidity.Since this therapy has many benefits,it is essential that qualified personnel do take an initiative to know,initiate and monitor the therapy.The study specifies the importance of active role of acute and critical care nurses in promoting this intervention for patients who are likely to benefit through improvement in cardiac function and efficiency.9

Jensen S B.;et al undertook a study for optimizing CRT in heart failure patients and the nurses’ role in it.The study specified on the need for the affiliated professionals like nurse practitioner,clinical nurse specialist and physician to be aware of the current treatments and technology such as CRT in order to improve the symptoms and reduce the mortality rates in patients with heart failure.The study finally concludes that through awareness of current guidelines and advocacy for the patient,nurses and affiliated professionals have an essential role in reducing mortality and improving outcomes for heart failure patients with the help of CRT.10

Cardiac resynchronization therapy holds the promise of improvement in quality of life and prolonged survival in the patients with the former mentioned disorders of the heart.Since CRT has become a multidisciplinary therapy for chronic heart failure,it creates an essential need for the nurses to be aware of it and thereby render cost-effective care to the patients.11

Finally,since CRT is an innovative therapy,the nurse has to be familiar with the relevant information required to communicate it to the patient.The researcher therefore takes this study to educate the staff nurses regarding cardiac resynchronization therapy so that they can be instrumental in alleviating suffering and supporting the health care system of INDIA.

6.2. REVIEW OF LITERATURE

Balasundaram R. et al. (2009) performed a study on hemodynamic benefit of multiple programmable pacing configurations in patients with biventricular pacemakers.The study was conducted on 10 men and 4 women,55 +/- 13 years of age on average who were capable of multiple left ventricular stimulation (LVS) configurations.The biventricular capture was confirmed for each polarity and echocardiographic measurements were made. The cardiac output(CO),myocardial performance index(MPI) and the severity of mitral regurgitation were recognized for all LVS configurations determined by cardiac output.The CO and MPI changed significantly by changing the LVS configurations.The findings of the study were as follows: The difference in a ranged from 0.3 to 1.5L and seven patients (50%) showed greater than equal to 20% difference in CO;severity of MR decreased by greater than or equal to 1 grade in 9 patients.Thus the study was concluded that changes made in LVS configuration changes the hemodynamic function in CRT system recipients.12

A study was done by Luthje L. et al. (2009) on cardiac resynchronization therapy and atrial overdrive pacing for the treatment of central sleep apnoea which aimed to evaluate the effect of CRT alone and CRT + atrial overdrive pacing (AOP) on central sleep apnoea (CSA) in chronic heart failure (CHF) patients.The study consisted of 30 patients with CRT indication who underwent full night polysomnography,echocardiography, exercise testing and neurohumoral evaluation before and 3 months after CRT implantation.CRT resulted in significant improvement in terms of left ventricular ejection fraction,N- terminal pro brain natriuretic peptide,VO2 max and the quality of life irrespective of the presence of CSA.Cardiac Resynchronization therapy also reduced the central apnoea-hypopnea index(AHI) and central apnoea index without altering sleep stages.Thus the study showed that CRT significantly improved CSA without altering sleep stages.CRT with atrial overdrive pacing resulted in a significant improvement of CSA.13

Williams L.K. et al. (2009) conducted a study to prove the short term hemodynamic effects of cardiac resynchronization therapy in patients with heart failure,a narrow QRS duration and no dyssynchrony.The study was done on 30 symptomatic heart failure patients with QRS duration < 120 ms and no evidence of dyssynchrony on conventional criteria.Pressure volume studies were performed before and during the delivery of CRT.The results of the study was as follows:cardiac output increased by 25 +/- 5%,absolute left ventricular stroke increased by 51 +/- 15% and dP/dt max increased by 9 +/-2%.Thus this study proved that CRT results in an improvement in short-term hemodynamic variables in patients with QRS or = 150ms.39 patients (32.2%) had NYHA class 1-2 symptoms and 82 (67.8%) had NYHA class 3-4 symptoms.By this study it was concluded that if the criteria for NYHA class 3 and 4 congestive cardiac failure with left bundle branch block,50% of patients need cardiac resynchronization therapy.19

