|Year : 2009 | Volume
| Issue : 1 | Page : 40-51
The 7th Gulf Heart Association (GHA) Cardiovascular Conference was held in Dubai, UAE, on April 9-11, 2009
|Date of Web Publication||17-Jun-2010|
|How to cite this article:|
. The 7th Gulf Heart Association (GHA) Cardiovascular Conference was held in Dubai, UAE, on April 9-11, 2009. Heart Views 2009;10:40-51
Interheart Middle East Study
On behalf of: INTERHEART Investigators in Middle East
Dr. A.M. Yusufali, MD, M.Med, FRCP (Glasg)
Dubai Heart Center, Dubai Hospital, Dubai, UAE
Objective: To evaluate the association of risk factors for acute myocardial infarction (AMI) in Middle Eastern countries.
Background: It is projected that CVD mortality in the Middle Eastern region would increase substantially by year 2020. However, there are no large studies examining the impact of risk factors for MI in the Middle Eastern region.
Methods: As part of the INTERHEART study, we enrolled 1364 cases of first acute myocardial infarction and 1525 controls from 8 countries in the Middle Eastern region. The association of smoking, self reported diabetes and hypertension, blood Apo lipoproteins, waist-to-hip ratio, physical activity, dietary patterns, consumption of alcohol and psychosocial factors withmyocardial infarction were analyzed using odds ratio(OR) and their 95% CI's and their population attributable risks (PAR) were calculated.
Results: Elevated ApoB/ApoA1 (OR 3.43, PAR 57.1% for top vs. lowest tertile) and smoking (odds ratio of 3.63 for current vs. never, PAR 45.6%) were the two most important risk factors. Diabetes (3.42, PAR 16.4%), hypertension (1.89, PAR 10.7%), abdominal obesity (2.12, PAR 26.1% for top tertile vs. lowest), and depression (1.97, PAR 45.3%), were all significantly associated with acute myocardial infarction (p < 0.0001). Daily consumption of fruits and vegetables (0.71, PAR 9.6% for lack of daily consumption) was protective (p = 0.0021). These findings were similar in both sexes, with consistent results in the participating countries. Collectively, these nine risk factors are responsible for 97.5% of the PAR.
Conclusion: The nine risk factors analyzed and reported in our study account for the large proportion of the risk of acute myocardial infarction in the Middle East region, and should be the focus of prevention efforts in this region.
Prevention of Cardiovascular Disease
Professor David Wood
National Heart and Lung Institute, Imperial College London, London, UK
The Joint European Societies guidance on prevention of cardiovascular disease (CVD) in clinical practice recommends a common approach to lifestyle and risk factor intervention for patients with established atherosclerotic CVD and high risk persons in the population. This is based on the concept of total risk assessment and management, first advocated in the Joint European recommendations on coronary prevention in 1994.
The most recent report by the Joint European Societies published in 2007 now addresses cardiovascular disease as a whole. The clinical priorities are (1) patients with established atherosclerotic disease; (2) asymptomatic individuals who are at high risk of developing atherosclerotic disease because of (i) multiple risk factors resulting in a ten year risk of > 5% now (or if extrapolated to age 60) for developing a fatal CVD event (ii) markedly raised levels of single risk factors (iii) diabetes mellitus; and (3) close relatives of patients with early onset atherosclerotic disease and asymptomatic individuals at particularly high risk. A new model for total risk estimation called SCORE (Systematic Coronary Risk Estimation), based on European populations, is recommended and can be adapted to correspond with national CVD mortality in any European country. The risk threshold for more intensive lifestyle intervention and, where appropriate, the use of drug therapies is now defined as ≥ 5% fatal CVD risk over 10 years. Lifestyle, risk factor and therapeutic goals have been set for all priority patient groups.
The most recent results from EUROASPIRE III show a continuing large gap between the professional standards set by guidelines and everyday clinical practice. The EUROACTION demonstration project in preventive cardiology has stepped up to this professional challenge through a nurse coordinated multidisciplinary prevention programme which has set a new standard of preventive care for Europe.
Building ACS Systems of Care
Paul W. Armstrong, M.D.
Canadian VIGOUR Center, Canada
The enormous advances in the management of patients with ST elevation myocardial infarction now provide a paradigm from which to extend the lessons learned to other acute cardiovascular disorders. Patients with STEMI have been an attractive phenotype for building a system of care because they have a disease that is 1) life-threatening, 2) associated with major morbidity, 3) exquisitely sensitive to time interval between symptom onset and commencement of appropriate diagnosis, treatment, and triage, 4) amenable to early on-site field diagnosis, which in turn can be facilitated by novel information technology and remote physician oversight, 5) responsive to novel first-line therapies that have both benefit and risk, and 6) characterized by subsets of patients: some are optimally treated in high-tech/tertiary care centres, yet for the majority initial management in community facilities is appropriate.
Building a system to optimally address these realities requires;
This presentation will include characterization of a collaborative and coordinated approach, formalizing patient treatment strategies, using standardized guidelines and pathways to achieve desired outcomes. In addition to establishing and promoting appropriate time to treatment goals, defining patient populations most appropriate for one versus another reperfusion strategy, the need for a dedicated quality assurance program to track objectives and provide appropriate feedback to ensure achievement of these goals will be discussed.
