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Table of Contents
ABSTRACTS FROM THE 4TH ECSC
Year : 2013  |  Volume : 14  |  Issue : 3  |  Page : 121-153  

Abstracts from the 4th Emirates Cardiac Society Congress held on November 7 - 9, 2013


Date of Web Publication28-Jan-2014

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How to cite this article:
. Abstracts from the 4th Emirates Cardiac Society Congress held on November 7 - 9, 2013. Heart Views 2013;14:121-53

How to cite this URL:
. Abstracts from the 4th Emirates Cardiac Society Congress held on November 7 - 9, 2013. Heart Views [serial online] 2013 [cited 2018 Nov 17];14:121-53. Available from: http://www.heartviews.org/text.asp?2013/14/3/121/125930

Long-Term Pacemaker Dependency Following Transcatheter Aortic Valve Implantation

Ramiz Emini, Christian Skrabal, Christian Liewald, Andreas Liebold


Department of Cardiothoracic and Vascular Surgery, Germany

Background: Atrioventricular (AV) conduction disorder after transcatheter aortic valve implantation (TAVI) is a common complication with the requirement of a permanent pacemaker implantation (PPI). Uncertainty exists whether PPI should be performed in patients presenting with left bundle branch block (LBBB) following TAVI. The aim of our investigation is to find out if these conduction disorders persist during follow-up.

Materials and Methods: A total of 183 patients (68 males, mean age 81.4} 6.7 years) underwent TAVI using the self-expanding Medtronic Core Valve Revalving System. PPI indications were higher degree AV block as well as new-onset LBBB. A 12-lead electrocardiogram was performed preoperatively, immediately after the procedure, at discharge, after 2 weeks and every 3 months during follow-up.

Results: Forty patients (22%, mean age 83.1± 5.4 years,) required PPI, of these 9 patients (5%) due to LBBB. The need for a PPI was higher in patients in whom the 29mm prosthesis was used (31 pts. =78%) as compared with the 26 mm prosthesis (9 pts. = 22%). After 12 months follow-up, 17 patients (43%) recovered from AV Block III° to normal sinus rhythm. LBBB sustained in all patients but did not degenerate to multifascicular block.

Discussion: A significant percentage of TAVI-induced AV block resolves during follow-up. LBBB per se should not be treated with PPI. Patients with persistent LBBB should be closely monitored and eventually considered for cardiac resynchronization therapy.

Predictors of Mortality in Patients with Acute Coronary Syndrome - A Hospital Admissions Study: 2000-2013

Mohammed Wasim


Pennine Acute NHS Trust, United Kingdom

Introduction: Acute Coronary Syndrome is a common condition that has been well studied. However, the predictors of mortality in patients with Acute Coronary Syndrome have not been well studied in a large hospital population in the UK. We investigated the predictors of mortality in patients with Acute Coronary Syndrome from a large sample of hospital admissions.

Materials and Methods: Anonymous information on patients with Acute Coronary Syndrome, co-morbidities and procedures attending large multi-ethnic general hospitals in Manchester, United Kingdom in the period 2000-2013 was obtained from the local health authority computerised hospital activity analysis register using ICD-10 and OPCS coding systems. Statistical analysis was performed using SPSS version 20.

Results: Out of 1221216 patients admitted, there were 25322 (2.1%) patients with Acute Coronary Syndrome; mean age 66.6 years} 14.4 (S.D); Male (64.2%), Female(35.8%). The main co-morbidities were Hypertension (11397; 45.0%), Previous Myocardial Infarction (9184; 36.3%), Hyperlipidaemia (6271;24.8%), Type 2 Diabetes Mellitus (4759;18.8%), Heart Failure (4670; 18.4%), Chronic Kidney Disease (1612; 6.4%). A multi-nominal logistic regression model accounting for variations in age, sex and ethnic group showed that Hypertension (RR0.8; C.I0.7-0.9), Previous Myocardial Infarction RR1.2; C.I1.1-1.3), Hyperlipidaemia (RR0.5; C.I0.4-0.6), Type 2 Diabetes Mellitus (RR1.5; C.I1.3-1.6), Heart Failure (RR2.9; C.I2.6-3.2) and Chronic Kidney Disease (RR2.3; C.I1.9-2.7) as significant predictors of mortality (p).

Conclusion: We have shown that Previous Myocardial Infarction, Type 2 Diabetes Mellitus, Heart Failure and Chronic Kidney Disease are significant predictors of mortality in patients with Acute Coronary Syndrome from a large hospital based sample in the UK. A diagnosis of Hypertension and Hyperlipidaemia seem to confer improved mortality possibly reflecting mortality benefit of drugs such as beta blockers and ACE-inhibitors. Our improved understanding of these predictors will guide clinicians to focus on these high risk groups to improve clinical practice and outcomes in patients with Acute Coronary Syndrome.

Bleeding Control After Teeth Extractions and Minor Oral Surgeries in Patients Treated by Antithrombotic Drugs

Boukais Hamid


Department of Oral Surgery, Algiers Faculty of Medicine, Algeria

Background: Since the placing on the market of antithrombotic drugs, the attitude to adopt these medications before teeth extractions and minor oral surgeries is still a controversial subject. Changing the anticoagulation expose to a high thromboembolic risk and its fatal complications, maintaining it, expose to a theoretical risk of bleeding.

Aim: To teste the effectiveness of local hemostasis technics after teeth extractions and minor oral surgeries without changing the antithrombotic treatment.

Materials and Methods: All the patients had a medical examination before the acts. Single or multiple Teeth extractions and surgeries have been performed on local anaesthesia with epinephrine. After the acts, local hemostasis technics (alveolar dressig by surgicel, sutures), have been systematically applied. All the patients have been controlled on days 3, 5, 8 after the act. The results have been analysed by Epi-Info Software.

Results: Among the 490 patients evaluated in this study, 1477 acts such as teeth extractions and minor oral surgeries were performed. All the patients were under antithrombotic such as: Aspirin (n = 282), Aspirin + clopidogrel (n = 230 acts), antivitamin k (n = 895), Heparin (n = 70). The INR value in antivitamin k group was ranged between (2 -4,5). For all the acts, there were no peroperative bleeding, but in the postoperative period, 49 bleeding cases (3,31%) have been reported. The distribution of the bleeding cases was: 8 in antiplatelet group (1,53%), 9 in heparin group (12,85%), 32 in antivitamin K group (3,57%). The statistical analysis of the results showed that the acts performed on heparin were more hemorrhagic than the ones on aspirin or antivitamin K. For the majority of the bleeding cases (95%), local causes have been found. In the antivitamin group, INR value was not a risk factor of the occurrence of post-operative bleeding.

Conclusion: The results of this study showed that the alteration of anticoagulation before teeth extractions and minor oral surgeries is not necessary when in patients under antiplatelet agents or antivitamin k when INR value is equal or less than 4,5. Local hemostasis technics such as sutures, surgical control successfully alveolar bleeding after teeth extractions. A theoretical risk of hemorrhage after dental surgery in patients at therapeutic levels of anticoagulation exists but it is minimal and overweighed by the risk of thromboembolism after alteration of the anticoagulant therapy.

Poincara Plot Analysis of Heart Rate Variability in the Diabetic Patients in the UAE

Hanin Baker Abubaker, Habiba Alsafar, Herbert Jelinek, Kinda Khala, Ahsan Khandoker


Biomedical Engineering Department, Khalifa University of Science, Technology and Science, United Arab Emirates

Introduction: With 18.9% of its population being diabetic, the UAE is ranked 11 th in the prevalence of type 2 diabetes. Major complications such as cardiac death and cardiac autonomic neuropathy are caused by diabetic autonomic neuropathy. The Heart Rate Variability (HRV) analysis has been shown to detect variations in autonomic balance of heart rate to allow earlier detection of autonomic dysfunction. Current HRV parameters used in HRV analysis are essentially static measures of a time signal. To obtain a better understanding of the relationship between autonomic control of the heart rate and diabetes a more dynamic measure of heart rate is required. The Poincara Plot allows determining linear components of the inter-beat variability associated with short and long term correlations of the signal. The aim of this study is to look at whether the short term variability, long term variability and the point-to-point variation of the Poincara plot of HRV are different in type-2 diabetic (T2D) than non-diabetic patients.

Materials and Methods: This study included 99 unrelated individuals of UAE national divided into two groups; nondiabetic and T2D with sample size of 44 and 55 respectively (Females 65 %; males 35%). The age average of the entire population is (50.0} 11.6) years. The study was performed with the approval of the Ethical review committee of Mafraq and SKMC in Abu Dhabi. The ECG signals were recorded over five minutes period and then filtered using a digital band-pass filter (0.5 30 Hz). This resulted in eliminating four recordings that has >5% noise. The RR intervals were calculated for the HRV analysis to determine the Poincara plot indices; the width (SD1) and the length (SD2) of the minor and major axes which represent short and long-term HRVand the complex correlation measures (CCM) which captures the temporal dynamics of HRV, and then performed the statistical analysis of variance on these results.

Results: Although SD2 did not show a significant difference among the groups (P = 0.27), both SD1 and the ratio SD1/SD2 were found to significantly (P values are 0.0003 and 0.0013 respectively) be lower in T2D patients than the nondiabetic group. The larger SD1/SD2 ratio in T2D patients (0.43}0.04) reflects that a greater percentage of its overall variance of the beat-to-beat intervals. leading to autonomic imbalance. CCM was found to be significantly (P = 0.05) lower in T2D (0.10 ± 0.02) patients than the healthy control group (0.14} 0.02).

Conclusion: The main conclusion is that short term heart rate variability (SD1) and temporal dynamics (CCM) of HRV were reduced in T2D patients. The reduced CCM in T2D patients might indicate that T2D patients are at high CVD risk. These results substantiate findings of our previous study on CVD risk, where CCM was found to decrease with increased CVD risk as determined by the Framingham risk equation. In conclusion, SD1 and CCM could be markers for CVD risk in T2D patients.

Factors Affecting the Prevalence of Chronic Diseases in Palestinian People: An Analysis of Data from the Palestinian Central Bureau of Statistics

Hesham Fahmi Abukhdeir, Lee S. Caplan, LeRoy Reese, Earnest Alema-Mensah


MoreHouse School of Medicine, Mercer University School of Medicine

Background: This study determined whether there are significant differences in the prevalence of diabetes, hypertension, cardiovascular disease (CVD) and cancer among Palestinians with respect to different demographic variables using secondary data from the Palestinian Central Bureau of Statistics.

Materials and Methods: Secondary data from the Palestinian Central Bureau of Statistics which were collected using cross-sectional surveys to gather general health information on the populations of the Palestinian territories were obtained. The dependent variables in this study were presence or absence of diabetes, hypertension, CVD, and cancer. The independent variables included region, sex, returnee status, refugee status, school attendance status, educational attainment, labor force status, smoking status, number of cigarettes smoked daily, marital status, locality type, age groupings, and type of health insurance. Frequency distributions were run on each of these variables to ensure they were representative of the population. Bivariate analyses were performed comparing each of the independent variables with each of the dependent variables, and chi-square analyses were used to determine whether there were statistically significant associations between any of them. These results were used to guide the selection of independent variables to be included in the logistic regression models constructed to determine the effects of each of the independent variables on the prevalences of diabetes, hypertension, CVD, and cancer, controlling for all the other variables in the models. All analyses were conducted using SPSS version 17.0.

Results: Living in the Gaza Strip was a protective factor, with this group being 21% less likely to have diabetes, 35% less likely to have hypertension, and 48% less likely to have CVD than those living in the West Bank. No significant difference was found for cancer. Being a refugee was a significant risk factor for diabetes and CVD while being married/engaged or divorced/separated/widowed was a risk factor for diabetes and hypertension. Gender was a risk factor for hypertension with females being 60% more likely to have hypertension than males. Living in a rural setting was protective against hypertension. As expected, age was a risk factor for diabetes, hypertension and CVD; the magnitude of this increased risk was alarming, 36 to 434 times greater in those aged 40-65 years compared with those aged 0-19 years.

Discussion: This study was unique in that it focused on comparing the Palestinians living in the West Bank and the Gaza Strip as 2 different entities, instead of lumping all the Palestinians together. Our results showed significant differences in the prevalence of cancer, hypertension, CVD and diabetes between Palestinians living in the Gaza Strip and those in the West Bank, with those living in the Gaza Strip having a lower prevalence of all 4 diseases. A strength of this study was that it identified the possible presence of health disparities between Palestinians living in the Gaza Strip and the West Bank. A limitation of the study was that it was limited to prevalence data which limited ability to assess risk factors. These results can help form the basis of future studies.

Effect of Vitamin-D Intake on Blood Indices in Diagnosed Rheumatic Heart Disease

Azza Abul-Fadl, Somaya Elwan, Ahmed Rabae


Benha University, Egypt

Introduction: Rheumatic heart disease (RHD) is a disease of poverty and usual;ly associated with malnutrition. Vitamin D is a micronutrient that has been found to influence cardiac function.

Aim of Work: To study the effect of vitamin D supplementation on the progress of the disease and overall health of the affected children.

Materials and Methods: This is prospective, interventional, follow-up study that was conducted for 60 RHD subjects including 30 patients with RHD proved by ECHO and who were subjected to vitamin-D administration and 30 patients with RHD who were administered placebo. Both groups were controlled for compliance and socioeconomic status. Laboratory studies for erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and antistreptolysin titre (ASOT) in serum before and after 3 months of vitamin D administration. Echocardiographic changes were assessed before and after the intervention.

Findings: There was a significant improvement in the laboratory findings between the cases exposed to the medication and those not exposed but there was no significant different in the echocardiography findings.

Conclusion: It is concluded that improvement of the nutritional status of these children can be key in control of the progression of the ongoing inflammatory changes in body systems of children who are affected by RHD and can play a role in management of these children.

Transcatheter Treatment of Systemic-to-Pulmonary Artery Shunt Occlusion: The Experience at Sheikh Khalifa Medical City

Elhadi H. Aburawi 1,2 , Mohamed Khan 1 , Haitham Talo 1 , Aref Alhakami 1 , Csaba Tamas 3 , Laszlo Kiraly 3


College of Medicine and Health Sciences, UAE University, United Arab Emirates

Introduction: Blalock and Taussig, 1945, described the anastomosis of the subclavian artery to the ipsilateral pulmonary artery (BT Shunt) for patients with duct dependent cyanotic CHD. Shunt thrombosis, stenosis and kinking is a well-recognized complication. Prophylaxis with aspirin and other anticoagulants have been shown to reduce the risk of shunt thrombosis and occlusion but do not prevent it. Occlusion of this shunt is a life-threatening complication and a major cause of mortality and serious morbidity. The most common presentation of shunt occlusion is hypoxemia (typically, oxygen saturation is).

Materials and Methods: Five infants underwent anticoagulation (heparin) therapy for BT shunt obstruction. The approach was through the femoral artery except in patient 2, who had hybrid procedure through the right common carotid artery. The diagnosis was confirmed by cardiac catheterization. Balloon angioplasty with stenting in all was performed for re-establishment of flow through occluded shunts. Patients 2 and 3 had further balloon dilatation of the BT shunts due to restenosis.

Results: These 5 infants presented with severe cyanosis and occlusive clot of the BT shunt. All the infants had thrombosis except one who had stenosis. The clots were fragmented and displaced by vigorous catheter manipulation and balloon angioplasty. Oxygen saturation increased from 80% immediately after the procedure. There were no post catheterization complications. All patients continued to have oxygen saturation >80% until later total corrective surgery except patients 2 and 3 who had further balloon dilatation. All patients were discharged home with saturation >80% except patient 4, who died after 2 days.

Discussion: Balloon angioplasty and stenting for re-establishment of flow through occluded shunts are probably safe procedure. The baby who died on the second day after the procedure had sudden desaturation and bradycardia with cardiac arrest. However, this procedure could prevent these babies of having surgical exploration and shunt revision with higher mortality. Close observation immediately after the procedure and follow up is mandatory until the corrective surgery done.

Qtc and Qtd Changes After Cardiopulmonary Bypass Surgery in Children

E. H. Aburawi 1,2 , Souid A-K 2 , P. Liuba 1 , E. Pesonen 1


UAE University, Al Ain Hospital and SKMC Abu Dhabi, United Arab Emirates

Objectives: The aim of the study was to assess the impact of cardiopulmonary bypass surgery on corrected QT (QTc) and QT dispersion (QTd) intervals. The possible role of inflammation on these variables was investigated.

Background: Systemic inflammation and altered myocardial repolarization are common consequences of cardiopulmonary bypass surgery.

Materials and Methods: ECGs were registered and C-reactive protein (CRP) as well as white blood cell (WBC) count were measured in 36 children with ventricular septal defect (VSD) or atrial septal defect (ASD) one day before and 5 days after surgery. QTc and QTd were calculated.

Results: QTc increased after surgery in 24 (67%) patients (mean ± SD =31 ± 25 ms, range =7 to 125); whereas QTc decrease was noted in 8 (22%) patients (28 ± 28 ms, range =1 to 77). After surgery, QTc was abnormally prolonged in 8 (22%) patients (461 ± 18 ms, range = 445 to 487) with normal QT times before surgery. Only one of these 8 patients had abnormally prolonged QTc before surgery. Abnormally prolonged QTc returned to normal in 3 of the 4 patients with prolonged QTc. A trend for increased QTd was also noted. The changes did not correlate with CRP, WBC count, bypass time or aortic cross-clamp time.

Conclusions: Impaired myocardial repolarization (abnormally prolonged QTc) appeared after surgery in 22% of pediatric patients. The natural history and clinical significance of these alternations, however, deserve further studies. Prolongation of QTc may predispose patients to post-operative arrhythmias.