A study was performed by Breihardt O.A. et al. (2002) to prove that echocardigraphic quantification of left ventricular asynchrony predicts an acute hemodynamic benefit of CRT.The study mainly aimed to determine whether radial left ventricular(LV)asynchrony in patients with heart failure predicts systolic function improvement with CRT on 34 patients who underwent echocardiographic phase analysis of LV septal and lateral wall motion and hemodynamic testing before CRT.The absolute value of phase relationship Phi(S) was used as an order-independent measure of synchrony:the absolute value Phi(LS)=the absolute value of Phi (L) – Phi (S).The findings presented an acutely reduced absolute value of Phi(LS) from 104+/-41 degrees after CRT.Thus the study was concluded that echocardiographic quantification of LV asynchrony identifies the patients likely to have improved systolic function with CRT.20

STATEMENT OF THE PROBLEM

“A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON THE KNOWLEDGE REGARDING CARDIAC RESYNCHRONIZATION THERAPY AMONG THE STAFF NURSES IN A SELECTED HOSPITAL,TUMKUR.”

6.3 OBJECTIVES OF THE STUDY

← To determine the existing knowledge of the staff nurses regarding cardiac resynchronization therapy.

← To prepare and administer structured teaching programme on cardiac resynchronization therapy to the staff nurses.

← To determine the effectiveness of structured teaching programme on cardiac resynchronization therapy among the staff nurses in terms of the gain in knowledge scores.

← To find out the association between the knowledge scores of staff nurses with selected demographic variables.

6.4. Operational definitions

❖ EVALUATE: It refers to determine the knowledge gained regarding cardiac resynchronization therapy after the structured teaching programme.

❖ EFFECTIVENESS: It refers to the extent to which the structured teaching programme on the cardiac resynchronization therapy achieves desired effect in improving the knowledge of the staff nurses as evident from the gain in knowledge scores.

❖ STRUTURED TEACHING PROGRAMME: It refers to the systematically developed instructional method and teaching aids designed for the staff nurses to provide information on cardiac resynchronization therapy.

❖ KNOWLEDGE: It refers to the correct responses of the staff nurses to the knowledge items on cardiac resynchronization therapy as achieved by the knowledge scores.

❖ CARDIAC RESYNCHRONIZATION THERAPY: It refers to the pacing techniques that change the degree of atrial and ventricular electromechanical asynchrony in patients with major atrial and ventricular conduction disorders.

❖ STAFF NURSE: It refers to a person who has successfully completed the Diploma Nursing and Midwifery course or Bachelor of Science in Nursing course and meets certain standards by getting registered in the Indian Nursing Council and State Nursing Council and is working in the medical wards,surgical wards, intensive care units and the emergency care units of a hospital.

6.5 RESEARCH HYPOTHESIS

H1:There will be a significant increase in the level of knowledge on cardiac

resynchronization therapy after the administration of structured teaching programme

than the level of pre-test knowledge.

H2:There is a significant association between the selected demographic variables and the knowledge score.

6.6 ASSUMPTIONS

← The tool which is prepared by the researcher will be adequate to measure the level of knowledge of the staff nurses and the effectiveness of structured teaching programme about cardiac resynchronization therapy.

← The staff nurses of the medical wards,surgical wards,intensive care units and emergency departments may not have adequate knowledge regarding cardiac resynchronization therapy.

← Structured teaching programme on cardiac resynchronization therapy for the staff nurses is an effective means to reduce the mortality and morbidity in cardiac patients.

← When staff nurses of the medical wards,surgical wards,intensive care units and emergency departments are educated on cardiac resynchronization therapy,they can be instrumental in providing cost-effective care to the patients.

6.7 DELIMITATIONS OF THE STUDY

← The study is delimited to the staff nurses of medical wards, surgical wards,intensive care units and emergency departments of the selected hospital at TUMKUR.

← Assessment of the knowledge of the staff nurses will be done through written responses as elicited by structured questionnaire;hence the knowledge displayed might not be comprehensive.

← The study is delimited to the diploma nursing and B.Sc nursing staff nurses working in the selected hospital at TUMKUR.

8. VARIABLES

Variables are an attribute of a person or objects that varies or takes different values.

❖ INDEPENDENT VARIABLE : Structured teaching programme.

❖ DEPENDENT VARIABLE : Knowledge of the staff nurses.

❖ DEMOGRAPHIC VARIABLES : Age,clinical experience,working area,inservice

Education.

9. PILOT STUDY

The pilot study will be conducted on 3 samples.

The purpose of the pilot study is to:

← find out the feasibility of conducting the final study.

← Determine the methods of data analysis.

← Assess the practicability of carrying out the main study.

6. MATERIALS AND METHODS OF THE STUDY

7.1.1 SOURCES OF DATA COLLECTION

The data will be collected from the staff nurses in a selected hospital at TUMKUR.