- Seamless collaboration between multidisciplinary health personnel i.e., cardiologists, cardiac surgeons, stroke neurologists, radiologists, and emergency physicians,
- Recognition of the key roles for advanced paramedic health care professionals in a collaborative linkage that engages nursing, pharmacy, and laboratory technology
- Delegated responsibility to well qualified field paramedics characterized by devolution of care, which in turn is back-stopped by physician oversight facilitated by rapid effective communication
Setting up a Heart Failure Clinic
Paul W. Armstrong, M.D.
Canadian VIGOUR Center, Canada
Congestive heart failure (CHF) has emerged as a major clinical and public health problem with an incidence and prevalence affecting at least 2% of adults. It increases in incidence with age such that 10-20% of octogenarians suffer from this disorder. As age increases so too does the likelihood that diastolic versus systolic left ventricular dysfunction forms the principal cause of morbidity and mortality. CHF is associated with impaired functional capacity, decreased quality of life, and increased morbidity and mortality. Moreover it has major social and economic repercussions. These challenges, notwithstanding extraordinary advances in the pharmacologic, electrical, and surgical approaches to heart failure, have mandated the emergence of specialized multidisciplinary approaches to care that address not only the medical but the social, emotional, and behavioural aspects of care.
Heart failure management programs are now a class 1A recommendation of the ESC, ACC/AHA and Canadian CHF guidelines. We have had a 20 year experience with a multi-disciplinary clinic at the University of Alberta Hospital that includes systematic follow up, data acquisition and incorporation of education and research: this has proven to be a worthwhile model. Systematic clinical, laboratory and functional assessments and linkage with health outcomes data at a population level within the 3.1million inhabitants of the province of Alberta provide an opportunity to characterize and effectively modulate the quality cycle of care.
The clinic is managed by a team of physicians, specialized HF nurses, pharmacists, dieticians who have ready access to social workers, psychologists, rehabilitation and palliative care. Our goal is to ensure collaborative care with community physicians, review patients admitted to hospital or seen in the emergency department with decompensated HF.
Specially trained nurses are the key to successful outpatient management especially as it relates to patient education, self care including avoidance of "decompensation triggers" and adherence to a tailored and carefully monitored treatment program as well as family counselling. Careful telephone follow-up, electronic data recording and community outreach have enhanced the clinic's ability to manage a large and growing population working in parallel with the cardiac transplant program (the largest in Western Canada). Because of the broadening indications for device therapy in CHF close collaboration with the electrophysiology service and CHF clinic have emerged as a central focus of future care. In this presentation the key lessons learned relating to implementation and maintenance of an effective heart failure clinic will be discussed.
Heart Failure: A Continuous Learning Process
Salvatore Maugeri Foundation, IRCCS, Ferrara, Italy
Heart failure (HF) is a complex clinical syndrome whose underlying cellular-molecular mechanisms are not completely understood. Indeed, heart failure is a continuous learning process. We learn, for example, from mistakes. The idea that positive inotropic agents could be an important treatment for HF was indeed logical. However, clinical trials with positive inotropic agents resulted in an increase of cardiovascular mortality and this approach has been consequently abandoned. The mistake was to assume that a direct interrelation between the heart and/or the myocytes could be beneficial. Being a syndrome, HF implies several changes occurring also in the peripherals such as the neuroendocrine and neurormonal activation occurring in response to the reduced cardiac output. Recognition of these mistakes have, paradoxically, lead to the idea that negative inotropic agents such as b blockers could be important for the treatment of HF. Indeed, in the long term, b blockers in HF allow an increase of ejection fraction, thus could be considered positive inotropic agents!
Recently, we have also learnt from oncology. The oncologist has to activate death signals in order to favour apoptosis of the neoplastic cells. To do this, they developed Herceptin, which blocks proteins expressed by breast cancer cells such as GP130 which inhibits apoptosis and HERG P185 which stimulates regeneration. In so doing, the net end result is more apoptosis and less regeneration. Surprisingly, however, 5-15% of women treated with Herceptin developed dilated cardiomyopathy of rapid onset with a classical embryonic phenotype similar, if not identical, to that observed in remodelling after myocardial infarction. So, we are learning some new pathophysiological concepts such as that death or survival pathways do matter, even in the heart, and particularly in the failing heart. Excess apoptosis to the level occurring in the embryonic myocytes today is recognised as one of the most important molecular and cellular mechanism for the progression from left ventricular dysfunction to overt heart failure and is leading to new forms of possible therapeutic treatments such as activators of GP130 or stem cells mobilisation and implantation.
However, in HF we are also learning from other specialities. It is clear that cardiologists cannot cope with the burden of a chronic syndrome such as HF. Thus, HF centres are created with a new approach to patient care, including telephonic contact, home care therapy, sensor device driven therapy etc. For sure, the cardiologist interested in HF will never stop learning from other specialities, advance technology, image modalities and learning is indeed required in such a complex syndrome.