Coronary Flow Dynamics in Children After Repair of Tetralogy of Fallot

Elhadi H. Aburawi, Peter Munkhammar, Marcus Carlsson, Erkki Pesonen


UAE University, Al Ain Hospital and SKMC Abu Dhabi, United Arab Emirates

Objectives: To assess the possible effect of a stiff right ventricle on the coronary flow (CF) in patients with post-operative Tetralogy of Fallot (TOF).

Background: Right ventricular restrictive physiology (RVRP) is characteristic to many patients with post-operative TOF.

Materials and Methods: A total of 34 patients with TOF anatomically corrected through transatrial repair were included. Coronary flow parameters were registered with transthoracic Doppler echocardiography from posterior descending (PDCA) and left anterior descending (LAD) coronary arteries in the same patient in 24/34 (71%) patients. Twenty age-matched healthy children were used as controls. Cardiac magnetic resonance (CMR) imaging was used to detect myocardial fibrosis, volume of right ventricle (RV), and forward flow during atrial contraction as a sign of right ventricular restrictive physiology (RVRP).

Results: The mean age at investigation was 8.9} 3.0 (range 3-16) years. RV volumes indexed for BSA were larger in patients without RVRP (P = 0.013). Peak flow velocities in diastole and flow velocity time integral were increased in patients compared to controls. They were increased in the LAD in patients with fibrosis of RV (n = 11) compared to patients without fibrosis (n = 9) (P = 0.01 and 0.047 respectively). LAD coronary flow was especially increased in patients with RVRP (n = 9) as compared with those without (n = 11), (P = 0.006 and 0.02 respectively).

Conclusions: Patients at mid-term follow up after correction of TOF show increase of coronary flow. This increase is more pronounced in patients with fibrosis and RVRP of the RV.

A Spectrum of Valvular Involvement in Patients with Rheumatic Heart Disease Taking Injection Benzathine Penicillin at Shahid Gangalal National Heart Centre, Kathmandu, Nepal

Chandra Mani Adhikari


Shahid Gangalal National Heart Centre, Nepal

Introduction: Acute rheumatic fever and rheumatic heart disease constitute important public health problems in developing countries. The disease results from an abnormal autoimmune response to a group A streptococcal infection in a susceptible host. We aim to describe the spectrum of valvular involvement and demographic features in patients taking Injection Benzathine Peniciliin for primary and secondary prevention of rheumatic Heart disease.

Materials and Methods: All the patients, who are taking injection Benzathine penicillin for primary and secondary prevention of rheumatic heart disease during the study period at SGNHC were included in this study. Demographic features like age, sex, echocardiograph diagnosis along with any adverse effects of Benzathine penicillin were collected.

Results: There were 661 patients; compared to male, more female are taking penicillin injections. Most are taking it due to rheumatic heart disease rather than rheumatic fever. Mitral valve involvement is the common valve involved. Pure Mitral stenosis is most common valvular involvement. Mitral valve involvement was more common in female whereas aortic valve involvement was common in male. Forty two percentage patients underwent intervention; among them Percutaneous transluminal mitral commisuorotomy is the most common. There was no adverse event during the study time following penicillin injection.

Conclusions: Rheumatic Heart disease is public health problems of developing countries. Patients coming for Injection Penicillin are more commonly for secondary prevention rather than primary prevention.Women are more likely to suffer from it. Mitral valve is the most common valve involved in rheumatic heart disease patients.

Trends of ST Elevation Myocardial Infarction and in-Hospital Mortality at Shahid Gangalal National Heart Centre, Kathmandu, Nepal

Chandra Mani Adhikari


Shahid Gangalal National Heart Centre, Nepal

Objective: ST-segment elevation myocardial infarction is a life-threatening disease. This study aimed to evaluate in-hospital mortality rates and mode of reperfusion over the period of twelve year at Shahid Gangalal National Heart centre, Kathmandu, Nepal.

Materials and Methods: A hospital data base was used to analyze 5599 patients admitted due to ST-segment elevation myocardial infarction in Cardiac care unit from September 2001 till December 2012. We evaluated types of myocardial infarction, in-hospital mortality rate and mode of reperfusion in ST-segment elevation myocardial infarction.

Results: Among the 5599 patient 3491 were male and 1108 were female. Each year there is an increase in the number of patient admitted due to ST-segment elevation myocardial infarction. Inferior wall Myocardial infarction is the most common reason for admission followed by anterior and extensive anterior wall myocardial infarction. In hospital mortality was 7.89%. Number of patient who underwent reperfusion therapy for ST elevation myocardial infarction is almost same throughout last 12 years. There is a gradual increase in Primary percutaneous Coronay intervention as a mode of reperfusion therapy whereas there is a decrease in the rate of thrombolysis.

Conclusion: Increasing number of patient was admitted due to ST-segment elevation myocardial infarction. In-hospital mortality rate is comparable to international standard. Change in the Mode of reperfusion can be noticed.

Early Detection of Right Ventricular Diastolic Dysfunction by Pulsed Tissue Doppler Echocardiography in Iron Loaded Beta Thalassemia Patients

Hala Mounir Agha, Amal Beshlawy, Mona Hamdy, Alae Sobih, Fatma El Zahrae, Inas Abd El Satar, Antoine Abd El Mesih, Fadwa Said, Ossama Abd El Aziz, Mona El Tagy, Dudley J Pennell


Pediatric Cardiology Unit, Children Hospital, Cairo University, Egypt

Background: Iron overload contributes to cardiac dysfunction in patients with beta thalassemia major. Early heart iron overload can be quantified through T2* cardiovascular magnetic resonance (CMR).

Objective: To clarify the value of tissue Doppler imaging (TDI) in early detection of global myocardial dysfunction in iron loaded thalassemia major patients diagnosed by CMR.

Patients and Methods: Two groups were included in the study; Group I: 69 asymptomatic thalassemia patients (28 females, 41 males), mean age 18.1 ± 7.03 years (range 6 to 39 years); Group II (n = 41) healthy normal controls matched for age and sex. Serum ferritin and CMR were performed to assess the cardiac siderosis (T2* < 20 ms). Group I was subdivided into two subgroups; Group Ia (n = 26) T2 * 20 ms. Conventional and Doppler echocardiography of LV, RV dimensions and functions and pulmonary artery pressure were evaluated.

Results: Right ventricular diastolic function assessed by tricuspid annular E'/A' was positively correlated with T2* value; lower tricuspid E'/A' ratios were correlated with lower T2* values (r = 0.366, P = 0.002). Tricuspid annular A' was significantly higher in group Ia compared to group Ib (16.7} 5.2 cm/s versus 12.1}4.0 cm/s, P20 ms) (6,357}2478 microgram/L versus 2,965}2289 microgram/L (P < 1) was associated with serum ferritin and T2* level of the thalassemia patients.

Conclusion: TDI is a promising tool for quantitative assessment of myocardial function and early detection of right ventricular diastolic dysfunction in iron loaded beta thalassemia major patients.

Six-Minute Walk Test: An Independent Correlate of Pulmonary Hypertension in Young Sickle Cell Patients

Hala Agha, Mona El Tagy, Mona El Ghamrawy, Marwa Abd El Hady


Pediatric Cardiology Unit, Children Hospital, Cairo University, Egypt

Background: Elevation of echocardiography-determined tricuspid regurgitant jet velocity predicts high systolic pulmonary artery pressure. The present study tested the hypotheses that elevated jet velocity is associated with both hemolysis and hypoxia and abnormal 6-minute walk test results. Objectives to correlate pulmonary hypertension (PHT) with different clinical, laboratory findings and 6-minute walk test (6 MWT) and to find the independent correlates of increased tricuspid regurgitant velocity.

Patients and Methods : A prospective study of 80 patients aged 5-25 years old with sickle cell disease under basal conditions and 40 age and sex matched controls was conducted. Hemolytic analysis was assessed by the levels of reticulocytic count, haemoglobin and serum bilirubin. Oxygen saturation by pulse oximeter and 6-minute walk test were done.

Results: The overall prevalence of pulmonary hypertension (TRV‰\2.5 m/sec) was 28.75%. Risk factors associated with PHT was increasing age (r = 0.28, P = 0.01), longer duration of disease (r = 0.25, P = 0.025), high reticulocytic count (r = 0.344, P = 0.002), low O2 saturation (r = −0.574, P = 0.000) and shorter walked distance in 6 MWT (r = −0.75, P = 0.000). By multivariate logistic analysis, only the distance walked during 6 MWT was the independent correlate of pulmonary hypertension (P = 0.033, odds ratio = 0.85; 95% CI = 0.74 to 0.98).

Conclusion: The study provides evidence for independent associations of elevated tricuspid jet velocity with hemolysis, oxygen desaturation and abnormal 6 minute-walk test results. Six-minute walk test can be used as non-invasive index of pulmonary hypertension in sickle cell disease patients.

Left Atrium and Left Trial Appendage Function in Patients with Giant Left Atrium

Abdallah Alasray, Hussien Rizk, Zainab Ashour


Cairo University, Egypt

Background: The giant left atrium (GLA) appeared to be a significant morbid condition. The left atrial appendage (LAA) is the site most commonly associated with thrombus formation. This study aimed to determine the LA and LAA function in patients with GLA.

Patients and Methods: We studied 83 patients with mitral valve disease, 32 of them had GLA. All were subjected to clinical evaluation, transthoracic and transoesphageal echocardiography with 2D and both conventional and tissue Doppler study (TDI). GLA was defined as an antero-posterior LA diameter of ≥ 7 cm.

Results: Patients were divided into 2 groups: GLA and non GLA group. The left atrial pump and reservoir functions were more affected in GLA group with statistically significant differences between the 2 groups regarding LA indexed volume (LAVI) (204} 96.5 v.s 70 ± 30 p= Furthermore the LAA active myocardial contraction velocity (LAAAm) (by TDI) appeared slightly higher in non GLA patients (7.1 ± 3.8 v.s 7.4 ± 3.2 cm/s respectively, P = 0.6) The LAA velocities were significantly reduced in patients with LAA thrombus than in others without (19.6} 7.9 v.s 41.8} 12.8 cm/s respectively for LAAEV, p LAAAm velocity is lower in patients with SEC and/or thrombus compared to others without (3.9} 0.8 v.s 8.2} 0.3 cm/s). LAAAm of 4.1 cm/s has a 89% sensitivity and 86% specificity to predict LAA thrombus (P = 0.001). The value of 5.6 cm/s could predict embolization with sensitivity and specificity of 86.6 and 67.5 %.

Discussion: This contradictory data between GLA and the unpredicted low incidence of LA and LAA thrombus could be attributed to the common valvuar lesion causing GA which is severe mitral regurgitation.

Conclusions: However the LA function appeared to be severely reduced in GLA, the LAA function was predominantly linked to the underlying valvular lesion more than to the LA size.

Detection of Premature Coronary Artery Disease by Cytokines

Wafa Munir Ansari, Dilshad Ahmad Khan, Farooq Ahmad Khan


National University of Sciences and Technology, Pakistan

Research Background: Effective management of Premature Coronary Artery Disease requires timely detection and accurate evaluation of these patients. The objective was to evaluate diagnostic accuracy of high sensitivity C-reactive protein (hS-CRP), Interleukin-18 (IL-18), Tumor Necrosis Factor-alpha (TNF-alpha), Interleukin-10(IL-10) and IL-18/IL-10 ratio for identification of PCAD patients.

Materials and Methods: The Diagnostic validation case-control study was performed at Clinical Pathology Laboratories, Army Medical College, Rawalpindi, Pakistan, from October, 2010 to September, 2012. Two hundred and fifty patients with >70% stenosis, in at least one coronary vessel, on angiography were labelled to have PCAD. An equal number of angio-negative subjects were taken as controls. Serum IL-10, IL-18 and TNF alpha were measured using Enzyme linked Immunosorbent Assay (ELISA), hS-CRP on Immulite 1000.

Results : Mean} SD age of PCAD patients was 40.7} 4.23 yrs (100 males and 25 females) while in controls it was 35.1} 7.55 yrs (110 males and 15 females). Serum IL-18 and hS-CRP were significantly raised in patients with 86%-100% stenosis (n = 73) compared to patients with 71%-85% stenosis (n = 52) (P).

Discussion: HS-CRP and IL-18 have the best diagnostic potential among the cytokines for detection of PCAD with high sensitivity and specificity. Significant positive correlation was observed between hS-CRP and IL-18 highlighting the role and probable synergism of pro-inflammatory cytokine mediators in the diagnostic evaluation and pathogenesis of PCAD.

Analytical Validation and Method Comparison of a Multi-Analyte Serum Protein Based Test for Assessing Coronary Heart Disease Risk

Niamh Nolan, Jumar Pasion, Gabriela Korzus, Lilian Tee, Laura Teigiser, Snjezana Covic, Abby Tyler, Chris Lyman, Ahalya Tirupsur, Evangelos Hytopoulos, Michael Beggs, and Douglas S. Harrington


Aviir, Inc., California, United States

Background: Coronary Heart Disease (CHD) remains a leading cause of morbidity and mortality around the world despite efforts to develop improved methods for CHD risk assessment. Over half of the individuals who experience an acute cardiac event, such as Myocardial Infarction (MI) or Unstable Angina (UA), have at most one risk factor as included in the commonly used Framingham Risk assessment. This highlights the inadequacy of relying on typical risk factors to identify individuals with subclinical cardiovascular disease. The Aviir MIRISK VP„ c/ test, a clinically validated, multi-analyte immunoassay was developed to improve upon the assessment of CHD risk in individuals currently identified as intermediate risk. Here we describe analytical validation of a Q-Plex„ c/ multiplex assay version of the novel biomarker assays comprising the MIRISK VP panel compared to a previously validated version of the assays using xMAPR and MULTI-SPOTR technologies.

Materials and Methods: Multiplexed Quansys Biosciences Q-Plex Array assays were developed to measure the seven serum proteins used in the MIRISK VP CHD risk assessment algorithm that currently are performed with a combination of Luminex xMAP and Meso Scale Discovery MULTI-SPOT technologies. Commercially available control and donor serum samples were used to evaluate the specificity, sensitivity, interfering substances, and reproducibility of the MIRISK VP assessment assays. Concordance and correlation of MIRISK VP CHD risk scores obtained with the different technologies were also evaluated.

Results: Individual analytical measurements for all proteins (CTACK, Eotaxin, Fas Ligand, HGF, IL-16, MCP-3 and sFas) included in the MIRISK VP panel were found to exhibit accuracy (100 ± 30%), cross-reactivity.

Discussion: The operational performance demonstrated by the Q-Plex Array version of the MIRISK VP assessment assays in a clinical laboratory setting meets or exceeds the performance of the xMAP and MULTI-SPOT versions of the assays. The performance also meets specifications established during test development and the clinical association studies used to validate clinical utility. By combining the seven protein assays of the MIRISK VP test in one format, the Q-Plex technology streamlines the testing and minimizes the hands-on time to obtain a patient™s CHD risk score. The high reproducibility of the risk score for the same individual across multiple tests suggests the Q-Plex assays are not susceptible to analytical sources of variation typically encountered in clinical testing labs.

Consumption of Fruit and Vegetables and Risk of Cardiovascular Diseases of Mothers Consulting Health Centers of Errachidia City in the South-West of Morocco

Amina Bidi 1 , Bachir El Bouhali 1 , Isaad Nasri 2 , Mohamed Benlyas 1

1 Team of Nutritional Physiology and Endocrine Pharmacology, Faculty of Science and Technique, Morocco Faculty of Science and Technique, University Moulay Ismail, Errachidia, Morocco

Objectives: The aims of this study was to evaluate the nutritional status of mothers consulting health centers in the city of Errachidia and determine whether, as in other populations in nutrition transition, there is a coexistence of insufficiency and overweight and CVDs risk.

Subjects and Methods: Performing a cross-food investigation through an evaluation of the frequency of food consumption survey of the most widely consumed in Morocco. The survey was conducted among 387 mothers consulting health centers in the city of Errachidia aged 28.13} 6.5. The food frequency questionnaire has a very wide range of simple food consumed in the city of Errachidia. For each food, notes are recorded on the frequency of current consumption, consumption compared to other times and regularity of consumption according to the method of 24-hr recall. Information from the food-frequency questionnaire was used to calculate intake of energy and nutrients. Weight, height, and Body mass index (BMI). BMI categories were as follows: Nonobese (BMI ‰.25), overweight (BMI >25 to 30).

Results: The Comparison of the frequency of consumption of foods studied of a total of 387 mothers frequenting the health centers in the city of Errachidia revealed a relatively high percentage of mothers consumed vegetables (86.82% Hazard ratio (HR) = 0.15), pulses (88.63%, HR = 0.12), fresh fruit (77%, HR = 0.29), cereals (98.45%, HR = 0.01), a high percentage of households consumed olive oil (57.36%, HR = 0.74), meat (58.14%, HR = 0.72) and poultry (60.47%, HR = 0.65) and low to moderate percentage of households consumed fish and dairy products. In this model of consumption, there are the characteristics of the traditional Mediterranean diet, which is dominated by daily olive oil consumption, high consumption of cereals, vegetables and fresh fruits and secs, moderate consumption of milk and dairy products, low consumption of meat in meat products and poultry, a relatively high consumption of fish. In this study of 58 mothers (15%) only for all participating had a higher BMI (the weight in kilograms divided by the square of the height in meters), 5.17% have high blood pressure and 12.4% are people who suffer from cardiovascular disease in their family. Persons, who consume large amounts of fruits, vegetables, legumes, and nutrients such as folate and potassium, may have other lifestyle factors which could reduce their risk of CVDs.