7.1.2 RESEARCH DESIGN

One group pre-test post-test research design which is a sub type of the pre-experimental design is selected to assess the knowledge of the staff nurses regarding cardiac resynchronization therapy.

7.1.3 RESEARCH APPROACH

An evaluatory approach is considered appropriate for this study

7.1.4 RESEARCH SETTING

The study will be conducted in a selected hospital at TUMKUR.

7.1.5 POPULATION

The target population of the present study comprises of the diploma and B.Sc staff nurses who are working in a selected hospital at TUMKUR.

The accessible population of the present study comprises of the staff nurses who are working in medical wards,surgical wards,intensive care units and emergency departments of a selected hospital at TUMKUR.

7.1.6 METHODS OF DATA COLLECTION

The data collection procedure will be carried out for a period of 1month.

The study will be initiated after obtaining permission from the concerned authorities.

On the first day,the researcher will collect the data from the staff nurses by conducting a pre-test to assess the knowledge regarding Cardiac Resynchronization Therapy.

On the same day,the researcher will provide structured teaching programme to the staff nurses.

On the seventh day,a post-test is conducted to assess the knowledge regarding Cardiac Resynchronization Therapy by using the same structured questionnaire.

7.2.1 SAMPLING TECHNIQUE

In this study,the subjects will be selected by non-probability convenient sampling technique.

7.2.2 SAMPLE SIZE

The sample size of the study consists of 30 staff nurses of the medical wards,surgical wards,intensive care units and emergency departments from a selected hospital at TUMKUR.

SAMPLING CRITERIA

7.2.3 INCLUSIVE CRITERIA

Staff nurses:

← who have undergone General Nursing and B.Sc. Nursing course.

← who are working in medical wards,surgical wards,intensive care units and emergency departments.

← who are available during the period of data collection.

7.2.4 EXCLUSIVE CRITERIA

← Staff nurses who are not willing to participate in the study.

← ANM nurses and Post-graduate nurses working in the selected hospital,TUMKUR.

7.2.5 TOOLS FOR DATA COLLECTION

The structured questionnaire is used to collect the data from the staff nurses.Content validity will be established by requesting the experts to go through the developed tool and give their valuable suggestions.

The structured questionnaire schedule consist of the following sections:

Section A : Questions related to the demographic data.

Section B : Questions related to assess the level of knowledge regarding cardiac

resynchronization therapy.

7.2.6 DATA ANALYSIS METHOD

The data will be organized,tabulated and analysed by using descriptive and inferential statistics.The data will be planned to present in the form of tables and figures.

← DESCRIPTIVE STATISTICS:

Frequency and percentage for analysis of demographic data; mean percentage and standard deviation will be used for assessing the level of knowledge.

← INFERENTIAL STATISTICS:

“Chi-square test” will be used to find out the association between the knowledge and the selected demographic variables.

“Paired t-test” will be conducted to compare the pre-test and post-test knowledge of the staff nurses regarding Cardiac Resynchronization Therapy.

7.2.7 TIME AND DURATION

The time and duration of the study will be limited to three months as per the guidelines of the university.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS?IF SO PLEASE DESCRIBE BRIEFLY.

Yes. Structured teaching programme will be conducted as an intervention to the staff nurses.

7.4 HAS ETHICAL CLEARENCE BEEN OBTAINED FROM YOUR INSTITUTIONS?

The pilot study and the main study will be conducted after the approval of the research committee.Permission will be obtained from the concerned head of the institution.The purpose and the details of the study will be explained to the study subjects and an informed consent will be obtained from them.Assurance will be given to the study subjects regarding the confidentiality and anonymity of the data collected from them.

8. LIST OF REFERENCES

1. Cardiac Resynchronization Therapy.Available from files/resync therapy.pdf.

2. Cardiac Resynchronization Therapy: Overview.Available from .

3. Cardiac Resynchronization Therapy:HISTORY.Available from article/425300_2

4. Cardiac Resynchronization Therapy:State of Art.Available from

5. Cardiac Resynchronization Therapy:Current Status.Available from

6. Kate O’Donovan.Cardiac resynchronization Therapy:Biventricular Pacing for Heart Failure.British Journal of Cardiac Nursing.Vol 4,Iss 9,02 Sep 2009,pp 406-414.Available from

7. Patient selection for Cardiac resynchronization Therapy.Available from

8. Sunsaneewitayakul B. et al.Feasibility,Safety and Mid-term Efficacy of Cardiac Resynchronization Therapy in patients with severe Heart Failure and Ventricular Conduction Delay,Chulalongkam experience.Journal of Medical Association of Thailand.2007 July:90(7):1458-66.Available from ncbi.nlm.pubmed/17710992.