Optimal Goals During Hospitalization in Acute Decompensated Heart Failure
Dr. Awatif Al Sousi
SKMC, Abu Dhabi, UAE
Heart failure resulting in hospitalization represents a significant and growing health care burden. Hospitalization for acute heart failure (AHF) is one of the most important predictors of post - discharge mortality and readmission in patients with chronic heart failure.
As a diagnosis at hospital discharge, HF has tripled over the last 3 decades , this trend will likely continue due to an aging population, improved survival after myocardial infraction, and better prevention of sudden cardiac death.
Heterogeneity characterizes this group in terms of mode of presentation, pathophysiology, and prognosis. Management of AHF is challenging given the heterogeneity of the patient population, absence of a universally accepted definition, incomplete understanding of its pathophysiology, and lack of robust evidence - based guidelines. The vast majority of patients with AHF symptomatically improve during hospitalization; however, their early post-discharge rehospitalization and morality rates continue to be high . Worsening signs and symptoms, neurohormonal, and renal abnormalities occruing soon after discharge may contribute to these high post-discharge event rates.
Currently available assessment modalities combined with recent advances in cardiovascular therapies provide present-day opportunities to improve post-discharge outcomes. Further investigation into pathophysiologic targets and novel approaches to clinical trial design are needed. Improving post-discharge outcomes (mortality and rehospitalization) is the single most important goal in the management of acute heart failure syndromes.
Registry of Stent Thrombosis in Dubai Hospital
Dr. Yahya Kiwan; Dr. Talib Majwal; Dr. Hind Elzein; Dr. Obaid Al Jasim
Dubai Hospital, Dubai, UAE
Objective: To evaluate the incidence, predictors, risk factors, & clinical presentation of stent thrombosis (ST) in our center, To confirm whether the incidence of (ST) is within the accepted international rate and to compare between the incidence of (ST) in the drug eluting stents(DES) & the bare metal stents(BMS) .
Methods: Adata collected from all the patients who successfully underwent PCI & presented with (ST) in a period of 3 years (January/2006 - December /2008). 65 incidents of stent thrombosis involving 56 patients (56+ 9 recurrence)out of 1894 patients in whom 2890 stents were inserted (1326 BMS & 1564 DES). Total number of the stents deployed in all vessels in the 56 pts is 107 stents (34 DES+ 73BMS) 1.9 per stent only (81) stents were involved (25) DES and (56) BMS. We applied the classification & definition of stent thrombosis recently set up by the A cademic Research Consortium(ARC).
Clinical Characteristics: Risk factors prior to PCI were: initial presentation with ACS (85%), LV dysfunction ( 43%), Diabetes mellitus (40%), long lesion > 15 mm (69%), multiple stenting (27 %), small vessels (vessels diameter ≤ 2.5) (23%). inflow out flow disease (20%).
Results: 65 incidents of stent thrombosis involving 56 patients (9 recurrence) in whom (107) stents (34 DES&73BMs) were deployed and only 81 stents were involved (25)DES&(56)BMS.
Recurrence rate mortality: 14% (9 /65)
Mortality: Over all: 14% (9 /65)
In hospital mortality: 8% (5 /65)
The clinical presentation of stent thrombosis included : STEMI (55.4% ), NON STEMI (27.7%) , unstable angina 1.5% incidental finding during staged PCI (7.7%), sudden death (7.7%).
The over all incidence of stent thrombosis according to the (ARC) definitions 2.8% (81 /2890) (per stent),(3.4%) per case Incidence of stent thrombosis in DES :- 1.6 % (25 /1564)
Incidence of stent thrombosis in BMS :- 4.2% (56 /1326)
(ARC) documentation: Definite (47) 72%, probable (17 ) 26%, possible 1 (1.5 %)
Limitations: No follow up for all the PCI patient.,most patient with acute myocardial infarction (high risk) were having BMS .Doubt full compliance of BMS patients to dual antiplatelet therapy (financial issues).DES patients more educated &more compliant and more reliable follow up.
- The over all incidence of stent thrombosis in our institute is (2.8%) per stent , (3.4%) per case,comparable to the incidence reported in the literature (0.5-3.4%)
Incidence of ST in DES : 1.6 %
Incidence of ST in BMS : 4.2%
- The clinical presentation of stent thrombosis was mostly STEMI, however NONSTEMI & silent stent thrombosis were also not rare presentation.
- Few patients with stent thrombosis had been effectively treated with thrombolytic therapy. 12 stents in those presented with STEMI received thrombolysis . (7 patent, 5 blocked)
Baseline Characteristics, Management Practices and Inhospital Outcome of Patients Hospitalized with Acute Coronary Syndromes in the Gulf
(Gulf Registry of Acute Coronary Events)
Mohammad Zubaid MB, FRCPC, FACC
Mubarak Al-Kabeer Hospital, Kuwait, Kuwait
Introduction and Objectives: Acute coronary syndrome (ACS) is a leading cause of morbidity and mortality in Gulf countries. Our aim was to describe the epidemiology, treatments and in-hospital outcomes of patients with ACS in this region.
Methods: The Gulf Registry of Acute Coronary Events (Gulf RACE) is a prospective, multinational, multi-center survey of consecutive patients hospitalized with the final diagnosis of ACS over a period of 5 months from February to June 2007.