Young Women with Heart Disease

Hanan Bugaigis


Benghazi Cardiac Center, Ministry of Health, Libya

Background: Maternal Mortality MM is one of the strongest indicators for development of nations. The millennium development goals 2015 aim for all countries to reduce by three quarters the MM ratio by the year 2015. However, in the developing world this looks like a far away goal to achieve. Cardiac disease presents one of the major causes of maternal mortality, where improving outcomes for young women with heart disease and pregnancy has been a challenge, not only due to the lower standard of healthcare services in such countries, but due also to ethical and social variants which have been overlooked in many of the current guidance for best practice and evidence based medicine published by the ESC and AHA/ACC. Scope of work In this paper we present three challenging cases of young pregnant women with severe forms of heart disease, their management until delivery, their wishes and how our culture and society plays an important part in decision making in this group. As will be seen in many instances of their care, social and cultural values play an important role in undermining the use of published recommendations, and provision of good care especially when it comes to clinical practice of local Obstetricians. Which in turn calls for the strong recommendations to perform further studies into the importance of having local guidelines sensitive to local practices and social cultures and values.

Case Summaries

Case I:
33 years old lady with double mechanical valves replaced at the age of 11 years, presents with first conception after 5 years of marriage, on warfarin, no follow up for a long time, echocardiography reveals severe mechanical aortic stenosis with a mean gradient of 50 mm Hg.

Case II: 26 years old lady presents with pulmonary edema at 33 weeks of gestation, echocardiography shows dilated cardiomyopathy with severely reduced systolic function.

Case III: 37 years old lady known to have rheumatic valve disease with no follow up for the last 4 years presents at 15 weeks gestation after two years of marriage. Echocardiography shows severe mitral stenosis with pulmonary hypertension.

Induced Pluripotent Stem Cell-Derived Cardiac Progenitors Differentiate to Cardiomyocytes and Form Biosynthetic Tissues

Nicolas Christoforou


Biomedical Engineering, Khalifa University of Science, Technology and Research, United Arab Emirates

The mammalian heart has little capacity to regenerate, and following injury the myocardium is replaced by non-contractile scar tissue. Consequently, increased wall stress and workload on the remaining myocardium leads to chamber dilation, dysfunction, and heart failure. Cell-based therapy with an autologous, epigenetically reprogrammed, and cardiac-committed progenitor cell source could potentially reverse this process by replacing the damaged myocardium with functional tissue. However, it is unclear whether cardiac progenitor cell-derived cardiomyocytes are capable of attaining levels of structural and functional maturity comparable to that of terminally-fated cardiomyocytes. Here, we first describe the derivation of mouse induced pluripotent stem (iPS) cells, which once differentiated allow for the enrichment of Nkx2-5(+) cardiac progenitors, and the cardiomyocyte-specific expression of the red fluorescent protein. We show that the cardiac progenitors are multipotent and capable of differentiating into endothelial cells, smooth muscle cells and cardiomyocytes. Moreover, cardiac progenitor selection corresponds to cKit(+) cell enrichment, while cardiomyocyte cell-lineage commitment is concomitant with dual expression of either cKit/Flk1 or cKit/Sca-1. We proceed to show that the cardiac progenitor-derived cardiomyocytes are capable of forming electrically and mechanically coupled large-scale 2D cell cultures with mature electrophysiological properties. Finally, we examine the cell progenitors' ability to form electromechanically coherent macroscopic tissues, using a physiologically relevant 3D culture model and demonstrate that following long-term culture the cardiomyocytes align, and form robust electromechanical connections throughout the volume of the biosynthetic tissue construct. We conclude that the iPS cell-derived cardiac progenitors are a robust cell source for tissue engineering applications and a 3D culture platform for pharmacological screening and drug development studies.

The Laparoscopically Harvested Omental Flap and Transverse Plate Fixation for Sternal Reconstruction in Complicated Sternal Wound Infection After Cardiac Surgery

J. M. De Raet, P. T. Sergeant


Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig Leipzig, Germany

Background: Complicated sternal wound infection after cardiac surgery has an incidence of 0.4 6.9 % and mortality of 7 80 %. The ideal reconstructive procedure is still a matter of debate.

Aim: To report our experience with the laparoscopically harvested omental flap and transverse plate fixation for sternal reconstruction after complicated sternal wound infection.

Materials and Methods: Between 2010 and 2011, 6 patients with type IV deep sternal wound infection underwent a sternal reconstruction with a laparoscopically harvested omental flap and transverse plate fixation. The median age of the cohort (1 female and 5 males), was 72.5 years (range: 49-78 years). In 5 patients, a bilateral internal thoracic artery had been used. Considerable preoperative risk factors were present: Obesity with Body Mass Index (BMI) 33 (range: 33 " 35: 3 patients); chronic obstructive pulmonary disease (COPD) without steroid therapy preoperatively (4 patients); Diabetes mellitus (type 1: 2 patients; type 2: 1 patient). Abdominal surgery had previously been performed in 4 patients. In 5 cases, the mediastinal wound was prepared with negative pressure wound therapy following surgical debridement. An internal fixation of the sternum was made by titanium locking plates with sternal and rib-to-rib fixation. The postoperative course of these patients was followed by clinical follow-up.

Results: Early postoperative sternal stability was seen in all 6 patients. The 30-day perioperative mortality rate was zero, with an overall survival of 100% until today. Postoperatively no superficial or deep surgical site infections (SSI) were appreciated. Follow-up ranged from 25.5 to 42.5 months (median: 29.5 months).

Conclusions: Combination of a laparoscopically harvested omental flap and transverse plate fixation can contribute to a successful outcome following complicated sternal wound Infection and deserves serious consideration, regardless of the co-morbidity or previous abdominal surgery.

Bilateral Pectoralis Advancement Flaps and Transverse Plate Fixation System for Sternal Reconstruction in the Complicated Sternal Wound

J. M. De Raet, H. De Praetere, P. T. Sergeant


Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig Leipzig, Germany

Objective: To report our experience with bilateral pectoralis advancement flaps and a transverse plate fixation system for sternal reconstruction in the complicated sternal wound.

Materials and Methods: Between 2008 and 2012, 24 patients with a complicated sternal wound underwent a sternal reconstruction with bilateral pectoralis advancement flaps and a transverse plate fixation system. The median age of the cohort (4 female and 20 males), was 65.8 years (range: 33-83 years). In 19 patients, a bilateral internal thoracic artery had been used. Considerable preoperative risk factors were present: Morbid obesity with Body Mass Index (BMI) 35 (range: 35 " 49.7: 13 patients); chronic obstructive pulmonary disease (COPD) without steroid therapy preoperatively (7 patients); Diabetes mellitus (7 patients). Concomitant laparoscopically harvested omentoplasty was performed in case of overt mediastinits (4 patients). In 14 cases, the mediastinal wound was prepared with negative pressure wound therapy following surgical debridement. An internal fixation of the sternum by titanium locking plates with sternal and rib-to-rib fixation and bilateral pectoralis advancement flaps were performed in all patients. The postoperative course of was followed by clinical follow-up.

Results: Early postoperative sternal stability was seen in all 24 patients. The 30-day perioperative mortality rate was zero, with an overall survival of 100% until today. Postoperatively 2 (8.3%) small superficial and 1 (4.1%) deep surgical site infection (SSI) were appreciated. Follow-up ranged from 8 to 56 months (median: 28 months).

Conclusions: Combination of bilateral pectoralis advancement flaps and a transverse plate fixation system for sternal reconstruction can contribute to a successful outcome following a complicated sternal wound.

Intraoperative Annulus Measurement Under Emergent Cardiac Surgery for Failed Transcatheter Aortic Valve Implantation

Ramiz Emini


Department of Cardiothoracic and Vascular Surgery, University of Ulm Medical Center, Germany

Background: The aim of this investigation was to determine the appropriateness of preoperative aortic annulus measurement compared with intraoperative measurement by patients undergoing ultimately emergent cardiac surgery for failed transcatheter aortic valve implantation.

Materials and Methods: In this retrospective investigation a total of 243 patients (102 males, mean age 79,8 ± 7.9) with severe aortic stenosis undergoing TAVI were included. 5 Patients required ultima ratio cardiac surgery due to failed TAVI. The aortic annulus was measured prior with 2D midsystolic transthoracic, tansesophageal echocardiography and ECG triggered multislice computer tomography at 75% systole. Operative measurements were performed with 3 different prosthesis sizers. The different preoperative measurement techniques and direct operative measurement was compared for the best possible correlation.

Results: Calculated average difference between operative and prior transthoracic Echo (mean difference=23,6%) was higher than transesophageal Echo (mean difference=20,89%). The best correlation (mean difference=15,5%) was found using a contrast-enhanced CT scan (256-row multislice Philips Brilliance iCT). Especially the perimetric measurement (mean difference=12,3%) correlates signicantly with intraoperative measurements and showed the lowest difference. Correlation of transthoracic echo and intraoperative measurements was weak. The TEE tends to underestimate the dimensions of aortic annulus.

Discussion: Although the number of treated patients is low the perimetric measurement with the CT was closest to the operative measurement and should be accepted first line in decision making and choosing or preparing the correct prosthesis.

Three Times Lucky Successful Third Valve in Valve for Failed Tavi by Changing Valve Principles

Ramiz Emini, Stephen Wildhirt, Γ. Ÿ. Jochen Spie, Christian Liewald, Andreas Liebold


Department of Cardiothoracic and Vascular Surgery, University of Ulm Medical Center, Germany

Background: Valvular Aortic regurgitation after implantation of two transfemoral transcatheter Edwards Sapien led to recurrent cardiac decompensations. The aim of this Case report is to show the feasibility of changing the valve concepts from balloon expanded to self-expanding to correct a failed valve in valve TAVI with a severe valvular leakage.

Methods and Results: A 76 year old female with an Society of Thoracic Surgery score of 24,22 and a logistic Euroscore of 9,89% underwent TAVI for severe aortic stenosis in February 2011 with a 23-mm Sapien XT (Edwards Lifesciences, Irvine, California). Due to an initial signicant aortic regurgitation (AR) and a valve malposition a second valve was implanted as valve-in-valve. Directly after the procedure a remaining mild aortic regurgitation was described and accepted by the heart team. After a short time period of 2 months the patient had recurrent cardiac decompensations with edema, dyspnea and pleural effusion. She was admitted to our institute at a clinical state of New York Heart Association III to IV. Primarily we optimized the medical treatment of the congestive heart failure. Semi quantitative and quantitative diagnosis with transesophageal echocardiography and magnetic resonance imaging was performed showing a severe transvalvular aortic regurgitation and two small paravalvular leakages with a total regurgitation of 32%. Echocardiography and magnetic resonance imaging described normal leaflet movement and could exclude a frozen leaflet. The computer tomographic scan (256-row multislice Philips Brilliance iCT) demonstrated a severely atherosclerotic aorta (porcelain aorta). Considering the porcelain aorta and the comorbidities open heart surgery would bear an unjustifiable risk so the heart team decided to perform a third-time TAVI by changing the valve principles. The procedure was done percutaneously via the right femoral artery. Without any complications 26 mm CoreValve prosthesis was placed within the Sapien prosthesis. The angiography after alignment demonstrated a very good function of the new valve with the remaining mild paravalvular leakage. After an uncomplicated intra- and postoperative course the periodic follow up was realized after 3 and 6 months. The patient was advised to take dual antiplatelet therapy for 6 months and is now doing well in New York Heart Association class I with an estimated ejection fraction of 65%. Considering the initial clinical stage New York Heart Association III to IV when the procedure was done, the third aortic prosthesis represents a good long term result demonstrating competent valvular function.

Discussion: The additional implantation of the CoreValve prosthesis (Medtronic Inc., Minneapolis, MN, USA) resulted in successful correction with sufficient valve closure and opening. The report shows that changing the valve concepts, thereby using the radial force of a shape-memory self-expanding valve construct, results in excellent valve function with no valvular or paravalvular leakage.

Asymptomatic Dissecting Aortic Aneurysm in a Young Adult: A Case Report

Ehab M Esheiba, Mais Mamoon


Gulf Medical College Hospital and Research Centre, Gulf Medical University United Arab Emirates

Aortic dissection is a rare condition, yet it is potentially fatal. We report here a case of a 37-year old asymptomatic male who came for a cardiology checkup as he was concerned that seven of his family members had been diagnosed with aortic aneurysm and some of them had progressed to aortic dissection. He had a history of hypertension that was controlled with medications. Although the patient was entirely asymptomatic, the diagnosis of a dissecting aortic aneurysm was confirmed. The aneurysm was confined entirely to the ascending thoracic aorta. The clinical presentation, diagnosis and management of ascending aortic dissection were reviewed. It has to be noted that early and accurate diagnosis and treatment of such a potentially lethal condition are essential for survival. Long term follow up is also required as there is always a risk of recurrence.

An Unusual Diagnosis for Chest Pain Takotsubo Cardiomyopathy: A Case Report

Ehab M. Esheiba 1 , Ani Purushothaman, Kasturi Mummigatti


Gulf Medical College Hospital and Research Centre, Gulf Medical University United Arab Emirates

Takotsubo Cardiomyopathy or Stress Cardiomyopathy is a non-ischaemic cardiomyopathy which mimics acute coronary syndrome (ACS). It is becoming an increasingly reported condition, accounting for approximately 2% of all suspected cases of ACS. It is a well-recognized cause of acute heart failure, lethal ventricular arrhythmias, and ventricular rupture. Herein, we describe a patient who exhibited this syndrome and we review the existing literature on this condition and its associations. The case is about a 35 year old female who developed severe chest pain one hour following a normal vaginal delivery of twin babies. In view of her electrocardiogram and cardiac biomarkers, she was immediately diagnosed and managed as a case of ACS. But her subsequent investigations revealed a diagnosis of Takotsubo Cardiomyopathy. Her coronary angiography was normal and her echocardiogram which initially showed significant LV dysfunction improved drastically within a few weeks.

Self-Care in Patients with Coronary Artery Disease

Bahnaz Farahani-Shanaz Panahi Azar


Islamic Azad University of Iran UAE Branch, United Arab Emirates

Aims: Self - Care involves those learned behaviors that individuals perform in Order to preserve or promote their life, health, well-being and prevention or treatment of their disease. Self-care can play an effective role in the management of individuals with chronic diseases including coronary artery disease. The aim of this study was to determine the self-care ability and the relationship between self-care ability and some demographic variables such as sex, age, occupation, education and income level in patients with coronary artery diseases.

Materials and Methods: In this analytical- descriptive, cross sectional study, 307 patients, 40 years old and older(195 male and 112 female and all of the married) with coronary artery disease, referred to the military™s hospital in Tehran between July and November in 2012, had been selected through a goal oriented or purposive sampling method. The data were collected through an interview. The research instrument was the self-care ability Questionnaire in arterial coronary disorders and a one Demographic questionnaire. The self-care ability Questionnaire had 43 questions and been rated in Likert Scale which ranked in three level, good, moderate and poor. For reliability of the Scale the Test Retest Method had been used and the Correlation between the two tests was 86%. Data were analysed using SPSS 20 software and descriptive statistical methods and one-way ANOVA.

Results: The self- care ability mean was 59.1312.62. Demographic Factors including sex, age, occupation, education and income level had not a significant relationship with self-care ability (P > 0.05).

Conclusion: In 28 pateints (9.1%), Self-care ability of individuals with arterial coronary disorders was in Good level and 229 (74.6%) in moderate level and 50 (16.3%) in poor level. Self-Care ability and health are not affected by socio demographic variables and were not significant relationship between Self Care and demographic Incidences.

The Safety of Ivabradine During Long-Term Management of Heart Failure

Sergiy Fedorov


Therapy and Family Medicine Department of Ivano-Frnkivsk National Medical University, Ukraine

Background: Approximately 1"2% of the adult population in developed countries has heart failure (HF), with the prevalence rising to 10% among persons 70 years of age or older (ESC, 2012). About of 70% of HF etiology is myocardial ischemia. The new class of medications the if-channels blockers of sinus node (Ivabradine), are prescribered for patients with systolic variant of HF. The aim of our study was evaluation of the dynamics of renal function and basic majors minerals levels (sodium, potassium) in patient with HF after myocardial infarction.

Materials and Methods: The 35 patients with chronic heart failure (HF) II-III FC (NYHA) with reduced LVEF after myocardial infarction (MI) were observed during period of 2 years. The serum levels of hs-CRP, potassium, sodium and creatinine were investigated at inclusion, after 1 and 2 years of study. The creatinine clearance (by Cockgroft-Gault equation) was calculated. All patients were divided into 2 groups: With or without additional treatment by Ivabradine (Coraxan, Servier) 7.5 mg bid. Basic therapy: Beta-blocker, RAAS inhibitor, diuretic and statin.

Results and Discussion: The middle period after MI was 5.112.93 years. After 2-years of observation 1 patient in group with Ivabradine and 2 patients in control group were died from HF decompensation. In the control group of HF we haven't noticed of significant changes in levels of Na, K and creatinine in serum: Na (144,01,63 mmol/l, 144,011,62 mmol/l, 143,03,05 mmol/l), K (4,980,29 mmol/l, 4,650,35 mmol/l, 5,070,61 mmol/l), creatinine (91,5}10,9 mcmol/l, 91,756,24 mcmol/l, 90,07,64 mcmol/l). In patient with HF which additional received of Ivabradine we founded a similar dynamics of serum creatinine, sodium and potassium levels. There were no significant differences in parameters of hs-CRP levels and creatinine clearance in both groups during 2-years of patients observation.

