Day 2 :
Wayne State University, USA
Time : 09:05-09:30
A repaired congenital heart defect (CHD) does not equate to a normal heart. With time, residual or new patient (pt) age-related issues including valve stenosis or insufficiency, changes in vessel dimensions, stunts, and arrhythmias will require continued intervention and medical management. Early heart failure, based solely on cardiac anatomy, remains an important concern for which there are evolving therapies. The newly coined term, ”Structural Heart” as it applies to valve and vessel issues, other than coronary arteries, often is only a substitute term for CHD among older patients. At the current time, there are about 2 million pts > 18 years of age in North America and Europe alone, with repaired CHD. A number far greater than children with CHD. The recognition of this increasing and evolving patient population data base has prompted the American Board of Internal Medicine to create a new sub-specialty training program and Board examination in Adult Congenital Heart Disease (ACHD). Comparable recognition in England utilizes their Grown-up Congenital Heart (GUCH) programs. The purpose of this presentation is to identify the scope of the problem facing clinicians today and to illustrate current advances in recognition and therapy.
In the field of anatomical diagnosis, non-invasive imaging now includes standard 2D and 3D ECHO/Doppler studies as well as MRI/CT scans. Recently, physicians have been aided by the development of 3D printed soft tissue models of precise. Considering the complexity of certain repaired CHD, these precise anatomical models allow pre-operative planning and familiarization with cardiac/vascular structures as well as patient education. Since repeat open thoracotomies are often technically challenging, expensive as well as associated with high patient morbidities, non-surgical interventions have been greatly aided by use of vascular-accessed devices to open stenotic valves and vessels by use of various balloon catheters or stents, both covered and expandable. A major paradigm shift has evolved over the past ten years with more interventional cardiac catheterization laboratory procedures now being performed indeference to repeat surgical operations. At present, about 70% of residual CHD problems are now be amenable to interventional catheterizations, including insertion of valves.
Certain CHD may intrinsically predispose to arrhythmias and the addition of prior surgical operations leaves residual scars which only augment the arrhythmia burden among CHD pts. Ablation mapping with non-fluoroscopic techniques has greatly reduced radiation exposure to patients and catheterization lab personnel. Non-fluoroscopic procedures eliminate the need for lead aprons, which decreases orthopedic problems commonly seen among electrophysiologists and lab technicians. Although not included in current published “guidelines’, resynchronization pacing for heart failure has been applied to CHD pts with variable success.om
ACHD is an evolving field and will continue to expand as more children survive to adulthood from what previously had been fatal heart defects due to improvements in interventional procedures. Continued knowledge and awareness in the field will be required by all involved in patient care.
- Interventional Cardiology | Coronary Heart Diseases | Cardiac Surgery
Location: Madrid, Spain
King Abdulaziz Medical City, Saudi Arabia
Wayne State University, USA
Title: When the guidelines don't apply: Contractility (dp/dt-max)-guided resynchronization pacing among patients with congenital heart and heart failure
Time : 10:00-10:30
Dr Karpawich completed his Masters in Science degree from The University of Detroit and his Medical Degree from Hahnemann/Drexel University in Philadelphia, PA. His postdoctoral Residency in Pediatrics at The Children's Medical Center, University of Texas (Dallas), and Pediatric Cardiology Fellowship at Texas Children's Hospital, Baylor University (Houston). He founded and is Director of the Cardiac Electrophysiology Program at the Children's Hospital of Michigan and Professor of Pediatric Medicine, Wayne State University School of Medicine (Detroit). He has published over 200 scientific papers, textbook chapters and textbooks typically in the field of cardiac electrophysiology, pacing and heart failure management both in children and adults with congenital heart disease, and is on the editorial staff of several internationally-recognized medical journals.
Objectives: Patients (pts) with repaired congenital heart disease (CHD) can later develop heart failure (HF), leading to heart transplant (HT). Although cardiac resynchronization pacing therapy (CRT) has been applied to pts with normal anatomy, there is little information on CRT and CHD. This study evaluated acute hemodynamic contractility (dP/dt), not guidelines, among CHD pts to determine if it can predict chronic CRT efficacy.
Methods: Forty pts with CHD and HF (NYHA II-IV) underwent cardiac catheterization (cath) with dP/dt-max both before and after acute CRT pacing. If acute paced-dP/dt-max improved ≥ 15% from baseline with CRT pacing, pts were given the option of CRT. Clinical follow-up after CRT testing was from 2-144 months (mean 35).