Results: A total of 6706 ACS patients were recruited. The mean age was 56 years and 76% were men. Half of the patients had a history of hypertension while 41% were diabetics and and 41% were smokers. The majority (78%) were Killip class I at presentation. The final diagnosis was ST elevation myocardial infarction (STEMI) in 39%, non-ST- segment elevation myocardial infarction in 32% and unstable angina in 29%. Among patients with STEMI, reperfusion therapy was administered to 63%. Primary Percutaneous coronary intervention (PCI) was performed in 6% of these patients. The median door to needle time was 40 minutes and the median door to balloon time was 79 minutes. Coronary angiography during hospitalization, other than for primary PCI, was performed in 19% of the patients. At discharge, aspirin was prescribed in 97% of patients, clopidogrel in 51%, beta blockers in 78%, Angiotensin converting enzyme inhibitors/Angiotensin receptor blockers in 79% and statins in 83%. The in-hospital mortality rate was 3.8%.
Conclusions: This is one of very few ACS registries relating to patients from the Middle East. It provides an insight into a different patient population and practice patterns compared to those of Europe and North America. Our patients are about a decade younger and have more diabetes as a risk factor. The reperfusion strategy used in the majority of patients is thrombolytic therapy and the use of in-hospital cardiac catheterization is low.
Guidelines for the Management of
Peripheral Vascular Disease
H. Al-Thani, N. Al-Busaidi, A. Jawas, S. Abdulla, M. Al-Bader, N. Al-Khaja
The prevalence of cardiovascular risk factors in the Gulf countries has increased; the prevalence of diabetes mellitus is the highest worldwide approaching 25% of the adult population. In 2003, the five countries with the highest diabetes prevalence in the adult population were Nauru (30.2 %), The United Arab Emirates (20.1 %), Qatar (16%), Bahrain (14.9%), and Kuwait (12.8%). More than 70% of the adult population has excess body weight. Twenty six percent of the adult populations are hypertensive, 54% have hypercholesterolemia and from 13 % to 40 % are smokers. The risk factors that favor the development of peripheral arterial atherosclerosis are similar to those that promote the development of coronary arterial disease.
The Gulf Heart Association (GHA) assigned a working group to develop guideline for the management of the PAD in the Gulf Countries. This review has adopted the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). The management of the patient with PAD has to be planned in the context of the epidemiology of the disease, its natural history and, in particular, the modifiable risk factors for the systemic disease as well as those that predict deterioration of the circulation to the limb. The text is presented in such a way that vascular specialists will still find most of the information they require, while general practitioners and primary health physicians will easily find guidance for diagnosis and diagnostic procedures, referral of patients and expected outcome of various treatment options.
Faisal Abdulla Alsayegh
Venous thromboembolism (VTE) is a major health hazard in hospitalized patients. It has been estimated that 10% of in-hospital mortalities are attributed to VTE. In the United States, 200.000 patients die annually as a result of VTE or its complications. In the Arabian Gulf countries, the incidence of VTE in hospitalized patients and related mortalities is unknown due to the lack of epidemiological surveys and post-mortum studies. In the last 5 years, there have been attempts to study the epidemiology of VTE in the Arabian Gulf countries and the practice of VTE prophylaxis in high risk hospitalized patients. These attempts have resulted in 2 major multicenter studies: GRIP-VTE and ENDORSE trials. In addition, a concise VTE prophylaxis pocket guidelines based on ACCP recommendations, mainly intended to practicing physicians and surgeons, was published and made available online to help improving the practice of VTE prophylaxis in the Arabian Gulf region.
Recently, A group of hematologists interested in thrombo-embolic disorders have initiated the Gulf Thrombosis Collaboration with an intention to establish a VTE registry in the Arabian Gulf countries and encouraging research in this field.
Device Closure of Atrial Septal Defects Technical Considerations, Complications and Long-term Outcome
Ziyad M. Hijazi, MD, MPH, FSCAI
Rush University Medical Center, Chicago, Illinois, USA
Device closure of secundum atrial septal defects (ASD) is now the accepted first choice for patients with appropriate ASDs. Acute and long-term results have been very good and comparable to those after surgical repair. However, when defects are large, they may pose technical challenge, even to the experienced operator. There are few different techniques "tricks" that may be utilized to keep the left atrial desk of the device from prolapsing into the right atrium. Further, closing defects in an elderly patient requires meticulous hemodynamic evaluation, with particular attention to the left atrial pressure pre closure. This is due to important pathophysiological differences that may negatively impact on how ASD closure is tolerated. This is especially the case in older patients with evidence of left ventricular diastolic dysfunction. Closure of a large interatrial communication in 'unprepared' patient with left ventricular diastolic dysfunction can lead to a significant increase in left atrial pressure due to the loss of "pop-off" via the atrial septum, with resulting pulmonary edema and ventilator dependency.
Complications encountered during or after device closure are not uncommon, however, compared to surgical repair, the incidence is still less. Such complications include: device embolization, thrombus formation, arrhythmia and conduction abnormalities, TIA/stroke, infective endocarditis and erosions. The last complication is the most fear some. I will discuss details of the incidence of erosions, possible mechanisms and how to avoid this complication.