Conclusion: Thus, Ivabradine has safe profile for renal function and basic majors minerals (sodium and potassium) metabolism, which is important in patients with HF.

Mechanical Atrial Dysfunction in Paroxysmal Atrial Fibrillation: Systematic Tissue Doppler Analysis and Evaluation of a New Electromechanical Time Index

Ali Ghanem, Andreas Goette, Hendrik Schmidt


Division of Cardiology Clinicum Magdeburg, Germany

Background: Atrial fibrillation (AF) leads to considerable degenerative changes in the atrial myocardium, which can influence the electrophysiological and mechanical function of the atria. The atrial mechanical dysfunction has a significant impact on atrial thrombus formation. So far, the possibility to assess the atrial contractile dysfunction using non-invasive measures is limited.

Purpose of the Study : To evaluate the atrial mechanical function in patients with paroxysmal atrial fibrillation (PAF) using tissue Doppler analysis (TDA). To examine the relationship between electrical impulse propagation and mechanical function (TDA).

Methods and Patients: 84 patients (56 ± 14 years; 59 M; 25 F) were examined using TDA. 46 patients with PAF. 38 Patients with normal sinus rhythm and no history of AF (Control). At the time of TDA all patients were in sinus rhythm. With TDA the Velocity (V), Strain (S) and Strain rate (SR) were measured in the medial segment of each wall of the left atrium (anterior, posterior, inferior und lateral wall) and velocity of the mitral valve annulus. An electromechanical Time Index was defined as the period from the onset of the P wave (surface ECG) to the peak of the late diastolic velocities of the left atrial wall segments (a).

Results: Mitral annulus late diastolic velocity (lateral, septal, anterior and inferior) was significantly reduced in patients with PAF. Velocity, Strain and Strain Rate (SR) were significantly reduced in the analyzed left atrial segments in patients with PAF (starin-rate: AF 2,1 ± 1,9 secund-1 vs. 3,7 ± 2,1 secund-1; strain 36 ± 26 % vs. 83 ± 52 %; p).

Conclusion: TDA is a useful tool for non-invasive assessment of atrial mechanical dysfunction in patients with PAF. Further studies are warranted to determine the role of TDA to predict thromboembolic events in PAF.

International Update in Screening for Critical Congenital Heart Disease with Pulse Oximetry

Anne de-Wahl Granelli


Heriot-Watt University UK, Canada/Sweden

Background: In September 2011, the US Secretary of Health recommended to add screening for critical Congenital Heart Disease (CCHD) with pulse oximetry to the mandated newborn tests in USA. The screening protocol was endorsed by American Heart Association, American College of Cardiology and American Association of Pediatrics.

Materials and Methods: The endorsed screening protocol; using a new-generation pulse oximeter, screening both right hand (pre-ductally) and one foot (post-ductally) will be covered. The international progress made in EuropAc and USA shared as well as efforts in Asia.

Results: Adding pulse-oximetry screening to the physical examination before discharge, can significantly improve early detection of new-borns with life-threatening congenital heart disease.

Discussion: A rapid progress in implementing screening for critical congenital heart disease with pulse oximetry has happened globally over the last years. Remaining obstacles reported by physicians will be discussed.

Abnormal Localization of Heart Due to Lung Disease: A Case Report

Erdal Gursul, Adnan Adnan Pinar, Can Usal, Omer Ozkan Duman


Buca Seyfidemirsoy State Hospital, Turkey

Introduction: The normal position of the organs is known as situs solitus; situs inversus is a condition in which the usual positions of the organs are reversed from left to right as a mirror image of the normal condition. Situs inversus is seen 0.01% percent of the population and the incidence of congenital heart disease diagnosed with situs inversus is 3- 5% (1-3). Situs ambiguous also known as heterotaxy or heterotaxia, is a rare congenital defect in which the major visceral organs are distributed abnormally within the chest and abdomen. The incidence of congenital heart disease diagnosed with heterotaxy is too high, changes between 50 to 100 percent (1-4). The terms levocardia and dextrocardia indicate only the direction of the cardiac apex at birth; they do not imply the orientation of the cardiac chambers. In levocardia, the base-to-apex axis points to the left, and in dextrocardia, the axis is reversed (4,5).

Case: A 46 years old man admitted our hospital with complaining atypical chest pain. He told that he had a diagnosis of lung infection but he had no medical records about it. There was no history of operation about lung disease. Blood pressure was measured 120/60 mm Hg and pulse was 77 beat per minute. Heart sounds were heard deeply. Hipovoltaj was observed at precordial derivation on electrocardiography (ECG). Mediastinum and heart skyline shifted to left hemithorax was seen on chest X ray. Echocardiography (ECHO) was planned. The heart was not visualized at routine (ECHO) points. Heart was visualized from the left rear seat line point while patient lying face down. Left ventricul ejection fraction was normal and there was no valve lesion. Thorax Computer Tomography (CT) was planned to understand lung pathology and location of heart. The left lung was not seen from the beginning of left main bronchus Mediastinal structures were shifted to the left hemithorax and left ventricular was found at posterior hemithorax on CT examination.

Conclusion: With this case presentation, we aimed to remind cardiac malpositions by introducing abnormal ECG changes, modified viewing angle of ECHO, interesting thorasic CT images and to emphasize the difficulties at clinical diagnosis.

Oxygen Saturation Trends in the First Hour of Life in Healthy Full-Term Neonates Born at Moderate Altitude

Hamed Habib


Faculty of Medicine, King Abdulaziz University Jeddah, Kingdom of Saudi Arabia

Background: Transition from a parallel circulation in utero to an in-series circulation immediately after birth is partly an oxygen-dependent process. Relative hypoxemia with increasing altitude above sea level exerts a certain degree of stress on oxygen-dependent metabolic processes throughout the body. The present study aimed to determine the reference values for oxygen saturation and the preductal and post-ductal oxygen saturation trends during the first 60 min of life in healthy full-term neonates born at moderate altitude using pulse oximetry.

Materials and Methods: In this observational study, arterial oxygen saturation in the right hand and right foot of each infant was recorded by pulse oximetry immediately after birth and continuously within the first 60 min of life. The respiratory rate, heart rate, and blood pressure were measured at birth and at 1 h after birth. Cord blood gas and haemoglobin levels were also measured.

Results: The study was conducted in a hospital situated at an altitude of 1640 m above sea level. Immediately after birth, the mean pre-ductal SpO 2 in the right hand was 68% (51"80%); in the right foot, the mean post-ductal SpO 2 was 60% (40"77%). This difference was statistically significant (P < 0.01); however, it became statistically insignificant at 20 min (4"45 min) and disappeared at 25 min, when the SpO 2 in both limbs equalised at 88% (83"96%). SpO 2 levels >94% were reached after 13 min (4"35) min preductally and after 22 min (10"45 min) post-ductally. The mean respiratory rate, heart rate, and mean blood pressure at birth were 56/min, 140/min, and 34 mm Hg, respectively; at 60 min, they were 40/min, 123/min, and 47 mm Hg, respectively.

Conclusion: This study defined normal range of SpO 2 values in healthy full-term neonates born at moderate altitude in the first 60 min of life. These are expected to serve as reference values for normal neonates born at similar altitudes. With regard to pre-ductal and post-ductal oxygen saturation levels, cut-off values lower than those used at sea level should be adopted for neonates born at moderate altitudes.

Results of ASD Percutaneous Closure with Amplatzer Devices of Larger and Smaller Dimensions

Hamad M. Hamad, Ladia de Sousa, Antonio Fiarresga, Jose Diogo Martins, Ruben Ramos, Filipa Ferreira, Jose Alberto Oliveira, Ana Agapito, Fa¡tima Pinto, Rui Ferreira


Santa Marta Hospital, Portugal

Background: Atrial septal defect (ASD) is one of the most frequent congenital heart diseases. Percutaneous closure of ASD Ostium Secundum type has become an estabilished alternative to surgical closure in selected cases, and the Amplatzer Atrial Septal Occluder (AmpASD) device use is widely spreaded.

Materials and Methods: To study the safety, effectiveness and early complications after percutaneous closure of large ASD (device ‰\ 26 mm) compared to ASD occluded with a device of smaller diameter (<26 mm) in adult patients, we studied 185 consecutive adult patients (mean age 43} 15 years, 66% female-F), submitted to percutaneous closure of ASD in our center between 1998 and 2011. P were divided in 2 groups.

Results: Group A (AmpASD ‰\ 26 mm): 56P, mean age 46} 14 years, 38 F (68%) F, arrhythmia in 7P, atrial septal aneurysm (ASA) in 15P, multiperforated septum in 8P and coexistent congenital cardiopathy in 1P. In this group te procedure success was 89%. 6P were scheduled for elective surgery (multiple or large >38 mm ASD). 3P (5%) had major complications during or after the intervention: 2P with cardiac tamponade submitted to pericardiocentesis (not related to the device) and 1P was submitted to urgent surgery due to device embolization. Group B (AmpASD <26 mm): 129P, mean age 42} 16 years, 85F (66%) F. 11P with arrhythmia, 3P with ASA, 6P with multiperforated septum, 10P with coexistent congenital cardiopathy and 19P had a previous ischemic CVA. Success rate was 98% (2 failures in 1P with small rims and 1P with a multifenestrated septum); there was 1 complication (inguinal hematoma with the need for blood transfusion in 1P). Comparing the 2 groups, a higher prevalence of ASA and multiperforated septum was found in group A. P in group B had a higher prevalence of previous ischemic CVA. No difference between the 2 groups was found in the prevalence of coexistent congenital cardiopathy, arrhythmia, success rate or complications.

Discussion: ASA and multiperforated septum are significantly more frequent in adult patients with large ASD. Complications and unsuccess rates are also more frequent in this group of patients, but without statistically significant difference. Previous ischemic CVA is significantly more frequent in smaller ASD.

Cardiac CT in the ER for Chest Pain Assessment

Sawsan Ismail Humaida, Roland Kalsberg


Tawam Hospital, United Arab Emirates

Population: Patients in cardiac outpatient clinic, presenting with chest pain, typical versus atypical in nature. All patients had primary negative cardiac biomarkers and unremarkable or un-interpretable ECGs.

Method Used: Coronary CT and cacium scoring.

Conclusion: Over the past 5-6 years, a significant drop of up to 50% in the required conventional cardiac catheterization. Significant successful discharges of patient with chest pain directly from the ER.

Cost Effective: Significant avoidance of unnecessary overall radiation exposure.

FFR, the Middle East Experience

Gohar Jamil, Swapna Sainuddin, Ahmed Siddiqui, Husam Ouda


Department of Medicine Tawam Hospital, United Arab Emirates

Background: Contrast angiography has been used for decades to evaluate the severity of coronary lesions. The physiological significance of an angiographically 40-70% lesions is difficult to access. Up to 30% of the times invasive angiography fails to distinguish between lesions that may or may not be able to produce ischemia. Currently large no of patients undergo cardiac catheterization without prior non invasive testing and this number is likely to increase. To resolve this dilemma, Fractional Flow reserve (FFR) can be performed in the cardiac catheterization lab. Scarce literature from the Middle East is present on this subject matter.

Objective: To analyze our experience in the Middle East.

Materials and Methods: The cardiac catheterization records of all patients admitted to Tawam Hospital who had FFR done between January 2011 to January 2013 were reviewed.

Results: Over a two year period 48 patients had FFR performed. The patients ranged between 39 to 79 years of age. Percutaneous coronary intervention (PCI) was performed on fifteen patients. Fourteen patients had positive FFR of less than 0.79 (physiologically significant lesion) on one patient PCI was performed with FFR of 0.82. 14 out of 15 patients had PCI of the left anterior descending artery (LAD) and one was on the obtuse marginal of the left circumflex artery (LCx). FFR of the LAD was performed on 33 patients, Lc×16 and Right Coronary Artery (RCA) 12 patients. In all patients radial approach and 6 fr system was used. All patients received intravenous adenosine infusion and all tolerated the procedure well without complications.

Discussion: FFR is safe, reliable and readily available technology. In our experience it is most often used for lesion in the LAD. Not all patients had post procedure FFR which would add prognostic valve.

Risk Factor Comparison Between Young Patients from UAE and Western Countries Presenting with Acute Myocardial Infarction

Mujgan Jamil, Sadek Mokahal, Abbas Ahmed, Bahaa Khairalla, Mohammed Nour, Gohar Jamil


Imperial College London Diabetes Center, United Arab Emirates

Background: Coronary artery disease (CAD) is the leading cause of morbidity and mortality worldwide. In the western countries CAD develops in the sixth decade of life. Studies from the 1970™s to 1980™s show the incidence of myocardial infarction (MI) in the young population ranges between 2-6%. Studies in the 90™s have shown increased incidence of 4-10%. There are very few studies from the Middle East.

Objective: The aim of our study was to see the percentage of patients presenting with MI are less than 45 years of age. Additionally to analyse their risk factor profile and compare it to the risk factor profile of studies done on young patients from the western countries. This is particularly important as MI at a young age has catastrophic psychological and socio-economic effects and preventive therapies could be targeted accordingly.

Materials and Methods: Over a two year period from 2011 to 2012, the medical records of patients presenting to Tawam Hospital with AMI were analysed. The patient's CAD risk factor profile i.e. history of diabetes, hypertension, hyperlipidaemia, family history and smoking were recorded. This was then compared to CAD risk factor profile of young patients with AMI from western countries, documented in medical literature.

Results: 148 patients were identified, which is about 10% of the total group presenting with AMI. The Median age was 36.4 } SD of 4.2 years. 92.6% were male patients, 7.4% female. 80.4% patients were South Asian, while 19.6% were Arabs. 48% of the Arabs were Emiratis. 67.6% of the whole group was smokers, 29.7% had hypertension, and 23.9% had family history of coronary disease.

Hyperlipidemia was noted in 22.3% and diabetes in 20.9% of patients. The average Body mass Index of the group was 30.39 kg/m 2 . The majority of patients had STEMI, accounting for 67.6% of the total, while the rest 32.4% suffered from NSTEMI. Comparing this to young western population, the incidence of most of the risk factors is approximately similar, with the exception of diabetes which is slightly higher in our patient population. Smoking is the most common risk factor in both groups.

Discussion: MI at a young age is seen in approximately 10% of our AMI patients. This incidence is slightly higher than the western population. Additionally diabetes is slightly more prevalent in our patient population. Smoking remains the most common risk factor in both groups. Preventive therapies focused to smoking cessation and diabetes control should be our primary goals in this age group. A Multi-disciplinary approach is recommended to help these patients in the most productive years of their life.

Initial Experience with the Jetstream Pathway Device for Femoro-Popliteal Disease

Imran Javed


Faculty of Medicine Fiji National University, Fiji

Objectives: To report safety and efficacy of Jetstream„ c/ Pathway rotational atherectomy/thrombectomy device for the treatment of femoro-popliteal arterial lesions with special emphasis on rate of re-intervention and intervention free period.

Materials and Methods : Duration of study is from Mar 2008 to Nov 2009 (21 Months). Total numbers of patients is 86. Males are 55(64%) and Females are 31(36%). Age range is 36 to 87 Years. All patients underwent Pathway Atherectomy during this time period regardless of their previous status were included. Re intervention in the same limb after atherectomy was endpoint of the study.

Results: TLR (Target Lesion Revascularization) was 15% in patients during follow up period. Re intervention was more common in first 3 months after first intervention. It was more common in TASC II type B lesions and mostly managed by Balloon Angioplasty.

Conclusion: The JetStream„ c/ Pathway device with thrombectomy and aspiration capabilities has added advantages to femoropopliteal atherectomy. Adjunctive stenting remains very low in this difficult segment. Long term follow up will definitely be needed for durability and patency.

CFC1 Gene Mutation in Tetralogy of Fallot and Dextro-Transposition of Great Arteries in Pakistani Population

Afsheen Arif, Sitwat Zehra, Syeda Qamarunnisa, Abid Azhar


Karachi Institute of Biotechnology and Genetic Engineering University of Karachi, Pakistan

Background: Congenital heart diseases (CHDs) are the most common of all birth defects and one of the leading causes of mortality in the first year of life. It can be broadly classified as cyanotic and acyanotic. Cyanotic Cardiac malformation accounts 25% of all CHDs; however, no data is available from Pakistan. Approximately 30,000 to 40,000 new cases are diagnosed annually, most children in rural areas remain undiagnosed and die or could not afford surgery. The study is designed to check genetic causes and among them CFC1 gene, which is a cell signaling protein and also a co receptor in nodal signaling pathway. It is involve in right and left axis determination during gastrulation.

Materials and Methods: This is a case-control study, recruited 225 non syndromic patients and 140 controls, healthy unrelated individuals. The study, after formal approval includes patients from various pediatric cardiology centers in three years. A detailed family history was taken to elucidate the genetic and environmental factors. Pediatric cardiologist confirmed the diagnosis on the basis of all standard testing like chest X-ray, CBC, ECG, ECHO, cardiac catherization reports etc. DNA extraction and sequencing was done and data was interpreted by multiple sequence alignment software. Statistical data was done by SPSS 17.0.

Results: The mean age for controls was 3.14} 1.82 years, for TOF; 2.97} 1.21, and for DTGA patients 1.84} 2.26 years. TOF and DTGA were frequent in males. The study demonstrates frequency of this disease; with its variation in Pakistani population. Consanguinity affects the rate of CHDs, as it is 62% in patients and 25% in controls. Two novel mutations were found in CFC 1 gene.