Results: Preexisting pacemakers were present in 70% of pts. CHD was variable with 16/40 (40%) pts having either a single or systemic “right” ventricle morphology. Of the 40 pts, 26 (mean age 22y) met criteria for CRT benefit while 14 (mean age 29y) did not. There were no differences in age, QRS duration, left ventricular (LV) ejection fraction, LV end diastolic diameter, V contractility (dP/dt-max), nor PM between CRT groups. Among the CRT recipients, 21 pts (81%) improved in NYHA class and were removed from HT consideration. All underwent a repeat cath 6-14 months later showing continued improved contractility.
Conclusion: Since published CRT guidelines do not apply to CHD pts, a better way to select which CHD pts may benefit from CRT is needed. Pre-CRT testing by direct paced-contractility response improve patient selection and responder rates.
Ben-Gurion University, Israel
Title: Acute MyoK+ardial Infarction: The association of changes in K+ levels and in-hospital mortality of patients with acute myocardial infarction
Time : 10:45-11:15
To be updated soon...
Background: Serum potassium levels (K, mEq/L) of patients with acute myocardial infarction (AMI) were found to be associated with short- and long-term outcomes. Nevertheless, significant fluctuations in K have been reported during the acute phase of an AMI.
Aims: To evaluate the association between K changes during the hospitalization and in-hospital mortality of patients admitted with AMI.
Methods: AMI patients hospitalized in a tertiary medical center, between 2002-2012, for 3 days or longer, were studied. Based on K levels during the hospitalization, the following parameters were calculated: minimal, maximal, range (maximal-minimal) and fluctuation (the gap between two consecutive K levels). The latter parameters were calculated for every K throughout the hospitalization. The associations between the parameters and outcome were assessed using generalized estimating equations model, adjusted to baseline patients’ characteristics and results of other routine laboratory tests (i.e. Sodium, Creatinine and Glucose).
Results: Overall 16,596 admissions of 12,176 patients were included (age 67.8±13.9 years, 66.6% males), and 111,457 K results registered. Overall, patients discharged alive from 15,564 admissions, with an in-hospital mortality rate of 6.2%. Compared with survivors, in-hospital mortalities had higher mean K (4.4±0.8 vs. 4.3±0.6), higher rate of fluctuation or range ≥0.4 (p<0.001 for each). Minimal K throughout the first 48 hours was significantly more prevalent among survivors compared to deceased (41% vs 25% p<0.001). In a multivariate analysis the following parameters were found to be independent prognostic marker for mortality: K<3.9 (adjOR=1.22) or K>4.8 (adjOR=1.17), range ≥0.8 (adjOR=1.53) and minimal K during the first 2 days of admission (adjOR=1.49). Furthermore K fluctuation ≥0.4 was associated with increased mortality within the following 72 hours (adjOR=1.37), (p<0.001 for each).
Conclusions: changes in K, in addition to extreme values throughout an admission of AMI patients are strong prognostic markers of in-hospital mortality. Close monitoring of K in addition to further evaluation of mechanisms and interventions in K are in order.
Armed Forces Institute of Cardiology and National Institute of Heart Disease, Pakistan
Title: Effectiveness of maximum functional capacity (VO2 Max): an assessment tool for preoperative suitability in cardiac surgery. A descriptive cross sectional study from Pakistan
Time : 11:15-11:45
Dr Imtiaz Ahmed Chaudhry did his Fellowship in General Surgery in 2004, and later completed his second Fellowship in Cardiac Surgery from College of Physicians and Surgeons, Pakistan in 2011. He completed one year training (IMGSS) in Cardiothoracic Surgery at Queen Elizabeth Hospital Birmingham UK, in 2013.
He is working as a consultant cardiac surgeon at Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi, Pakistan.
He is a member of Research Department, Institutional Ethical Review Board and in charge of Adult Cardiac Surgery Database. He has published more than 10 papers in reputed scientific journals.
Objective: There has been an increase in the number of cardiac surgeries, and there is a growing need to predict the morbidity, mortality and quality of life in patients following such surgery. According to recent studies preoperative identification of patients at risk of postoperative cardiac complications is readily achievable using noninvasive cardiopulmonary exercise testing (CPET). This study evaluated the value of VO2 max testing in the preoperative assessment of patients undergoing elective cardiac surgery and whether poor preoperative cardiopulmonary reserve and comorbid state dictate high risk status and predict complications in patients undergoing elective cardiac surgery.
Methods: A descriptive cross sectional study is being carried out at Armed Forces Institute of Cardiology and National Institute of Heart disease, Rawalpindi, Pakistan. All the patients undergoing elective CABG surgery were included according to inclusion criteria. Data were collected on functional status, postoperative complications, and survival.