Mitral Regurgitation - Operation or Not?
Curtis M. Rimmerman, M.D., M.B.A., F.A.C.C.
The timing of mitral valve surgery in the presence of mitral regurgitation is of critical importance. Mild and moderate forms of mitral regurgitation can be comfortably observed without the need for intervention. Patients with severe mitral regurgitation with evidence of functional capacity decline, left ventricular enlargement or dysfunction, pulmonary hypertension or new onset atrial arrhythmias are traditionally referred for mitral valve surgery. Those patients with severe mitral regurgitation with a preserved exercise capacity and devoid of the aforementioned symptoms and signs are heretofore most often followed clinically and with serial resting echocardiograms. In this instance, referral for mitral valve surgery is best guided by employing exercise echocardiography, assessing left ventricular dimensions and function at peak and post exercise coupled with a non-invasive assessment of pulmonary pressures by quantifying the tricuspid regurgitation velocity. In addition, referral for mitral valve surgery should be influenced by the mechanism of the mitral regurgitation - prolapse versus flail - plus the likelihood of a successful mitral valve repair in lieu of replacement based on surgical experience.
Current Trend on Infective Endocarditis Focus on Prophylaxis
Ahmed Al-Motarreb, M.D.
Sanaΰ University, Cardiac Centre, Sanaΰ ,Yemen
Infective Endocarditis (IE ) is a severe disease with high morbidity and mortality which results from bacteraemia and underlines cardiac valve disease. Although it has long been assumed that dental procedures may cause IE in patients with underlying cardiac risk factors and that antibiotic prophylaxis is effective, scientific proof is lacking to support these assumptions.
The risk of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy. In recent years, there is tendency to reduce prophylactic antibiotics because of unproven efficacy and high side effects.
Prophylactic antibiotic is not necessary for most patients with cardiac disease. Only patients at high risk should receive prophylactic antibiotic before dental and surgical procedures. Infective Endocarditis is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteraemia caused by a dental, GI tract, or GU tract procedure
Every day-life bacteraemia has an important role in Infective Endocarditis. Focus on preventive measures such as dental Hygiene and education of the patient and dentist are important steps to avoid Infective Endocarditis.
Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE.
There should be a shift in emphasis away from a focus on a dental procedure and antibiotic prophylaxis toward a greater emphasis on improved access to dental care and oral health in patients with underlying cardiac conditions.
Surgery of The Aortic Root
Jean Bachet, M.D. FEBTCS
Many pathological conditions, either chronic or emergent, associating dilatation of the aortic root with a certain degree of aortic regurgitation, require that the aortic valve and the ascending aorta be replaced. It has been clearly established that, in most cases, the techniques in which the valve and the aorta are replaced separately lead to unsatisfactory mid-term results and to the need of risky reoperations. Accordingly, there is a present consensus within the surgical community to consider that the use of composite grafts in which the coronary arteries are reimplanted, is mandatory in presence of annulo-aortic ectasia (with or without acute dissection), in patients with Marfan syndrome, and that it is advisable in many instances of chronic dissection or dystrophic aneurysm.
Many techniques have been described and are still in use to achieve the total replacement of the aortic root. They concern every step of the procedure.
The Valved Conduit: The first description of the procedure was made by Bentall and De Bono in 1968. This technique consists in implanting the composite conduit inside the aneurysmal sack which is not resected. The valvular prosthesis is sewn inside the Dacron(R) tube at about 5 mm of one extremity with a continuous suture. The rim of the Dacron graft is then secured to the aortic annulus with a running 3/0 polypropilene suture. The coronary ostia are not detached from the aneurysm wall and are reimplanted into the Dacron(R) prosthesis by direct approximation. After completion of the ascending aortic repair, the aneurysmal sack is wrapped aroud the composite graft.
This technique has several drawbacks: On the one hand, it reduces the gap between the valvular prosthesis and the coronary ostia; on the other hand, despite many expressed opinions, it seems to us that a running suture increases the risk of uncontrolled bleeding. We prefer to secure the conduit to the aortic annulus with a series of "U" shaped pledgeted stitches in an everting manner. Moreover this technique has been held responsible for the occurence of false aneurysms at the site of coronary reimplantation.
For all these reasons, the so-called "button" method or "modified Bentall's technique" stands presently as the method of choice for most surgical teams. It is particularly mandatory in case of fragile aortic wall, or when the distance between the aortic annulus and the coronary ostia is short.
As described by Kouchoukos and many others, the technique consists in totally resecting the pathological aortic tissues, in detaching the coronary ostia into small buttons and in reimplanting them directly into the aortic tube. No wrapping is carried out at the end of the repair.
In 1981, Cabrol et al. published an astute technique of reimplantation of the coronary ostia after implantation of a composite graft. It consists in inserting a small Dacron graft (8 to 10 mm in diamater) between the two coronary ostia in a end-to-end fashion and to anastomose it in a latero-lateral manner to the main aortic conduit, as a "moustache". In addition, to achieve complete and safe haemostasis at the end of the procedure, the aneurysmal sack is wrapped around the grafts and a small fistula between the inferior part of the sack and the right atrial appendage is carried out.