Conclusions: The study demonstrates frequency and prevalence for TOF, and DTGA, there variation and association with other cardiac defects. Environmental factors are taken into consideration and consanguinity proves to be an element for the increasing number of disease. CFC1 mutations can play a key role in cardiac malformation and its diagnosis

Orems Theory in Practice: Post-Operative Care of Pediatric Cardiac Surgery Patients

Saira Khimani


Aga Khan University, Pakistan

Introduction: The self-care theory proposed by Orem is a combination of three theories i.e theory of self-care, theory of self-care deficit and the theory of nursing systems. According to Orem's self-care deficit nursing theory, helping people to maintain a balance between activity and rest (a universal self-care requisite) is a legitimate concern of nursing. Applications of Orem self-care model in post-operative care of patients with congenital heart surgery help to assess their needs. It will consequently help nursing agency to intervene accordingly.

Materials and Methods: Literature Review of research articles related to post-operative care of pediatric cardiac surgery patients from 2005- 2012. And also studied conceptual articles on Orem self-care theory.

Discussion: According to Orem, self-care requisite is the totality of the self-care measures required. Therapeutic self-care needs of post congenital heart surgery pediatric patients were: Ineffective air way clearance, incisive pain, management of hemodynamic pa-rameters, sufficient nutritional requirement, maintenance of health status and rehabilitation, prevention from fall hazards, prevention of wound infection and anxiety of patients and families regarding prognosis. In addition, most of the articles also shared interventions for the above self-care needs. Orem™s theory has classified these interventions under the umbrella of 3 nursing care systems i.e wholly compensatory (totally dependent patients eg. Ventilated patients), partly compensatory (require minimal assistance in activity of daily living) and supportive or educative system (require information regarding care). This theory places responsibility on a nurse to identify patient care deficits and classify them according to compensatory care system required. It provides comprehensive bases for critical care nursing practice.

Results: The study of Orem self-care theory along with all its elements help to identify potential measures for meeting self-care requisites, and factors that might influence post-operative care. This model for determining a need for nursing, guides for a nursing clinical assessment, and guides for nursing action are suggested as potential ways to assist pediatric patients to survive effectively after congenital cardiac surgery.

Preoperative Selection for Transcatheter Aortic Valve Implantation: The New EuroScore II Vs Logistic EuroScore Vs STS Score

Malin Johansson, Shahab Nozohoor, Igor Zindovic, Johan Nilsson, Per Ola Kimblad, Johan Sjogren


Department of Cardiothoracic Surgery, Cardiothoracic Anesthesia and Intensive Care Skane University Hospital, Sweden

Background: The logistic EuroSCORE and the STS score have been used for selection of suitable TAVI patients, but the performance is unsatisfying. Our aim was to evaluate the ability for the EuroSCORE II, a recently updated version of the logistic EuroSCORE, to predict 30-day mortality after TAVI and to compare its performance to the logistic EuroSCORE and the STS scoring system.

Materials and Methods: Between January 2008 and April 2013, 123 consecutive patients underwent TAVI at our department (transapical, n = 85; transfemoral, n = 38). Calibration (Hosmer-Lemeshow test) and discriminatory ability (area under receiver-operating characteristics curves; [AUC]) was calculated for all three risks scores (logistic EuroSCORE, STS score, EuroSCORE II) and compared in predicting 30-day mortality. Follow-up was performed in May 2013 and was 100% complete for the primary endpoint (30-day mortality). The study was approved by The Ethics Committee for Clinical Research at Lund University, Sweden.

Results: The overall 30-day mortality was 4.1% (5/123). Predicted mortality was 25.0}15.7% by logistic EuroSCORE, 7.3}6.9% by STS score, and 7.8}8.7% by EuroSCORE II. A poor calibration was demonstrated for the logistic EuroSCORE both in the overall population (p).

Discussion: The data from our present study could not identify a clear advantage for the EuroSCORE II in respect of predicting 30-day mortality in TAVI patients when compared to the logistic EuroSCORE and the STS score. In conclusion, all three risk scores demonstrated an unsatisfying performance and our findings support the need for a more TAVI-specific risk score. However, EuroSCORE II demonstrated the largest AUC (0.70) in the transapical group and therefore the EuroSCORE II may be a valuable adjunct in the clinical setting.

Impact of Intraoperative TEE in Adult Cardiac Surgery

R. A. Kumar, C. Ahene, H. Mossinger, D. Saxena, L. Tambeur


Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates

Background: Intraoperative Transesophageal echocardiography (TEE) is recommended to improve surgical outcome in cardiac surgery 1. Intraoperative TEE is reported to significantly influence surgical decision making in more than 9% of cardiac surgical patients 2.

Materials and Methods: Intraoperative TEE is routinely performed, after obtaining informed consent, in all patients undergoing cardiac surgery at our centre. We examined prospectively the impact of intraoperative TEE on 240 consecutive patients undergoing cardiac surgery over a 1-year period. A comprehensive TEE examination, including 3D for valve cases, was done for all patients before and after cardiopulmonary bypass (CPB). All new TEE findings before and after CPB were recorded. TEE findings which lead to a change in surgical management and TEE findings which were helpful to the surgeon were also recorded. Information collected was entered into a database and results analysed.

Results: Overview of Surgical Procedures Performed, No of Cases (n = 240), CABG 165 (68.8%), On-pump 132, Off-pump 165, Aortic Surgery 7 (3.0%), Valve Repairs 24 (10%), Others (valve replacements, ASD etc.) 44 (18.2%) Intraoperative TEE Findings and Impact, No. of Cases (n = 240), New Findings 41(17%), Pre-CPB 35 (14.5%), Post-CPB 8 (3.3%), Surgical Procedure Changed 22 (9.1%), Helpful for Surgeon 27 (11.2 %), *2 patients had new findings pre and post CPB.

Discussion: In our study new TEE findings influenced a change in surgical management in 9.1% of all patients, of which 6.6% were based on pre-CPB findings and 2.5% post CPB. This concurs with the findings of a previous study of 12,000 patients which reported surgical alteration in 9% patients with a pre and post CPB impact of 7% and 2% respectively 2. We also found TEE to provide helpful information to the surgeons in another 11.2% of cases. Examples of this included cannulation of true lumen in aortic dissections, discerning the anatomy of mitral valve prior to repair etc. The crucial role of intraoperative TEE in about 20% of our patients is a marker of the prominent role of TEE in modern day cardiac surgery. The most common alteration to surgical plan from pre-CPB TEE findings were addition of Tricuspid valve repair to mitral surgery, addition of mitral surgery to CABG or closure of PFO. Common interventions based on post-CPB findings were re-do valve repair or replacement due to regurgitation of paravalvular leak or re-grafting in CABG. This prospective, consecutive, non-selected study gives an insight into the impact of intraoperative TEE in the current cardiac surgical practice in UAE.

Successful Stent Dilatation of Sub-Atretic Coarctation of Aorta in an Adult

Mohammed Khan, R. A. Kumar, A. El Tahir


Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates

Background: Sub-atretic coarctation of aorta (CoA) is a severe and complex form of aortic coarctation with complete obliteration of the lumen. CoA accounts for 5 to 10% of all congenital cardiovascular malformations; in some instances it may go undetected well into adulthood 1. Most untreated patients with CoA die before the age of 50 years 2. We report a case of an adult patient with sub-atretic CoA, who was successfully treated by percutaneous stent dilatation.

Case: A 27-year-old male with recently diagnosed severe CoA was referred to our cardiac centre with symptoms of refractory hypertension and NYHA II shortness of breath. A CT angiogram and echo had confirmed a bicuspid aortic valve with mild stenosis and severe preductal CoA with a 1-2 mm lumen and a gradient of 80 mm Hg. After obtaining informed consent, the patient was administered general anesthesia for a planned percutaneous stent dilatation of the Coarctation. A 14F sheath was placed in the right femoral artery via a surgical cut down. An initial angiogram revealed a blind end at the level of the coarctation [Figure 1].

Coarctation: A 0.65 mm TerumoTM wire was used to successfully perforate the membrane at the coarctation [Figure 2]. A 45 mm PTFE covered Cheatham-Platinum stent was positioned at the coarctation through a 14F Mullins sheath. A 16 mm × 4 cm Z-MedTM balloon was used to successfully inflate the stent distal to the left subclavian origin [Figure 3]. Post implantation gradient was noted to be about 3 mm Hg. The patient went on to make an uneventful recovery and was discharged home.

Discussion: Fluoroscopy guided catheter perforation of the coarctation 3 or a combined antegrade and retrograde kissing technique using axillary 4 or trans-septal 5 and femoral approaches have been described before for stenting sub-atretic CoA. We attempted gentle perforation of the coarctation using the stiff end of the Terumo wire and were successful in this, thereby obviating the need for a second vascular access. Percutaneous stent dilatation is a safe and acceptable alternative to surgical repair in complex sub-atretic CoA. Early and intermediate outcomes with covered stents appear to be promising 6.

Family History of Victims of Sudden Cardiac Death: A Population Based Study

Fatima Sadat Mirzadeh, Abbas Andishmand, Masoud Mirzaei


Shahid Sadoughi University of Medical Sciences, Islamic Republic of Iran

Background: When onset of death is sudden, probability of sudden cardiac death (SCD) is more than 95%. Understanding the predisposing factors of sudden cardiac death (SCD) in high-risk groups is important. Most of these factors can lead to an increased risk of SCD in the first-degree relatives. This study aims to evaluate the family history of sudden cardiac death in victims of SCD.

Materials and Methods: In a population based study, all death certificates issued in Yazd during 2011 were evaluated. Victims who had criteria of sudden cardiac death, according to the international classification of disease were identified. Verbal autopsies using a questionnaire were done by calling or visiting families and reviewing the hospital records.

Results: From all SCDs, 73.8% of deaths happened without familial history and 26.2% with familial history. Twenty three percent of men and 30.1% of women have had a familial history of SCD. Average age of victims with family history (65.9} 14.1) was less than victims without family history of SCD (67.09}16.32). Among the victims with family history of SCD, 27.6% have had major cardiac risk factors and 29.1% had heart diseases history. Coronary artery disease and previous angiography significantly related to SCD in those with family history of it. Having the history of angiography in victims with positive family history of SCD increases the risk of SCD approximately 2.5 times. About 1/3 of victims with positive family history of SCD had the history of MI.

Discussion: Family history of SCD has a direct relation with risk of disease in the first-degree relatives in this population. Incidence of SCD increases over two folds in individuals with family history and existing coronary artery disease. We recommend further genetic studies to investigate this relation more. Principle risk factors of cardiac diseases consist of hypercholestromia, diabetic mellitus, hypertension and obesity have no considerable effect on incidence of SCD in patient with positive family history of SCD.

Maximizing Coronary and Cerebral Perfusion During the Norwood Procedure

Bassem N. Mora, Csaba Tamas, Laszlo Kiraly


Sheikh Khalifa Medical City, United Arab Emirates

Background: The Norwood procedure is the mainstay of surgical therapy for the treatment of hypoplastic left heart syndrome. Traditionally, the Norwood procedure is performed using deep hypothermic circulatory arrest (DHCA) with typical circulatory arrest periods ranging from 40 to 60 minutes. We describe a novel modification of the Norwood procedure which maximizes cerebral and coronary perfusion during the procedure and completely eliminates the need for DHCA.

Materials and Methods: This modification of the Norwood procedure involves several unique steps. First, continuous antegrade cerebral perfusion is accomplished by sewing a 3.5 mm PTFE graft onto the right innominate artery then cannulating the graft for arterial perfusion during cardiopulmonary bypass. This eliminates the need for DHCA during the procedure, as it allows continuous perfusion of the cerebral circulation. Second, distal arch reconstruction is performed with continuous coronary and bilateral carotid perfusion by clamping the aortic arch just beyond the left common carotid artery. This decreases the aortic cross-clamp time as the heart is still perfused during this step. It also eliminates the need for DHCA as both carotid arteries are perfused. Third, the Sano right ventricle to pulmonary artery conduit is used to maximize myocardial perfusion postoperatively by eliminating diastolic pulmonary runoff. The use of a ringed PTFE graft, which is inserted into the right ventricle, eliminates the frequently-described proximal right ventricular anastomotic stenosis of the Sano conduit.

Results: This modification of the Norwood procedure has been used on a number of patients, including a recent 2.2 kg female neonate from the United Arab Emirates who had a 1.3 mm ascending aorta by preoperative echocardiography. The chest was closed on postoperative day (POD) #3 after appropriate diuresis. The postoperative course was unremarkable. She was extubated on POD #10, and transferred from the intensive care unit on POD #14. She was discharged home on POD #24 and is doing well on recent follow-up. Postoperative echocardiography revealed normal systemic right ventricular function with no obstruction to pulmonary or systemic blood flow.

Discussion: The Norwood procedure can be performed without the use of DHCA by using continuous antegrade cerebral perfusion. Performing distal arch reconstruction while perfusing the coronary and cerebral circulations not only minimizes the aortic crossclamp period but also maximizes cerebral and coronary perfusion. The use of a ringed Sano PTFE graft improves myocardial and pulmonary blood flow postoperatively. These modifications likely will continue to improve the overall mortality and morbidity associated with the Norwood procedure.

Discordance of LDL Cholesterol and Non-HDL Cholesterol and Future Coronary Events

Samia Mora, Julie E. Buring, Paul M. Ridker


Division of Cardiovascular Medicine, Preventive Medicine and Women's Health Brigham and Women's Hospital, United States of America

Background: LDL cholesterol (LDL-C) is the traditional measure of risk attributable to LDL. Non-HDL-cholesterol (NHDL-C), defined as total cholesterol minus HDL cholesterol, is an alternative measures of LDL-related risk. However, the clinical utility of NHDL-C may only become apparent among individuals for whom levels are inconsistent (discordant) with LDL-C.

Materials and Methods: Among 27,533 healthy U.S. women (median follow-up 17.2 years; 1,070 incident coronary events), baseline concentrations of LDL-C and NHDL-C were simultaneously obtained. LDL-C was directly measured by a homogenous direct method from Roche Diagnostics. Total and HDL cholesterol were determined using direct enzymatic colorimetric assays. NHDL-C was calculated as total minus HDL cholesterol. Participants were grouped by median LDL-C (121 mg/dL) and NHDL-C (154 mg/dL). Discordance was defined as LDL-C ≥median and NHDL-C < median or vice versa.

Results: Despite a high correlation of LDL-C with NHDL-C (Spearman r = 0.91, P < 0.0001), the prevalence of LDL-C and NHDL-C discordance as defined by median cut-points was 11.6%. Among women with LDL-C < median, coronary risk was underestimated for women with discordant (≥median) NHDL-C (age-adjusted hazard ratio 2.92, 95% CI 2.33-3.67, P < 0.001) compared to women with concordant levels. Conversely, among women with LDL-C ≥ median, risk was overestimated for women with discordant (< median) NHDL-C (0.40, 0.29-0.57, P < 0.001). After multivariable adjustment for potentially mediating factors including HDL cholesterol and triglycerides, coronary risk remained under or overestimated by ≈30-50% for women with discordant levels.

Conclusion: For women with discordant LDL-C and NHDL-C, coronary risk may be under or overestimated when relying on LDL-C alone. Thus, the current results support the use of NHDL-C among such discordant women.

Outcome of Congenital Portosystemic Shunt in Children

Shireen Mreish, Mohamad Hamdan


Tawam Hospital, United Arab Emirates

Background: Congenital portosystemic shunts (PSS) are rare vascular malformations that can lead to severe complications. They frequently require surgical or interventional treatment to avoid long-term complications. With the advanced imaging techniques in Doppler ultrasonography, computed tomography (CT) scan and magnetic resonance angiography, diagnosis is becoming more feasible, occuring in fetal life. The purpose of this series is to report the outcome of children diagnosed with congenital portosystemic shunts in Tawam Hospital, as well as to evaluate the role of prenatal sonography in early diagnosis of PSS and its impact on management and outcome, compared to patients diagnosed postnatally.

Materials and Methods: Retrospective chart review was performed for all patients who were diagnosed with PSS in our institution over 7 years.

Results: Between January 2006 and December 2012, six patients were diagnosed with PSS, among which 3 were diagnosed antenatally at a gestational age (median [SD]) of 33(4) weeks. During the same period, 8680 mothers carrying 9548 fetuses underwent fetal ultrasound examinations, resulting in a rate of fetal PSS of 0.31 (C.I. 0.06-0.92). Three patients were diagnosed postnatally at a 0, 2, and 43 months, respectively. At a median follow-up of 14.5 (7.5) months, 5 patients are alive, including 4 who received transcatheter closure for different indications, and 1 who had spontaneous resolution of her PSS. One infant died at the age of 6 weeks secondary to underlying cardiac disease.

Discussion: Liver functions as the detoxifying organ in the body, and diversion of the portal blood to the systemic circulation in PSS will prevent the passage of the toxic compounds such as ammonia, bile acids or galactose, and delay their metabolism. Several clues can help in diagnosing PSS in symptomatic patients. Neonatal galactosemia in the presence of normal enzyme assay for galactose metabolism, is quite characteristic for PSS, and can be found incidentally during newborn screening for galactosemia. The presence of any of the following main complication of PSS should also raise the suspicion of fistulae: Neonatal cholestasis, hepatopulmonary syndrome, pulmonary hypertension, liver tumors, and portosystemic encephalopathy. Portosystemic shunt can be detected on ultrasonogram in clinically asymptomatic patients before as well as after birth. In 2 out of our three patients who were diagnosed antenatally, fetal diagnosis contributed to understanding the underlying pathophysiology of the illness (CHF in cases 1 and 2), which further allowed timely proper intervention. In the third asymptomatic patient, complications were avoided and close monitoring was feasible until intervention was decided. PSS can result in significant complications in children. Antenatal diagnosis allows early intervention and may improve the outcome. Interventional therapy is feasible, but long-term follow-up is warranted.