9. Albert N.M..Cardiac Resynchronization Therapy through Biventricular Pacing in patients with Heart Failure and Ventrivular Dyssnchrony.Critical Care Nurse.2003 June; 23(3 Suppl):2-13:quiz 15-6.Available from ncbi.nlm.pubmed/12830691.

10. Jensen S.B. et al.Optimizing Therapy for Heart Failure patients:Cardiac Resynchronization and Defibrillator Therapy.The Journal of Cardiovascular Nursing. 2007 March-April:22(2):118-24.Available from ncbi.nlm.pubmed/17318037.

11. Review-Cardiac Resynchronization Therapy.Identifying Responders to Cardiac Resynchronization Therapy:State of Art.Available from

12. Balasundaram R. et al.Hemodynamic Benefit of Multiple Programmable Pacing Configurations in patients with Biventricular Pacemakers;Pacing and Clinical Electrophysiology.2009 March.32 Suppl:S211-3.Available from ncbi.nlm.pubmed/19250098.

13. Luthije L. et al.Cardiac Resynchronization Therapy and Atrial Overdrive Pacing for the Treatment of Central Apnoea.European Journal of Heart Failure.2009 March 11(3): 27-80 Epub 2009 Jan 12.Available from ncbi.nlm.pubmed/19147446.

14. Williams L.K. et al.Short Term Hemodynamic Effects of Cardiac Resynchronization Therapy in patients with Heart Failure,a narrow QRS duration and no Dyssnchrony. Circulation.2009 October 27.120(17):1687-94. Epub 2009 Oct 12.Available from ncbi.nlm.pubmed/19822812

15. Burri H. et al.Improvement in Cardiac Sympathetic Nerve Activity in Responders to Resynchronization Therapy.European Pacing,Arrhythmias and Cardiac Electrophysiology.2008 March 10(3):374-8.Available from ncbi.nlm.pubmed/18308757

16. Deshmukh R. et al.Influence of Intrinsic Myocardial Conduction on paced QRS Morphology during Cardiac Resynchronization Therapy and Follow up.Indian Pacing and Electrophysiology Journal.2008 August 1,8(3):211-7.Available from ncbi.nlm.pubmed/18679526

17. Ypenburg C. et al.Mechanism of Improvement in Mitral Regurgitation after Cardiac Resynchronization Therapy.European Heart Journal.2008 March 29(6):757-67.Epub 2008 Feb 27.Available from ncbi.nlm.pubmed/18305084.

18. Sinha A.M. et al.Cardiac Resynchronization Therapy improves Central Sleep Apnoea and Cheyne-Stokes Respiration in patients with Chronic Heart Failure.Journal of the American College of Cardiology.2004 July 7,44(1):68.711.Available from ncbi.nlm.pubmed/15234409

19. Gupta S.N. et al.Heart Failure:What proportion of patients satisfy the Electrocardiographic criteria for Cardiac Resynchronization Therapy.Indian Heart Journal.2003 November-December 55(6):619-23.Available from ncbi.nlm.pubmed/14989512

20. Breithardt O.A. et al.Echocardiographic quantification of Left Ventricular Asynchrony predicts an acute hemodynamic benefit of Cardiac Resynchronization Therapy.Journal of the American College of Cardiology.2002 August 7:40(3):536-45.Available from ncbi.nlm.pubmed/12142123.

| | | |

|9. |SIGNATURE OF THE CANDIDATE | |

| | | |

|10. |REMARKS OF THE GUIDE | |

| | | |

|11. |11.1 NAME AND DESIGNATION OF GUIDE |Prof. K. Ramu |

| | |Principal. |

| | |Shridevi College of Nursing. |

| | |Tumkur. |

| | | |

| |11.2 SIGNATURE | |

| | | |

| |11.3 CO-GUIDE | |

| | | |

| |11.4 SIGNATURE | |

| | | |

| |11.5 HEAD OF THE DEPARTMENT |Prof. K. Ramu |

| | | |

| |11.6 SIGNATURE | |

| | | |

|12 |12.1 REMARKS OF THE CHAIRMAN | |

| |AND THE THE PRINCIPAL | |

| | | |

| |12.1 SIGNATURE | |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download