The "Cabrol" method, although elegant and easy, is largely opened to criticism. In our experience, the supposed easier access to the anastomoses after completion of the procedure was never proved. In young patients (Marfan), the very long-term outcome of the small Dacron graft is unknown and may lead to difficult and risky reoperations. There is also a continuing uncertainty concerning the possibility of acute thrombosis of one limb of the coronary graft and the possibility of myocardial infarction or sudden death. Conversely, this technique may be usefull in case of reoperation in which mobilization of the aortic root is made very difficult by tight adhesions.
Although no randomised study was carried out, wrapping has never proved to be of benefit. Conversely, this method does not prevent from bleeding and is associated with a high risk of false aneurysm or graft tamponade.
Similarly, the use of a fistula between the wrapped ascending aorta and the right atrial appendage seems to be at least unuseful and at most deleterious.
The Valve-sparing Techniques: In 1992 David and Feindel published a technique allowing to totally replacing the aortic root while preserving the aortic valve. It consists in resecting the whole pathological aortic tissue down to the aortic annulus leaving only a small (about 3mm wide) rim of aortic tissue along the annulus. Then by passing U-shaped interrupted sutures below the aortic valve from inside to outside, a Dacron prosthesis is implanted around the aortic valve which is then swen inside the dacron tube in the manner of an homograft, before reimplantation of the coronary ostia.
This publication has given a certain revival to the technique described one decade earlier by Yacoub et al. It consists in resecting the aortic tissues as in the David's method but in scalloping the Dacron tube in order to make it fit the shape of the aortic annulus. The valve commissures are resuspended vertically at the apex of each groove in the Dacron tube. Each Dacron extension is then sewn along the aortic annulus with continuous sutures, before reimplantation of the coronary ostia in the usual manner.
Those two techniques are technically demanding. The risk of distortion of the native aortic valve with subsequent residual or recurring aortic regurgitation requires precise measurements and great surgical care.
In this regard, the Yacoub's or "remodelling" technique seems easier than the David's or "inclusion" one.
Wathever their respective advantages or drawbacks, those techniques are very promising, especially in young patients, but entail an actual risk of reoperation for residual or recurring aortic insufficiency.
We shall briefly report our experience.
The important observations that we made throughout this experience extending over more than 30
years is that:
This underlines the importance of indication and timing of surgery in patients with a dystrophic aneurysm of the aortic root. Any diagnosed aneurysm of this type, either in Marfan or non-Marfan patients, should be sent to surgery, as soon as the diameter of the aorta reaches 4.5 centimeters or shows evidence of increase at two successive (six months delay) measurements.
- The different techniques are not equivalent and may be adapted to the pathological features and to the circumstances of the operation.
- The "button" technique was not associated with a lower hospital mortality rate but was associated with a better long-term survival and a very low rate of reoperations.
- Valve-sparing procedures are safe and satisfactory but are associated with an undeniable increased surgical difficulty as well as a reduced but unforeseeable risk of reoperation.
- The hospital mortality rate between patients operated upon on an emergency basis is ten fold higher than the hospital mortality rate of patients operated upon electively.
20 Years Single Institution Experience With Ross Procedure
Zohair Al Halees MD, Ahmed Sallehuddin MD, Bahaa Al Soufi, Ziad Al Bulbul MD,
Ahmed Al Omrani, Mansour Al Joufan MD, Maie Al Shahid MD, Mohammed Al Amri MD,
Baha Fadel MD King Faisal Heart Institute, Riyadh, Saudi Arabia
Background: Ross procedure has emerged as an attractive option for Aortic Valve Replacement (AVR) particularly in the young. Controversy exists on long-term outcomes particularly in reference to aortic root dilatation. A 20-year experience of a single institution is presented.
Methods: January 1990 - September 2008, 486 patients (pts) underwent Ross procedure for various AV pathologies (67% rheumatic - 33% non-rheumatic etiology). 37 patients were ? 24 months of age and the rest 2 - 52 years (mean 18 yrs ±13). Autograft was implanted as free standing root. 40 pts required a mini-Ross-Konno procedure. Mean follow up 9.6 ±9 yrs.
Results: Hospital mortality was 6/486 (1.2%), late mortality was 1.5%. Freedom from all events excluding the reoperation was 97% ± 2.
Eighty-six patients required 91 reoperations, 48 involving the neopulmonary valve (10%). Lately few pts underwent percutaneous pulmonary valve implanataion. Autograft related reoperations were mostly in rheumatic patients with originally pure aortic regurgitation, and dilated aortic roots. The risk increased in the presence of concomitant severe rheumatic mitral valve regurgitation. Mode of failure was either root dilatation with progressive AR or recurrence of rheumatic activity or both. Restrictive selection criteria with surgical technique modifications were adopted fro rheumatic pts with subsequent reduction in autograft failure rate (from 27% to 5%). In contrast, there was only two autograft related reoperation in the non-rheumatic group with no incidence of neo-aortic root dilatation. Overall quality of life was excellent.