D-Transposition of Great Arteries Associated with a Right Aortic Arch, Bilateral PDA and Isolation of Left Subclavian Artery - A Case Report

M. Venkatraman M. T. Al Delamie


Royal Hospital, Oman

Isolation of Left Subclavian Artery is one of the rare anomalies of the Aortic Arch. It is normally associated with a right aortic arch and congenital heart defects, the commonest being Fallot's Tetralogy. We describe a very rare case of Isolation of Left Subclavian Artery associated with D-TGA, Right Aortic Arch and bilateral PDA.

Hypomagnesaemia a Contributory Factor to Acute Myocardial Injury

Ghulam Naroo, Bina Nasim, Ahmad Sajjad, Tanveer A. Yadgir, Omer Al Sakaf


Rashid Hospital, United Arab Emirates

Introduction: Magnesium has long been considered as an important intracellular cation; critical to normal human homeostasis. Recently, magnesium deficiency has been implicated in the pathogenesis of a host of clinical disorders including diabetes mellitus and hypertension, atherosclerosis and acute myocardial infarction. The aim of our study is to determine a correlation of hypomagnesaemia with Acute Myocardial Injury (AMI).

Materials and Methods: A retrospective study was conducted, involving 1210 patients, of all age groups, who attended Accident and Emergency department of Rashid Hospital, Dubai and were enrolled in acute coronary syndrome (ACS) pathway, over 3 years, from April 2010 to May 2013. The serum magnesium levels and cardiac markers were checked to determine the association of hypomagnesaemia with AMI.

Results: A total of 1210 patients were enrolled in ACS pathway, 693 were found to be troponin positive, among those 61 patients had low magnesium levels, Classification 2010 2011 2012 2013(End of May) Total cases with chest pain 201 357 430 222 n-1210 Positive Troponin 120 206 245 122 n-693, Low Magnesium 5 21 27 8 n-61, Correlation between low magnesium vs troponin positive- n-61 (8.8%) patients.Those with troponin positive and normal magnesium levels- n-632 (91.2%) patients. In gender,79% male and 21% females. Being Dubai a cosmopolitan city, among nationalities, 65.5% Asians, 21.3% Arabs, 1.6% Europeans and 11.4% were other nationalities.

Conclusion: This study shows the significance of hypomagnesaemia as a contributory factor for Acute Myocardial Injury. Many small studies being done worldwide have shown this association. However a large multicenter study will be required while considering other variables to show the importance of hypomagnesaemia as a significant contributory factor for AMI.

The Potential Role of Chronic Inflammation in Metabolic Syndrome: Focus on Menopausal Women

Lyubomyr Glushko, Anas Nasrallah, Sergiy Fedorov


Therapy and Family Medicine Department of Post-Graduate Faculty, Ivano-Frankivsk National Medical University, Ukraine

Background: The metabolic syndrome (MetS) has emerged as an important cluster of risk factors for atherosclerotic disease. Common features are central (abdominal) obesity, insulin resistance, hypertension, and dyslipidemia, namely high triglycerides and low high-density lipoprotein cholesterol. Many studies showed the high prevalence of metabolic syndrome among postmenopausal women, which varies from 32.6% to 41.5%. Chronic inflammation may represent a triggering factor in the origin of the metabolic syndrome: Stimuli such as overnutrition, physical inactivity, and ageing would result in cytokine hypersecretion and eventually lead to insulin resistance and diabetes in genetically or metabolically predisposed individuals.

Materials and Methods: The 81 postmenopausal and 20 premenopausal women with MetS, and 30 practically healthy persons were referred to the study. The blood serum was used for estimating fasting triglycerides, total cholesterol, LDL-cholesterol, and HDL-cholesterol concentrations, by biochemical kit. The level of endogenous intoxication investigated by test of the absorption ability of erythrocytes (AAE), the quantity of leukocytes in blood and some leukocytes' indexes (INM - Neutrophile/Monocyte Ratio, ILM - Lymphocyte/Monocyte Ratio, INLM - Ratio of Neutrophiles and Mononuclears) were calculated. The statistical analysis was done with StatistikaVersion 6.1 software.

Results and Discussion: The level of AAE in postmenopausal women was 37.35} 4.81% vs 24.56} 3.18% in control group (P < 0,01). We didn't find any differences between data of AAE in premenopausal and postmenopausal women with metabolic syndrome: 39.90 ± 4.63 % vs 37.35 ± 4.81 % (P = 0.43). We have found directly middle correlation between mentioned indicator of endogenous intoxication and level of triglycerides (r = 0.48, P = 0.03), and level of LDL-cholesterol (r = 0.69, P = 0.49) in postmenopausal women. MetS caused of high quantity of leukocytes in both groups: 7.10} 1.47 G/l (premenopausal) and 6.89} 2.42 G/L (in menopause) compared control group (5.49} 0.33 G/l) (P < 0,05). It's known that white blood cells are independent cardiovascular risk factor. Analyses of leukocytes' formula showed the following results: All patients with MetS have high quantity of lymphocytes: 1.94} 0.91 G/l (in premenopause), 1.95} 0.84 G/l (menopause) vs 1.40}0.16 G/l in control group (P < 0,05); and neutrophiles: 4.74} 1.38 G/l, 4.46} 1.84 G/l and 3.64} 0.24 respectively. Across, the significant difference in monocytes counts was only between control group and premenopausal women with MetS: 0.33} 0.06 G/l vs 0.47}0.09 G/l (P < 0,05). For our opinion, such changes in leukocytes' formula could be sign of activation of the inflammation before menopause. Menopause caused of the deviation of chronic immune activation from monycyte hyperreactivity to hyperactivation of lymphocytes as evidenced by the significant increase of ILM in menopausal women with MetS: 6.06±1.45 (p < 0,05) . We have found directly low correlation between body-mass index (BMI) and lymphocytes' count (r = 0.27, P < 0.05), and ILM (r = 0.30, P = 0.03).

Conclusions: Inflammation plays the crucial role in MetS, but it realize by different leukocyte' subpopulations depends of menopause period. New trials with evaluation of other parameters of inflammation are required.

Impact of Fenestration Creation on Managing Patients with Protein Loosing Enteropathy Complicating Fontan Procedure

Mashail Bin Obaidan


Prince Sultan Cardiac Center, Kingdom of Saudi Arabia

Introduction: Protein loosing enteropathy (PLE) is well known complication following Fontan procedure and one way of managing such complication is to create fenestration if it is not present or enlarging it if it is small to reduce the Fontan pressure and reduce venous congestion which end up by intestinal protein loss.

Aim: To evaluate the effect of such procedure in our population

Materials and Methods: From February 2006 through October 2011 9 patients who underwent fenestration creation due to development of PLE were assessed in regard to clinical, laboratory result and hemodynamic effect prior and post procedure.

Results: Median age is 7 years (4-21), median weight is 23 kg (15-52), male: Female ratio is 3.5:1 (male and 2 female), median saturation pre and post procedure was 93% and 82% respectively, median albumin pre and post procedure was 18 gm/dl and 31 gm/dl during the first 2 wks and 36gm/dl thereafter, median pulmonary artery pressure before and after was 25 mmhg (17-32 mmhg) and 16 mmhg. (14-19 mmHg), transpulmonary pressure gradient reduced from a median of 11 mmhg. To 5 mmhg, No immediate deaths, 2 patients need re-dilatation, there was 2 (22%) late deaths (one t has stent thrombosis one month after followed by fulminant pulmonary embolism, though all patients were on anticoagulant other one with sudden arrest came to the emergency could not be resuscitated) 3 (33%) patients have persistent low albumin though the fenestration is patent.

Conclusion: Transcatheter fenestration creation as a management of PLE following Fontan procedure is feasible procedure, can be done in the cath. lab with little morbidity and mortality and with beneficial effect, however late complication and complete resolving of PLE is of concern especially if done late.

Right Ventricular Outflow Tract Stenting in the Symptomatic Infant with Tetralogy of Fallot

Mashail Bin Obaidan, Jassim Abdulhameed


Prince Sultan Cardiac Center, Kingdom of Saudi Arabia

Background : The Debate continues regarding the initial management of cyanotic or duct-dependent infants with TOF especially those patients with pulmonary artery hypoplasia. While repair can and has been performed in these patients, it is associated with increased morbidity.

Objective: We review the effectiveness of right ventricular outflow tract (RVOT) stenting in the symptomatic young infant with TOF.

Materials and Methods: Clinical, echocardiographic, angiographic and hemodynamic data were reviewed for 11 patients who underwent 14 RVOT stenting procedures from June 2007 to March 2011.

Results: There were 7 girls and 4 boys with median age 3 month and weight 3.5 kg. The pulmonary valve was hypoplastic in all patients Median pulmonary valve diameter 3.1 mm (range 2.7-5.2), Z-score −5.5 (range −8.9 to −4.4) RVOT stenting improved arterial oxygen saturation from a median of 60% (55-66%) to 91% (82-94%). Median Z-score for the left pulmonary artery increased from −4.2 (−7.2 to −2.9) before stent implantation to −1.8 (−4.6 to −0.8) at time of surgery. Median Z-score for the right pulmonary artery increased from −3.1 (−6.2 to −2.1) to −0.5 (−2.1 to 0.2). There were no complications. 7 patients have undergone successful repair. There were no immediate or early deaths.

Conclusions: In the symptomatic young infant with TOF, who abandoned surgery for any reason or at high risk stenting of the RVOT provides a safe and effective management strategy, improving arterial oxygen saturation and encouraging pulmonary artery growth.

Cardiovascular Autonomic Function in Patients with Multiple Sclerosis Determined by Heart Rate Turbulence

Onder Akci, Serdar Oruc, Hayri Demirbas, Ersel Onrat, Mehmet Yaman, Alaettin Avsar


Cardiology Department, Afyon Kocatepe University, School of Medicine, Turkey

Introduction: Heart rate turbulence (HRT) is the baroreflex-mediated vagal and sympathetic short-term oscillation of cardiac cycle lengths after spontaneous premature ventricular contractions. HRT predicts cardiovascular autonomic functions. Multiple sclerosis (MS) can cause sympathetic dysfunction in autonomic cardiovascular functions. Cardiovascular autonomic neuropathy has been reported in patients with MS by heart rate variability (HRV). However, there is no study about HRT in multiple sclerosis patients. In this study, we aimed to determine the HRT of multiple sclerosis by 24-hours ambulatory electrocardiogram.

Materials and Methods: We examined 30 patients (6 males and 24 females, mean age 33,7 ± 10,1, range 21-57 years) with MS. Thirty healthy volunteers served as controls (mean age 35,5±6,3 years, 14 males and 16 females). ECG Holter recordings (HRT View Version 0.60-0.1, Munich, Germany) of patient and control groups were examined. HRT indices (turbulence slope [TS] and turbulence onset [TO]) were calculated from 24-h ambulatory electrocardiographic recordings.

Results: No differences were observed in blood pressure, heart rate, left ventricular diameters and ejection fraction in patients with multiple sclerosis patients, compared to the controls. Also there were no statistically significant differences in TO and TS between the multiple sclerosis and control groups (TO: -0.005} 0,029% vs 0,004} 0,043%; TS: 9.723} 6.4 ms/RR vs 11.335} 7,477 ms/RR, respectively).

Conclusion : HRT parameters were normal in patients with MS. Cardiovascular autonomic function does not seem to be altered in patients with MS.

Effect of Vagal Stimulation on Termination of Ventricular Tachycardia: A Case Report

Ersel Onrat, Onder Akci, Basri Amasyali, Gulay Ozkececi, Alaettin Avsar


Cardiology Department, Afyon Kocatepe University, School of Medicine, Turkey

Background: The role of vagus nerve in modulating ventricular dysrhythmia has recently been emphasized. Markers of abnormal autonomic function have been shown to be strong prognostic predictors highlighting the important relationship between reduced vagal tone and malignant ventricular arrhythmias such as ventricular fibrillation in cardiac patients. Mounting evidence from many species now support the presence of a rich vagal innervation in the ventricle. This potentially exploitable downstream pathway together with the availability of vagus nerve stimulators make it an exciting time to directly investigate the development of an effective strategy of vagal protection against ventricular fibrillation in the clinical setting. Here we report on a patient who had ventricular tachycardia (VT) which was terminated and converted to sinus rhythm while urinating.

Case: A 54-year-old man was admitted to cardiology department with palpitations, shortness of breath during walking and light headedness lasting for 1 day. The patient had been followed for ischaemic cardiomyopathy. Än implantable cardioverter (ICD) was implanted 3 years ago He had a blood pressure of 90/40 mmHg, heart rate 142 beats/minute and respiration 23 breaths/min.

Cardiovascular examination was unremarkable except for an irregular tachycardic pulse. A 12-lead electrocardiogram showed a wide QRS-complex tachycardia at a rate of 142 beats/minute (We could not send ECG because system does not allow sending photo).VT zone of ICD had begun at 150 beats/minute, for that reason ICD did not work at 142 beats/minute. Complete blood count and serum biochemistry were normal. Thyroid function tests and cardiac biomarkers were also normal. Firstly we thought that wide QRS complex taschycardia can be supraventricular tachycardia with bundle block and beta blocker and calcium channel blocker was given to the patient intravenously, respectively. But tachycardia did not stop. Then amiodarone infusion started to the patient. Six hours later, when 500mg amiodaron was given to the patient, he wanted to urinate. While he was urinating tachycardia was stopped and sinus rhythm was stored. 12 hours later the same tachycardia (wide QRS complex tachycardia) was started and 3 hours later it was stopped again while urinating. Electrophysiological study was done to get to know rhythm and the same tachycardia was induced at 130 beat/minute and it was ventricular tachycardia (VT). Patient™s rhythm was accepted as VT.

Results and Discussion: Parasympathetic system stimulation has profound effects on cardiac electrophysiology and arrhythmogenesis. It is known that parasympathetic system becomes dominant while urinating. It is reported that ventricular tachycardia turns to sinus rhythm by vagal nerve stimulation in the literature. But it is not known that ventricular tachycardia turns to sinus rhythm by the any vagal activation like swallowing, urinating etc. We thought that present case is the first patient whose tachycardia with wide QRS complex that was detected as VT in electrophysiological study was converted to sinus rhythm by vagal activation.

Atrial Fibrillation was Converted to Sinus Rhythm with Swallowing Reflex (Possible Effect of Vagal Stimulation): A Case Report

Onder Akci, Ersel Onrat, Gulay Ozkececi, Alaettin Avsar


Cardiology Department, Afyon Kocatepe University, School of Medicine, Turkey

Abstract: Vagal nerves stimulation (VNS) is well-known to have negative chronotropic, inotropic, and dromotropic effects. VNS has profound effects on cardiac electrophysiology and arrhythmogenesis. In the literature, there was a patient with atrial fibrillation (AF) whose rhythm was converted to sinus rhythm with digital rectal examination in a patient. In present case atrial fibrillation was terminated with another vagal activation method (Swallowing Reflex). This patient will be the second patient whose rhythm was converted to sinus rhythm with vagal activation.

Case: A 49-year-old man was consulted at the Emergency Department (ED) with complaints of palpitations, shortness of breath and dizziness lasting for 2 hours. He did not have any cardiovascular or systemic illnesses and was not taking any medication. On arrival to the ED, he had a blood pressure of 111/63 mmHg, heart rate 129 beat/minute and respiration - 20 breaths/min. Cardiovascular examination was unremarkable except for an irregular tachycardic and arrhytmic pulse. Electrocardiogram revealed atrial fibrillation with a rapid ventricular response (We could not send ecg because system does not allow sending photo). Complete blood count and serum biochemistry were normal. Thyroid function tests and cardiac biomarkers were also normal. Transthoracic echocardiography revealed normal left ventricular systolic function and diameters, normal left atrium and mild regurgitation of mitral valve. Cardioversion was planned to convert AF to sinus rhythm. While applying transesophageal echocardiography probe to the patient throat, he enforced swallowing and his rhythm (atrial fibrillation) was terminated and sinus rhythm was restored. We did not apply transesophageal echocardiography because he did not swallow and AF was terminated. After examination 12 derivation electrocardiography was taken and sinus rhythm was seen.

Results and Discussion: Transesophageal echocardiography -guided cardioversion is an established strategy for managing atrial fibrillation and flutter. In according to our knowledge there was a patient with AF whose rhythm has been converted to sinus rhythm after vagal activation. This vagal stimulation has been obtained by digital rectal activation. But according to our knowledge there was no report about patients turning to sinus rhtyhm stimulated by vasovagal stimulation produced by TEE in the literature so far. In this paper, we report a 49 year old man whose atrial fibrillation was terminated after a transesophageal echocardiography study. As we see in our case, one should remember that patients can return to sinus rhtyhm during TEE process by vasovagal stimulation.

Furthermore cerebro vascular accident may occur in patients with AF who return to sinus rhtyhm during TEE in the presence of thrombus formation in their LAA. So we should say that cerebro vascular accident may be a complication of TEE process itself. This must not be forgotten.

Successful Therapeutic Hypothermia and Thiopental Sodium Anesthesia Combination After Cardiac Arrest in a Patient with Congenital Heart Disease (Av Septal Defect)

Selauk Azkan


Cardiology Department, Gazi University Turkey, Turkey

Abstract: Therapeutic hypothermia is an effective intervention for post resuscitation syndrome in patients who have sustained a cardiac arrest. A 23-year-old woman with congenital atrioventricular septal defect experienced a cardiac arrest due to ventricular fibrillation. After successful resuscitation, she was treated with therapeutic hypothermia and thiopental sodium anesthesia combination. An implantable cardiac defibrillator was inserted and then she was discharged to home with an excellent prognosis for recovery.