Results: Initial analysis revealed a mean age of 52 years ± 10.37 and majority of male patients with a mean BMI of 25.1±. Mean VO2 max at admission was 13.6±4.3 whereas VeO2 and VeCO2 were (46.7±25.4) (30.1±15.72) respectively. Postoperatively our cohort of patients had a mean ICU stay of (54.4 hrs±58.09) and ventilation time of 5.3hrs±4.38. Majority of the patients were weaned off with mild inotropes and only one patient had peroperative IABP insertion. In our study preoperative VO2max cardiopulmonary status positively correlates with postoperative prolonged ICU stay and ventilation time at pearson coefficient r=0.422, r=0.485.
Conclusion: CPET is a useful adjunctive test for predicting postoperative outcome in patients being assessed for cardiac surgery.
Royal Brompton and Harefield NHS Trust, UK
Title: TLR-4, CD14 polymorphisms and plasma concentration of Soluble CD14; is there a genetic link with Coronary Artery Disease?
Time : 11:45-12:15
Ms Maria Kalliopi Konstantinidou studied at the Medical University of Crete with a Scholarship to Boston University. Subsequently she got involved in research at the University of Athens and completed her PhD, which focused on the genetic predisposition to coronary artery disease, as well as a Masters degree in Thoracic Oncology. Having concluded her cardiothoracic surgery training, in hospitals both in Greece and the UK, she is currently a Clinical Fellow in Cardiothoracic Surgery at Royal Brompton and Harefield NHS Trust in London. Ms Konstantinidou has continued to be active in research co-writing and publishing a number of articles.
Background: Inflammatory mechanisms have a key role in the pathogenesis of atherosclerosis. The most frequent functional polymorphisms of TLR-4- Asp299Gly and Thr399Ile- and of CD14 promoter area - C260T polymorphism- are studied in patients with coronary atheromatosis. Plasma levels of soluble CD14 are checked for possible correlation with the severity of Coronary Artery Disease (CAD).
Methods: DNA was obtained from 100 human paraffin-embedded aortic specimens, from cadavers with known coronary atheromatosis (Group A) and 100 blood samples from patients with CAD, as detected by cardiac Multi-Detector-row-Computed-Tomography (MDCT) (Group B). Our control group consisted of 100 healthy individuals (Group C). Genotyping was performed by Restriction Fragment Length Polymorphism-Polymerase Chain Reaction (RFLP-PCR). Plasma levels of sCD14 were measured with ELISA.
Results: For TLR-4 Asp299Gly and Thr399Ile polymorphisms, no statistically significant differences were observed. Regarding the C260T polymorphism, frequencies of T allele were significantly higher in the control group compared to the case group (p = 0.05). The Odds Ratio (OR) showed statistically significant association of TT genotype with healthy individuals (OR= 0.25, 95% Confidence Interval (CI) = 0.10–0.62, p = 0.0017). Plasma levels of sCD14 in patients with CAD (mean value = 1.35 μg/ml) were reduced when compared to reference value.
Conclusions: The studied polymorphisms of TLR-4 showed no association with CAD. Conversely, the studied functional polymorphism of CD14 has a statistically significant difference in expression between healthy and affected by CAD individuals. Further studies could prove the use of sCD14 as possible biomarker for severe coronary disease.
Interventional Cardiology | Coronary Heart Diseases | Cardiovascular Surgery
Armed Forces Institute of Cardiology and National Institute of Heart Disease, Pakistan
Title: Reducing surgical site infections through quality improvement initiative: A tertiary cardiac care facility experience in a developing country
Time : 12:15-12:45
Dr Farrah Pervaiz has completed her Masters in Public Health from Quaid e Azam University, Islamabad, Pakistan in 2012. Although, a clinician at genes, possesses a special interest in cardiac research, especially clinical / outcomes based research in order to make everyday medicine more up to date and beneficial to the patients.
She is currently working as Director Research and Development department AFIC/NIHD Rawalpindi. She is the founder member of Research Department and Institutional Ethical Review Board.She is also supervising master thesis and has been a research coordinator for national and international clinical trials. Her Research work is extensively disseminated through more than 50 peer reviewed publications in both National and International Scientific Journals.
Her thesis work has been recently published in British Medical Journal and has been an author of many national publications.