Conclusion: Ross operation is an excellent option for AVR. There are 2 distinct groups that behave differently in regards to late autograft function. (I) Congenital / nonrheumatic AV disease with excellent durability (II) Rheumatic AV disease with less favorable outcomes, however, with appropriate selection outcomes are improved. Reintervention for neopulmonary valve is required in about 10-12% of pts. Percutaneous pulmonary valve may become a valuable alternative to surgery in that regard.
Minimally invasive cardiac Surgery
Dr. Hilal Ali Al Sabti
Since cardiac Surgery became feasible in the last 50 years, there is a huge evolution in this field. Still the concept of minimally invasive cardiac Surgery (MICS) had started late in this specialty. This is due to the complexity and the invasiveness of the procedures done. The main aim of minimally invasive cardiac surgery with the era of catheter based treatment is to provide effective less invasive operation with long lasting benefits to the patients with least possible trauma. The two main aimed benefits of minimally invasive cardiac surgery is to avoid extracorporeal circulation of possible and to use smaller incision so you induce less trauma, preserve the integrity of the chest cavity and produce more acceptable cosmetic appearance. The concept of the MICS had evolved from the conventional way of doing the procedure to video assisted, video directed and last the robotic use during surgery.
Acute Aortic Dissection Surgical and Endovascular Treatment
A. El Bishry MCH MD FRCS FRCS( CT) FICA
Introduction: The established treatment modality of acute Stanford type A dissection includes repair of the ascending aorta and various portions of the aortic arch, whereas the descending aorta is left untreated. We report a simultaneous approach of open repair of the ascending aorta with transluminal stent grafting of the descending aorta to minimize the consequences of an untreated descending aorta.
Methods: Repair of the ascending aorta and transluminal stent grafting into the descending aorta during the period of deep hypothermic circulatory arrest. Circulatory arrest time ranged between 30 and 67 minutes (average, 38.8 minutes). Specially designed Ella stent grafts (32 to 40 mm in diameter, length 13 cm) were inserted under direct vision and deployed with the proximal end at the origin of the left subclavian artery
Results: Intraoperative stent graft placement was successful in 14patients and failed in 1 case. because of severe kinking of the distal arch,1 patient died of massive cerebral stroke mean ICU stay was 4.5 days CT follow up showed 6 complete false lumen thrombosis and 7 partial thrombosis.
Follow-up was complete and ranged from 1 to 9 months (mean, 5.4 months).
Conclusions: This preliminary study shows that combined surgical and endovascular treatment of acute type A dissection is feasible, and at least partial thrombosis of the false lumen can be achieved, potentially minimizing the risk of further dilatation or rupture. Additionally, the stent graft expands the otherwise sickle-shaped true lumen, thereby ameliorating distal aortic perfusion. Longterm results are warranted to demonstrate the effectiveness of this new combined treatment modality.
Left main Stent: Is it Feasible
Talib K Majwal MD,FRCPI,FRCP(UK),FACC Dubai Heart Center, Dubai Hospital, Dubai, UAE
Significant narrowing of the left main coronary artery is a high risk condition with significant mortality risk.
Trials from the 1970s and 1980s involving patients with LM disease showed a clear survival advantage for bypass surgery over medical therapy.
Bypass surgery is the current gold-standard treatment for unprotected left main (ULM) disease.
Stenting utilizing drug-eluting stents (DES) is another therapeutic option for patients with ULM disease considered too high risk for bypass surgery or for patients who simply refuse bypass surgery.
Initial endeavors using bare-metal stents in the 1980s and 1990s were hampered by high restenosis rates, which commonly manifested as sudden death or the need for a repeat procedure or bypass surgery .The development and release of drug-eluting stents (DES) in 2002, and the dramatic reduction in restenosis associated with DES, have led to a resurgence of interest in ULM stenting.
Worldwide experience is accumulating, and initial observational studies have shown short-term outcomes that rival those of bypass surgery Until randomized trials are completed, ULM stenting using DES can be considered in select patients: patients who are candidates for revascularization but are not suitable for bypass surgery, either because of confounding co morbidities or patient preference.
The ideal patient would have non bifurcation LM disease (i.e., ostial or mid- shaft) and normal left ventricular function, though other subset of patient may also eligible for stenting.
The patient would also have to accept the need for prolonged anti-platelet therapy and likely surveillance follow-up angiography.
Percutaneous Pulmonary Valve Implantation Using the Edwards Sapien™ THV
Ziyad M. Hijazi, MD, MPH, FSCAI, FACC
Rush University Medical Center, Chicago, Illinois, USA
Significant pulmonary valve regurgitation results in progressive right ventricle dilation that may lead to the risk of development of ventricular arrhythmias, right ventricle dysfunction and sudden death. The occurrence of pulmonary regurgitation and or obstruction is not uncommon after surgery for congenital heart defects, including tetralogy of Fallot, pulmonary atresia and any other surgical procedure requiring reconstruction of the right ventricle outflow tract. Even if a valved conduit or a bioprosthetic valve has been used for this purpose, progressive pulmonary regurgitation and or stenosis of such conduits or valves (homografts, Contegra, porcine valves) can occur. Surgical pulmonary valve implantation at an appropriate age may restore right ventricular function and improve the symptoms, however cardiopulmonary bypass and ventriculotomy needed for such operations may further impair the right ventricular function. Therefore timing and indications for resurrection of a competent pulmonary valve are still controversial issues.