Discussion: Hypoxic and ischemic brain injury is one of the most important cause of the acute mortality and long term neurologic disability after cardiac arrest. After return of spontaneous circulation mortality rate is 60% among these patients. The mortality rate decreased around 12 % from 2001 to 2009. Early successful resuscitation, defibrillation and access to emergency department are crucial to improve the survival rate. Also post resuscitation care which includes proper oxygenation keeping systolic blood pressure above 90 mmHg treating the disorder leading to cardiac arrest and therapeutic hypothermia are also very important to decrease in hospital mortality and morbidity rate of cardiac arrest patients. After return of spontaneous circulation main aim is protect the brain from hypoxic and ischemic injury. Because mammalian neurons are very susceptible to anoxia due to arterial hypoxia. During cerebral hypoxic and ischemic event the pathologic process begins with depletion of the energy sources produced as ATP in mitochondria. This is followed by acidosis, glutamate excitotoxicity, and production of oxygen free radicals. Also inflammatory cascade activation causes further neuronal damage. All of this process ends up with cell death and apoptosis. Hypothermia is a therapeutic option to prevent neurologic damage. Therapeutic hypothermia (TH) interrupt the vicious cycle by slowing inflammatory process reducing excitatory neurotoxic amino acid and free radical molecule release. Also TH decreases the intracranial pressure reduces the brain edema. Än increased infection risk, diuresis and hypovolemia, electrolyte imbalance, insulin resistance, changing of drug levels, and some degree of coagulopathy are the main side effects of TH. Thiopental, a short-acting barbiturate, has been used for anesthetic induction. Thiopental depresses the release of reactive oxygen species from neutrophils. Thipental also has antioxidant properties by inhibiting lipid peroxidation. Thiopental is an anesthetic that can protects the brain against I/R injury in animal models.

Conclusion: In selected patients mild hypothermia and thiopental sodium infusion combination can be used for maximum neuron protection.

Treatment of Acute Brachial Artery Oclussion with Coronary Stent

Gulay Ozkececi, Ersel Onrat, Serkan Berktur, Ander Akit, Alaettin Av


Department of Cardiology, Afyon Kocatepe University Medical School Turkey

Introduction: Ischemia of the upper extremities is a rare entity in comparison to the lower extremities. The most common etiology is thromboembolism due to intravascular trauma in the setting of atherosclerosis. Ischemic signs in upper extremities are seen in 12% of patients with occlusive brachial artery disease. Because this is a rare entity the optimal treatment procedure is still controversial. Surgery and endovascular approaches like angioplasty, stent implantation and directional atherectomy are methods applied for the treatment.

Case Report : 45 years old female patient has no risk factors for peripheral artery disease except hypertension. She complains of numbness and mild pain in the left arm for a month. Two days ago she felt over her left arm and her symptoms aggreaviated and bruises appeared. The physical exam showed up syanosis of the fingers of the left hand, and brachial, radial and ulnar arteries were pulseless. Complete blood count, renal function tests, clotting time, PT, aPTT were all within normal limits. Upper extremity Doppler ultrasonography showed thrombus that almost occluded the left brachial artery. Via right femoral artery cannulation we visualised left subclavian and brachial arteries. The distal of left brachial artery was almost totally occluded. In the same session we passed across the stenosis using right judkins catheter and 0,014 PTCA guidewire and advanced the guide wire to radial artery. We predilated the lesion with Maverick tm 3.0 × 2.0 mm coronary balloon. There was critical lesion in the proximal of the radial artery and proximal ulnar artery was extensively diseased. We implanted Liberty tm (Boston Scientific Corporation) consecutively 3.5 × 28 and 3.0 × 20 mm sized coronary bare metal stents to the proximal and to the distal of brachial artery. Control physical exam showed full pulse of the brachial and radial arteries. After the procedure we gave 300 mg clopidogrel loading dose then prescribed clopidogrel 75 mg/day and acetylsalicylic acid 100 mg/day. One month later we performed a control coronary angiography and found out the stents were still clear and functional.

Conclusion: Self expandable stent implantation and balloon expandable stents are the percutanious treatment approaches. Because we don™t have peripheral stents, we treated our patient with coronary stents in emergency settings. In such conditions, using coronary stents for peripheral artery disease can be a wise alternative.

A Randomized Comparative Trial on the Efficacy and Safety of Dorocontin ® Versus Nitrocontin ® in Patients with Chronic Stable Angina

Yunes Panahi, Amirhossein Sahebkar, Bahram Pishgoo


Chemical Injuries Research Center, Baqiyatallah University of Medical Sciencesb Tehran, Iran

Background: Vasodilators are a key component of pharmacotherapy for patienst with ischemic heart disease. Sustained-release nitroglycerin (nitrocontinR) is the prototype of vasodilators currently used in routine clinical practice. DorocontinR is a generic form of nitroglycerin recently produced in Iran. The present trial aimed to evaluate the efficacy and safety of DorocontinR versus the innovator drug, nitrocontinR, in a randomized double-blind comparative trial.

Materials and Methods: In this trial, 140 subjectswith established chronic stable angina (mean age: 58.88; mean duration of disease: 5.87; males: 57.3%) were randomly assigned to nitrocontin® 6.4 mg TID (n = 70) or dorocontin® 6.4 mg TID (n = 70) for period of 2 months. Assessment of cardiac function was performed using maximum equivalent of task (MET), myocardial perfusion imaging (MPI) and ECG. Also the effects of drugs on hematologic parameters (WBC, RBC, Hgb, Hct, Plt, MCV, MCH, MCHC and RDW), electrolytes (Na+ and K+), lipid profile (total cholesterol, LDL-C, HDL-C and triglycerides), liver (AST, ALT and ALP) and renal (BUN and creatinine) function were assessed at baseline as well as at the end of trial. The frequency of adverse effects during the course of trial was recorded. The study protocol was approved by the Ethics Committee of the Baqiyatallah University of Medical Sciences, Tehran, Iran.

Results: A total of 110 subjects (63 in the dorocontinR and 47 in the nitrocontinR group) completed the trial. No clinically relevant difference in electrocardiographic was observed between the studied drugs on electrocardiographic measures (ST depression and T inversion), MPI and MET results and heart rate. In the same manner, both drugs had comparable effects on hematologic parameters, lipid profile, electrolytes, and biomarkers of hepatic and renal function. No serious adverse event was reported with either of drugs. Common adverse effects were headache, vertigo, tinnitus, gastrointestinal upset and ortostatic hypotension.

Discussion: Findings arising from the current trial suggests comparable efficacy and safety profile of the generic drug dorocontin with the innovator drug nitrocontin.

Angiographic Profile of Patients with Diabetes Mellitus

Toufiqur Rahman, Syed Azizul Haque, Afzalur Rahman, Abdullah Al Shafi Majumder


National Institute Of Cardiovascular Diseases, Dhaka, Bangladesh

Background and Purpose: Diabetes mellitus is a well known cause for accelerating atherosclerosis and complex lesions. Earlier studies have established more incidence of multivessel and diffuse vascular disease in diabetics. This study aimed to investigate the type, pattern and extent of coronary artery involvement in diabetics in comparison with nondiabetics.

Materials and Methods: A total of 4230 patients admitted in National Institute of Cardiovascular Diseases (NICVD),Dhaka; Al-Helal Specialized Hospital, Mirpur and Uro-Bangla Heart hospital,Dhaka from August 2003 to June 2013 were angiographically documented for coronary artery dirsease, 2775 of whom were diabetics and 1455 were nondiabetics according to the WHO diabetes criteria (1999). The patients in these two groups were matched for age, sex, and body mass index (BMI). The 75 g oral glucose tolerance test (OGTT) was performed in all patients, for whom blood glucose, glycosylated hemoglobin (HbA1c), triglyceride (TG), total cholesterol (TC), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C) were measured. The clinical features and the data from invasive coronary angiographies were compared between the diabetic and nondiabetic coronary artery disease patients.

Results: Diabetic CAD patients had significantly higher waist to hip ratio (WHR) (P = 0.014), fasting plasma glucose (FPG), 2 h plasma glucose (2hPG), glycosylated hemoglobin (HbA1c) (p non-diabetics were 41%, 20% and 5% respectively (P < 0.001).

Conclusions: Diabetics were presented with more severe and diffuse angiographically documented coronary artery disease compared to nondiabetics. Diabetes mellitus results in a higher incidence of chronic total occlusions and more diffuse coronary lesions. LMCA involvement was also higher in diabetics. Majority of diabetics had 3-vessel disease. Complex lesions (bifurcation) and calcification was significantly higher in diabetics.

Transesophageal Echocardiographic Evaluation of Patients with Atrial Fibrillation

Toufiqur Rahman, Syed Azizul Haque, Afzalur Rahman, Abdullah Al Shafi Majumder


National Institute of Cardiovascular Diseases, Dhaka, Bangladesh

Purpose: Atrial fibrillation (AF) is a frequently encountered arrhythmia that has significant impact on cardiovascular morbidity and mortality. The prevalence of AF increases with age, affecting 0.2% of patients younger than age 50 years, 2% to 5% of patients older than age 60, and greater than 10% of patients older than age 80. The most devastating consequences of AF include thromboembolic sequelae, which arise from thrombi that form in the left atrium or appendage. In fact, AF has been implicated in 6% to 24% of all ischemic strokes. This risk increased substantially with age: From 1.5% per year in patients aged 50 to 59 years to 23.5% per year in patients aged 8 to 89. Based on such significantly elevated risk, anticoagulation strategies have been developed to reduce the thromboembolic risk. The advent of transesophageal echocardiography (TEE) especially multiplane TEE has ushered in new concepts and methods in the management of AF. TEE allows for a detailed anatomic assessment of the atria and the left atrial appendage. From this broadened knowledge, concepts, such as TEE-guided cardioversion, have been developed. So, aim of the study is to evaluate the patients with atrial fibrillation using transesophageal echocardiography.

Materials and Methods: 452 patients with atrial fibrillation were studied during the period of May 2006 to May 2012 in National Institute of Cardiovascular Diseases (NICVD), Dhaka. All patients underwent transthoracic echocardiography and transesophageal evaluation by GE VIVID S5 machine with multiplane TEE probe.

Results: 78% were female, 22% were male. Mean age of the study population was 32 A} 08 years. 86% patients had chronic rheumatic heart disease (CRHD), 5% patients had hypertension, 3% patients had thyrotoxicosis, 2% patients had congenital heart diseases, 1% had dilated cardiomyopathy, 1% had ischemic cardiomyopathy, 1.5% had ischemic heart disease and 0.5% had hypertrophic obstructive cardiomyopathy. Transthoracic Echo examination showed left atrial spontaneous echo contrast in 25% cases and left atrial clot in 26% patients. Transesophageal echocardiograph examination showed left atrial spontaneous echo contrast in 76% cases and left atrial clot in 54% patients. Mean left atrial appendage flow velocity in patients with left atrial thrombus was 0.15 A} 0.04 m/sec and in patients without left atrial thrombus was 0.32 A} 0.07 m/sec. Conclusion: AF is one of the commonest arrhythmia in clinical practice. 67% patients with rheumatic heart disease had left atrial thrombus and proper anticoagulation must be addressed for these patients.

Minimally Invasive Valve Surgery by Right Anterior Thoracotomy A Single Center Experience

Roberto Coppola, Marco Gucciardo, Leopoldo Bardaro Francesco Miceli, Sergio L. Chierchia


Cardiovascular Department, ICLAS (Villa Azzurra Hospital), Genova, Italy

Background: Mitral and aortic valve surgery by right ventricular mini - thoracotomy has now gained acceptance among the surgical community and has evolved into a safe, efficient treatment option. Compared to the traditional approach that employs full median sternotomy, minimally invasive surgery results in comparable mortality rates and often provides fewer complications and greater patient satisfaction. Initially confined mostly to the mitral valve, the mini - thoracotomic technique has progressively been extended also to aortic and combined valvular surgery. We report here the results of a single centre experience that we gathered in the last 2 years.

Patients and Methods: From January 2011 246 (127 men and 119 women) pts underwent cardiac surgery by the right minithoracotomy approach. Mean age was 69 with 109 pts (44%) aged 70 or older and 24 (9%) older than 80 years; 37 pts (11%) had diabetes, 18 (7.3 %) had renal and 20 (8%) respiratory insufficiency; 8 (3%) had cerebrovascular disease; 114 were in NYHA Class III or greater and 42 (17%) had impaired ejection fraction. The EUROSCORE was 6% or more in 107 and greater than 10 in 14. Surgery consisted of mitral valve replacement or repair (77) in 142 pts, of aortic valve replacement in 53 and of combined mitral and tricuspid valve replacement or repair in 46.

Results: CPB and aortic cross-clamp time were respectively 108 and 88 minutes. Mean admission and ITU stay were respectively 7.4 and 2.8 days; 6 patients (2.4%) died during hospital admission and 240 were discharged home. Death was caused by intractable heart failure (1 pt), multiorgan failure (2 pts) and lung infection (3 pts). Major postoperative complications were respiratory (16 pts, 6.5%), neurological (4 pts, 1.6%), infectious (10 pts, 4%) and renal (15 pts, 6%). Re-exploration for bleeding occurred in 7 pts (2.8%) and transfusions were required in 90. There were no deaths in the 53 pts undergoing aortic valve replacement whose mean age was 71 years (28 were 70 years or older and 8 were older than 80) and mean EUROSCORE was 5.8. In this patient group postoperative complication rate was 9.4% (3 lung infections, 1 re-exploration, 1 renal insufficiency).

Conclusion: Our experience indicates that in a relatively old population of patients with valvular disease and an elevated pre-operative risk profile, a minimally invasive approach by right thoracotomy affords low mortality and complication rates and is associated with short admission times. The favourable results obtained in patients with aortic valve disease, suggest that this technique may represent a valid surgical alternative, especially in older patients as well as in those with elevated surgical risk, due to severe comorbidities.

Effects of a Bioavailability-Boosted Curcumin Formulation on Inflammatory Mediators in Patients at High Cardiovascular Risk

Amirhossein Sahebkar


Cardiovascular Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

Background: Traditional risk factors have limited prognostic value for ischemic heart disease (IHD). vascular endothelial growth factor (VEGF), tumor necrosis factor-I} (TNFI}) and monocyte chemoattractant protein 1 (MCP-1) are among the emerging contributors to the pathogenesis of atherosclerosis. The present study aimed to assess the impact of curcumin, a natural polyphenol with claimed cardioprotective properties, on circulating levels of these markers in subjects at high risk of IHD.

Materials and Methods: In a randomized 2A-2 cross-over study, thirty obese individuals were assigned to either A bioavailabbility-boosted curcumin product (C3 ComplexAR; Sami Labs LTD, Bangalore, India) at a daily dose of 1g or a matched placebo for 4 weeks. Treatment phases were separated by a 2-week wash-out period. A multiplex biochip array technology was employed to determine serum levels of VEGF, TNFI} and MCP-1 at baseline and endpoint of each treatment phase. The study protocol was approved by the Ethics Committee of the Mashhad University of Medical Sciences, Mashhad, Iran.

Results: Mixed-model statistical analysis indicated a significant reduction in serum VEGF (P = 0.01) but not TNFα and MCP-1 concentrations (P > 0.05).

Discussion: Curcumin may exert cardiovascular protective effects via reducing circulating levels of VEGF. This effect could be attributed to the putative anti-inflammatory and immune-regulating properties of curcumin.

Investigation of the Short-Term Effects of Curcumin on Circulating Lipid Indices: A Randomized Cross-Over Study

Amirhossein Sahebkar, Majid Ghayour-Mobarhan, Mohsen Moohebati, Shima Noorandoust, Mohsen Mazidi, Zahra Sharghi Shahri


Cardiovascular Research Center, Mashhad University of Medical Sciences Mashhad, Iran

Background: Dyslipidemia is a key contributor in the pathogenesis of atherosclerotic cardiovascular disease (ACVD). Curcumin, the active polyphenol present in turmeric, has been reported to possess lipid-modifying properties in experimental models. The present study aimed to investigate the impact of curcumin therapy on conventional and novel indicators of lipid status in obese dyslipidemic individuals.

Materials and Methods: This study was a randomized double-blind placebo-controlled cross-over trial recruiting 30 obese dyslipidemic subjects (mean age: 38.43 yrs; BMI: 32.60 kg/m2; females: 83.3%). Participants were randomized to bioavailability-enhanced curcuminoids (C3 complexAR; Sami Labs Ltd., Bangalore, India; 1 g/day) or placebo for 4 weeks, intermitted by a 2-week followed by a 2-week wash-out period. Serum levels of small-dense LDL (sd-LDL), total cholesterol, LDL-C, HDL-C, triglycerides, and antibody titres against oxidized LDL (anti-oxLDL) were measured at baseline and weeks 4, 6 and 10 of trial. The study protocol was approved by the Ethics Committee of the Mashhad University of Medical Sciences, Mashhad, Iran.

Results: Treatment with bioavailability-improved curcuminoids significantly reduced triglycerides concentrations (P < 0.05) but did not affect other indices of lipid profile including sdLDL, anti-oxLDL, total cholesterol, LDL-C and HDL-C (P > 0.05).

Discussion: Short-term supplementation with curcuminoids is associated with hypotriglyceridemic effects but no significant effect on cholesterol, sdLDL and anti-oxLDL.

Pulmonary Artery Banding: Fez Experience

Atmani Samir, Elkouach Mustapha


Faculty of Medicine, University Hospital Hassan II, Fez, Morocco

Material and Methods: A retrospective study was done with 26 patients undergoing a PAB procedure at the Hassan II hospital university center between January 2011 and July 2013. Criteria for banding were not closely defined; patients presented with severe cardiac insufficiency with failure to thrive, severe pulmonary hypertension which they were regarded as high risk for cardiopulmonary bypass or they cannot do it. Cardiac catheterization was done before the procedure in two cases.

Results: The mean age of PAB was around 16 months, between 3 months and 6 years. The male: Female ratio was 1:1, no sex predominant. The mean weight was 7 kg, the extreme are 3 and 20 kg. Six patients have Down™s syndrome. The diseases are; ventricular septal defect (II b) (8 patients), Swiss cheese ventricular septal defect (2patients), double-outlet right ventricle (2 patients), atrio-ventricular canal (6 patients), Transposition of the greats arteries with VSD (2 patients), single ventricle with tricuspid atresia (2 patients), single ventricle (1) and coarctation with VSD (3 patients). The pulmonary artery systolic pressure prior to banding was 60 to 100 mm Hg. This was reduced to 25 - 55 mm Hg after banding. The same surgical technique was used for all patients (Trusler™s formula). The re-interventions that were done following the application of the band were as follows: The PAB was moved and replaced since there was left coronary artery compression by the band in one case. Pericardial effusions were drained in two patients. A pneumomediastinum in one case spontaneously improved. The mean hospital stay was 10 A} 3 days. After banding, Positive growth was shown in 16 patients. The mean number of intercurrent hospital admissions to our department was 2. Full correction was achieved in only 3 (3/26) of patients. Two patients died by nosocomial infection with a hospital mortality of (2/26). An additional 6 patients died while they were awaiting definitive repair, total mortality is 30 %.

Conclusion: PAB still helpful under our area, can relieve heart failure symptom. But the mortality in our study is high, significant factor of death are advanced disease with high pulmonary hypertension, repeated infection especially with down™s disease and low weight.

Robotic Assisted and Endoscopic Minimal Invasive Mitral Valve Repair Clinical Experience from a Swedish University Hospital

Johan Sjogren, Per Ola Kimblad, Shahab Nozohoor, Per Wierup


Department of Cardiothoracic Surgery, Cardiothoracic Anesthesia and Intensive Care, Skane University Hospital, Sweden

Background: Excellent long-term mitral valve repair outcomes in combination with early referrals for asymptomatic patients have shifted the focus toward less invasive options. Previous reports have shown that endoscopic minimal invasive, and robotic assisted, mitral valve repair is effective in treating degenerative mitral valve insufficiency and may reduce the length of temporary postoperative disability and hospital stay. Our aim was to evaluate the safety and outcome in our initial experience with robotic assisted and endoscopic minimal invasive mitral valve repair.

Materials and Methods: In February 2011 endoscopic minimal invasive mitral valve repair was introduced in our hospital. Robotic assisted mitral valve repair (daVinci Surgical System; Intuitive Surgical) was introduced in September 2012. Between February 2011 and April 2013 a total of 20 patients (18 male/2 female; mean age 55A}9 years; range 36-73 years) underwent mitral valve repair through a right mini-thoracotomy with robotic support (5 patients) or endoscopically (15 patients). Patients with concomitant coronary artery disease, known peripheral vascular disease, or prior right thoracotomy were not accepted for minimal invasive mitral valve repair. Follow-up was performed in September 2013 (mean FU 14A} 8 months). The study was approved by The Ethics Committee for Clinical Research at Lund University, Sweden.

Results: Overall 30-day mortality was 0%. No patient had to be converted to sternotomy or reoperated for postoperative bleeding. The mean ECC time was 170A} 73 min and the mean cross clamp time was 110A}54 min. One patient had a second pump run during the procedure due to an echocardiographically demonstrated SAM following weaning from ECC (the SAM was successfully managed with additional neo-chordae). All patients had a successful valve repair without significant regurgitation at discharge (none/trivial regurgitation). The length of stay in ICU was 1.3A}0.4 days (median 1 day) and the total length of stay in our department was 7.3A} 1.9 days (median 7 days). All 20 patients were alive at late follow up. Freedom from re-operation at 1 year was 100%.

Discussion: Our initial experience with robotic assisted and endoscopic minimal invasive mitral valve repair suggests that these procedures may be introduced and performed with a high level of safety and with very satisfying outcome in carefully selected patients. Prolonged operative times related to the surgical learning curve did not seem to influence early and midterm mortality.

Repair of Isolated Posterior Mitral Leaflet Prolapse: PTFE Neochordae Vs Resection - A Multi-Center Study

Sigurdur Ragnarsson, Shahab Nozohoor, Johan Sjogren Ricardo Sanchez, Per Wierup


Department of Cardiothoracic Surgery, Cardiothoracic Anesthesia and Intensive Care, Skane University Hospital, Sweden

Background: Resectional techniques are the established method of posterior mitral valve leaflet repair for degenerative disease. However, implantation of polytetrafluoroethylene (PTFE) neochordae is gaining acceptance. The aim of this study was to compare the effectiveness, durability, and clinical outcome for patients undergoing mitral repair using PTFE neochordae in comparison to the widely adopted technique of leaflet resection.

Materials and Methods: A retrospective study of 224 patients (mean age 61A} 12 years; M/F 71%/29%) that underwent isolated mitral valve repair (February 1998 - May 2012) for degenerative posterior mitral leaflet prolapse at two cardiothoracic centers in Sweden and Denmark was conducted. Follow up was performed in February 2013 (mean FU 5.9A} 3.9 years) and was 100% complete for survival and freedom from reoperation, 80% complete for freedom from moderate to severe mitral insufficiency by echocardiography controls (mean 3.4A} 3.4 years), 77% complete for freedom from chronic atrial fibrillation (mean 5.5A} 3.5 years), and 78% complete for freedom from the composite endpoint of major adverse cardiac events (mean 6.1A} 3.4 years). The study was approved by The Ethics Committee for Clinical Research at Lund University, Sweden.

Results: Repair was successful in 201 patients (96%) of which 146 (73%) underwent leaflet resection and 55 (27%) PTFE neochordal repair. All patients received an annuloplasty ring with a mean ring size 33A} 4 mm in the PTFE group and 31A} 3 mm in the resection group. The PTFE group had shorter mean operative times than the resection group. Survival at five years was 98% in the PTFE group and 94% in the resection group. At five years, freedom from all cause reoperation was 100% in the PTFE group and 98% in resection group; freedom from moderate or greater mitral regurgitation was 92% in the PTFE group and 96% in the resection group; freedom from chronic atrial fibrillation was 97 % in the PTFE group and 95% in the resection group; and freedom from major adverse cardiac events was 92 % in PTFE group and 85% in resection group. At the latest follow up, 89% were in NYHA Class I-II. Nine percent were deceased.

Discussion: Both repair techniques for posterior mitral leaflet prolapse are associated with excellent results and appear comparable in the early and midterm postoperative course with low mortality, incidence of reoperation and moderate or greater mitral regurgitation. PTFE neochordal repair allows larger mitral annuloplasty rings and may be associated with better hemodynamic performance. However, this finding must be evaluated in future studies.

Cross-Talk Between Tripartite Motif Family Member and Toll Like Receptors in Cardiovascular Conduction Tissue

Brenda Bin Su


The Hospital for Sick Children, Canada

Introduction: Tripartite motif family member 21 (TRIM21) predominantly negatively regulates nuclear factor (NF-B)-dependent proinflammatory cytokine responses and it is well-known an autoantigen in patients with Sjogren's syndrome and systemic lupus erythematosus. Maternal anti-TRIM21 antibodies are almost always present when autoimmune congenital heart block (CHB) is identified in the fetus or newborn, but predict the occurrence of CHB only 2-4% of the time. Thus, TRIM21 is necessary but not sufficient for CHB prediction. Like TRIM, Toll-like receptor (TLR) is involved in pathogen-recognition and plays a pivotal role in innate and acquired immunity.

Unlike TRIM21, TLR4 ligand bacterial endotoxin lipopolyssacharide (LPS) activates NF-B to trigger pro-inflammatory cytokine production. We thought both TRIM21 and TLR4 may contribute to CHB disease development and have cross-talk in CHB pathogenesis.

Objective: TRIM21, TLR4 and the inflammatory molecules which related to both TRIM and TLR signaling were validated by microarray and protein array using cardiac conduction tissue and material serum with CHB child respectively.

Materials and Methods: Affymetrix human U133 plus 2 arrays was employed for gene expression in atrioventicular conductive tissue from human fetal heart (n = 6) and the data were analyzed by Affymetrix console and Partek® Genomics SuiteTM. A set of genes were confirmed by RT-PCR. Gestation-matched maternal sera (n = 13) were applied on protein array (Invitrogen V5) for autoantigen screening and the data was analyzed by Prospector v5.2, Partek and SAS v9.1, as well as bioinformatics and systematic biology analysis.

Results: We found that TLR4 is preferentially expressed in AV conductive tissue (P < 0.04). TRIM21 (P < 0.0002) was preferentially immunogenic in maternal sera from mothers with CHB babies. Bioinformatics analysis showed that TRIM21 has highly homologues to RPRX which is highly expressed on atrioventricular conductive tissue from human fetal heart. Some of inflammatory molecules that involve in both TRIM and TLR signaling pathway are also preferentially expression in AV conductive tissue.

Conclusion: TRIM and TLR signaling both contribute CHB development and may have a cross-talk during cardiac conduction diseases progression.

Gene Expression in Atrioventricular Junction from Fetal Hearts, Identify Potential Biomarkers for Congenital Heart Block by High-Throughput Approaches

Brenda Bin Su


The Hospital for Sick Children, Canada

Background: Congenital heart block (CHB) is a frequent complication to the pregnancies of autoimmune mothers. The antigenic target of this phenotype is thought to be within the fetal atrioventricular (AV) node tissue. Several potential targets in the pathophysiology of CHB have been reported by one by one study including calcium ion channels. However, the efficiency of the predicting CHB pregnancies with current potential targets is not sufficient for CHB pathogenesis. As murine AV node-specific gene expression has been well characterized (Horthius, 2009), we sought to identify genes expressed within human fetal heart AV junctional tissue (AVJ) relative to apical myocardium (Apx), and to compare any upregulated genes identified in the AV junction to those previously identified in mouse.

Materials and Methods: Total RNA was extracted using Qiagen kit, quantified by Nanodrop and Bioanalizer, labeled and applied onto Affymetrix human U133 plus 2 arrays. The results were normalized and analyzed by Partek Genomics Suite. A subset of the data was confirmed by Real-Time PCR. Peptide (Epitope)-library screening, ELISA, immunoprecipitation, Western blots analysis and immunostaining from sera samples were employed for further study on three peptide libraries of T-type calcium channel CACNA1G (CACNA1G).

Results: 1532 genes were found significantly (P < 0.01) expressed in fetal heart AV junction than that in apex in the human fetal hearts at 20-22 weeks of gestation. 496 genes were greater than 2-fold genes and 62 genes were 5-fold differential expressed in AVJ than in Apx. We found 245 genes highly expressed in human AV conductive tissue matched to the gene expression in AV nodal cells of mouse in both E10.5 and E17.5 (P < 0.01). A subset (103) of these genes matched in human fetal AV conductive tissue in E10.5 enriched in the AV canal and/or node (P < 0.01). T-type calcium ion channel subunit CACNA1G (a1G gene) not only expressed in high level in human AVJ, but the 1G also expressed on the surfaces of cardiomyocytes. In addition, maternal sera reactivity to an extracellular epitope of a1G was significantly higher in CHB maternal sera as compared to the control sera.

Conclusion: An extracellular epitope on the a1G T-type calcium channel is one of targets reorganized by CHB material sera antibodies. The high-throughput approaches can provide specific markers for the human fetal atrioventricular conduction system, which might be potential combinational targets in the pathophysiology of congenital heart block.

Stress Treadmill Echocardiography in Evaluation of Exertional Dyspnoea Using Diastolic Parameters

Rohit Tandon


Hero DMC Heart Institute, India

Aims and Background: Exertional dyspnoea in a patient is an ominous symptom requiring evaluation and is difficult for physicians to ascertain a cause by single investigation. Treadmill test is often ordered for ischaemia evaluation added echocardiographic evaluation of diastolic parameters seems to be practical in providing a clue towards evaluation of dyspnoea. We aim to assess diastolic function parameters to evaluate dyspnoea in our patient subset.

Materials and Methods: Patients with complaints of exertional dyspnoea were included in the study. Patients of COPD, valvular heart disease, past h/o coronary artery disease with severe left ventricular systolic dysfunction,severe anaemia,osteoarthritis and poor echo window were excluded.

Results: 58 patients complaining of dyspnoea on exertion were taken up for this study in a period of three months referred by physicians from OPD. Seven patients were excluded either due to baseline E/E'™ ratio >13 or unstable diastolic parameters determined by 3 min leg rising. Mean age was 54 ± 5 years and average BMI was 30A} 4. There were 46 hypertensives,11 diabetics, 31 had sedentary lifestyle i.e. Findings of stress test 10 patients had abnormal exaggerated blood pressure response to exercise, delta E/E™ i.e. increase in E/E'™ from baseline to peak and DFRI ranged from 3A} 2.5 and 30A} 5 respectively in 39 (76%) patients while E/E™ ratio increased to >13 at peak exercise only in 9 (17%) patients.Conclusions: It is prudent to estimate these parameters during routine testing in patients who complaint of exertional dypnoea.

In Hospital Outcomes After Aspiration Thrombectomy During Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction

Ellouze Tarek


Cardiology Department, Hedi Chaker Sfax, Tunisia

Aims and Background: Exertional dyspnoea in a patient is an ominous symptom requiring evaluation and is difficult for physicians to ascertain a cause by single investigation. Treadmill test is often ordered for ischaemia evaluation added echocardiographic evaluation of diastolic parameters seems to be practical in providing a clue towards evaluation of dyspnoea. We aim to assess diastolic function parameters to evaluate dyspnoea in our patient subset.

Materials and Methods : Patients with complaints of exertional dyspnoea were included in the study. Patients of COPD, valvular heart disease, past h/o coronary artery disease with severe left ventricular systolic dysfunction, severe anaemia, osteoarthritis and poor echo window were excluded.

Results: 58 patients complaining of dyspnoea on exertion were taken up for this study in a period of three months referred by physicians from OPD. Seven patients were excluded either due to baseline E/E'™ ratio >13 or unstable diastolic parameters determined by 3 min leg rising. Mean age was 54 ± 5 years and average BMI was 30A} 4. There were 46 hypertensives,11 diabetics,31 had sedentary lifestyle i.e. Findings of stress test 10 patients had abnormal exaggerated blood pressure response to exercise, delta E/E™ i.e. increase in E/E'™ from baseline to peak and DFRI ranged from 3A}2.5 and 30A} 5 respectively in 39 (76%)patients while E/E™ ratio increased to >13 at peak exercise only in 9 (17%) patients.

Conclusions: It is prudent to estimate these parameters during routine testing in patients who complaint of exertional dypnoea.

Succesful Transcatheter Closure of Perimembranous Ventricular Septal Defect with Inlet Extension Using Adoi

Mashail Binobaidan


Prince Sultan Cardiac Center, Riyadh, Saudi Arabia, Interventional Pediatric Cardiology, Riyadh, Saudi Arabia

Introduction: Transcatheter closure of perimembranous ventricular septal defect (PM VSD) is abandoned in many center and in some became restricted to certain age and criteria because of the risk of complete heart block (CHB). The risk of damaging the tricuspid valve (TV) in the presence of inlet extension is another risk. I am presenting successful closure of such defect using Amplatzer occlude device for PDA with reasonable follow up period in Prince Sultan Cardiac Center PSCC.

Material and Methods : Through 2011 4 patients underwent transcatheter closure of PM VSD with inlet extension, all patients were consented and procedure were done under general anesthesia, Transesophageal echocardiography was done in all, one has 3D assessment Hemodynamics were assessed pre procedural, A-V loop was applied in 2 patients, ADOI were used in all,heparin and antibiotics were giving during and 24 hr post procedure, 3 patients were extubated same day and one the following day, all patients were kept on aspirin for 6 months.

Results : Median age 17 kg, 3 female and 1 male, median age 7 year, Median ventilatory duration is one day, Median hospital stay is 2 days, Median Follow up is 10 months, No immediate or early complication or deaths, normal ECG immediately and during follow up period, normal Echocardiography with no residual leak during follow up period.

Conclusion : In selected patients with PM VSD and inlet extension ADOI device can be used safely and effectively to close the defect with no immediate or early complications.

Early Result of Patients Underwent Transcatheter Completion of Fontan and Fenestrated Extracardiac Fontan

Mashail Binobaidan


Consultant Interventional Pediatric Cardiology, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia

Introduction : Fontan surgery and its modifications are well-recognized palliation for univentricular types of heart lesions. Nowadays palliation can be achieved by combined surgical and transcatheter approaches, which offer good immediate and early results for the high-risk patients.

Materials and Methods : Between September 2006 through January 2012, 18 patients underwent transcatheter completion of Fontan (gp 1), 28 patients underwent surgical fenestrated extracardiac Fontan (gp 2) GP 1: Patients were ventelated and angiogram and hemodynamic assessment followed by opening of the SVC-RA junction and fdevice closure of the ASD II, some with use of covered stent GP 2: Extracardiac Fontan is done with Fenetration by single Surgeon

Results : Mean age 4.8 year for (gp1), 3.5 yr for (gp2) mean weight is 20 kg and 14 kg respectively, median median sat is 95% and 88% (p).

Conclusion : We conclude that Trans catheter completion of Fontan approach in selected patient is safe and considered an alternative approach.






 

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