Bonhoeffer was the first one to implant a percutaneous valve in the pulmonic position using a bovine jugular vein with a valve mounted inside a stent. Since then, Cribier and his colleagues reported on the first human application of another percutaneous heart valve (PHV) in the aortic position. This valve was designed initially for application only in the aortic position and the early clinical experience with this PHV in the aortic position is ongoing.
We have tested the same valve in the right side of the cardiac circulation. The testing involved acute and chronic animal studies that demonstrated the valve can perform well in the pulmonic position.
In December 2005, we implanted this valve in a 16 yr old patient who had a failed conduit between the right ventricle and pulmonary artery. Since then, a clinical trial sponsored by the United States FDA has been approved to test the safety and efficacy of this valve. To date, 10 patients have undergone an attempt of percutaneous valve implantation in the pulmonic position. Their ages ranged from 15-71 yrs (8 males/2 females) and weight >35 kg in all. The valve was successfully deployed in 9/10 patients, in one patient, prestenting was unsuccessful. In one patient the valve was not positioned well and migrated to the RV. This valve was removed under inflow occlusion and another valve was deployed using the "perventricular approach", without CPB. All 9 patients are doing well with no pulmonary insufficiency.
I'll discuss the valve and technical aspects and share with you the results to date and selection of patients.
Management of Haemopericardium during Percutaneous Mitral Commissurotomy
Dr. Georges Ghanem
Background: Haemopericardium is a severe complication of percutaneous mitral commissurotomy (PMC) due to transseptal catheterization. Its incidence varies from 0.5% to 12%3. There are no particular recommendations in the literature on the management of this complication during PMC. Our objective is to review and analyze the cases of haemopericardium in a series of 245 patients with severe mitral stenosis, and provide certain recommendations for its management during PMC.
Patients and Methods: Between January 1993 and June 2008, 48 males and 197 females with severe mitral stenosis were enrolled. The mean age was 43 years old. Two hundred forty patients (98%) were class III NYHA. Twenty-eight patients (11.4%) had undergone previous commissurotomy and their history was as follows: 10 patients (4.1%) had previous open mitral commissurotomy, 12 patients (4.9%) had closed mitral commissurotomy and 6 patients (2.45%) had percutaneous mitral commissurotomy. The mean echo score was 8.4, the mean gradient was 14.8 mmHg and the mean mitral valve area was 1cm2.
Results and Haemopericardium Management: The Inoue technique was used for all the procedures. Overall, the procedure was performed successfully in 239 patients (97.5%). The mean mitral valve area was increased from 1cm2 to 2cm2 and the mean gradient was reduced from 14.8mmHg to 5.8mmHg. Death occurred in 1 patient (0.4%), severe mitral regurgitation occurred in 2 patients (0.8%) and haemopericardium in 6 patients (2.45%). The management of haemopericardium in these patients was as follows:
The 1st patient, a 45 year-old female, was sent immediately to surgery for open pericardiocentesis and mitral valve replacement. The 2nd patient, a 28 year-old female, had a needle pericardiocentesis in the cath lab after reversing heparin with Protamin, and then surgery was performed on an elective basis. The 3rd patient, a 50 year-old female, had a needle pericardiocentesis in the cath lab after reversing heparin with Protamin, and then 24 hours later a PMC was done with successful results.
The 4th patient, a 35 year-old 7-months pregnant female, was managed as follows: First, heparin was immediately reversed with Protamin. Then, a needle pericardiocentesis was done after 6F sheath installation into the pericardium under echoguidance. Due to pregnancy, the patient was at high risk for surgery (10% fetal mortality and 3% mother mortality), therefore, the procedure was continued with one balloon inflation immediately at the appropriate diameter corresponding to the patient's height (height/10 + 10) with successful result. The sheath was then retrieved from the pericardium 6 hours later. The patient reached term and delivered a normal infant.
The 5th and 6th patients, 53 and 64 year-old females, were managed exactly the same way as the 4th patient with successful results.
Conclusion: Although haemopericardium is a major complication of PMC, our clinical experience demonstrates that it could be successfully managed in the cath lab through continuing PMC after reversing heparin with one optimal inflation; in such cases, surgery could be prevented. Such management regime could be particularly beneficial for patients at high risk for surgery.
International Guidelines, Do They Need Local Adaptation?
Dr. Hassan Baaqeel
Evidence based Clinical Practice Guidelines (CPG) as a tool to implement best research evidence into practice are gaining more acceptance by both health care providers and health care institutions. Development of high quality evidence based CPGs is a time consuming and resource intensive process. This is the reason why their development is undertaken by well funded institutions/organization. The methodology of developing such high quality CPGs is fairly standard and widely accepted. When resources (time, funds and technical expertise) are limited, adaptation of such high quality CPGs into local/regional setting is an option. An adaptation methodology, led by the New Zealand Guideline Center, has been developed by international entities involved in the development of CPGs. This presentation will address the development and adaptation of CPGs.
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