Amongst healthcare associated infections (HAIs), surgical site infections (SSIs) are a preventable cause of increased morbidity and mortality and are associated with substantial financial costs. SSI rates are an indicator of the quality of surgical and postoperative care, which necessitates the need for robust surveillance systems for these healthcare associated infections. Patients undergoing coronary artery bypass grafting (CABG) are at a greater risk for infection due to their relatively older age and the presence of comorbid conditions like diabetes mellitus and obesity.
Objective: To establish the adult cardiothoracic surgical site infections registry to determine adult surgical site infection (SSI) rates and study impact of quality improvement initiatives on SSI rates.
Methods: The Adult Cardiothoracic SSI registry was developed at Armed Forces Institute of Cardiology and National Institute of Heart Disease, Rawalpindi, Pakistan. Monthly SSI rates were monitored for both CABG and valvular heart surgeries inclusive of chest and leg SSIs instituted to control the increased SSI rate in October 2014 after a multidisciplinary approach.
Results: A total number of 1341 cardiac surgeries were carried out and the cumulative SSI rate was 1.7% (n=23) for a period of one year i.e. August 2014 to August 2015, The SSI rate for chest infections was 22% (n=6) and for leg wound (harvest site) infections was 78% (n=17). There was an increase in SSI rate 5% (n= 04) during October 2014. After process improvements the rate declined to 1% in November 2014 and has remained less than or equal to 2% as of August 2015.
Conclusion: A high SSI rate was investigated and multi-modal process improvements and infection control measures were implemented, leading to a decrease in SSI rate from 4% to 1%.
Ain Shams University, Egypt
Title: Review of sixty tracheal resections and anastomosis. A seven year experience of a tertiary egyptian referral institute
Time : 12:45-13:15
Dr Ahmed MOSTAFA completed his Thoracic Surgery MD in 2009 from Faculty of Medicine- Ain Shams University. He got his pre MD training in France and worked at reputed hospitals such as HEGP-Hôpital Européen Georges-Pompidou, Tenon Hospital. He acquired the MRCS, and he is GMC registered. He has special interest in Airway Surgery. The division of thoracic surgery at Ain Shams University hospitals has quadrupled its annual number of tracheal surgeries since 2009 due to the persistent adoption of the aforementioned management
Introduction: Tracheal stenosis is one of the major complications following prolonged endotracheal intubation. Tracheal resection and anastomosis has proved to be the best solution for this serious problem. This study aims to review the experience of our institute in 7 years with patients presenting with postintubational tracheal stenosis.
Methods: A retrospective study was performed in the period between January 2009 to January 2016. This study involved patients who presented to Ain Shams University Hospitals with postintubational tracheal stenosis, and who underwent tracheal resection and anastomosis as a primary treatment.
Results: We operated upon 60 patients. We excluded glottic stenosis pathology, and patients with major co-morbidities with tracheostomies or stents as definitive treatment . Patients included 42 males (70%), 18 females (30%). Mean age was 28.35 (ranging from 2 to 72 years). At presentation, 45 patients ( 70%) had previous endoscopic dilataions, 38 patients (63.3%) had tracheostomies, 19 patients ( 31.6%) had history of tracheal stenting. Seventeen patients (28.3%) had cricotracheal resections (CTR) for subglottic stenosis. Cervicotomy was sufficient in 41 patients (68.3%), additional manubriotomy was needed in 15 patients (25%), while full sternotomy was done in only 4 patients (6.6%). All patients were given a chance for immediate postoperative extubtion. Anastomotic success rate was (96.6%). In hospital mortality was (1.6%).
Conclusion: Tracheal resection and anastomosis proves to be a safe and satisfactory option for postintubational tracheal stenosis. This intervention must be applied widely in developmental countries where there is frequent rush for tracheostomies, and abuse of tracheal stenting and dilatation. Quality of life improves dramatically following an effective surgery.
She has completed her Medical degree (Professional Doctorate) at the age of 26 years from Guilan University of Medical Sciences. She has 5 published and 3 under publish articles. She is the reviewer of the Journal of Biology and Today`s World (An International Biomedical Journal).
Background: Nowadays, percutaneous coronary intervention (PCI) is the most commonly used nonsurgical procedure which restores blood flow to the heart tissue. Such procedures may stimulate myocardial injury and release of myocardial necrosis biomarkers. Although higher levels of cardiac troponins (cTns) are associated with later adverse events, the prognostic importance of the lower levels of cTns, especially highly sensitive assays, is still a matter of controversy.
According to the above points, in the present study, we aimed to assess the prognostic power of mild to moderate elevations in hs-cTnT levels (as an indicator of periprocedural myocardial necrosis) for predicting the one-year outcome of PCI.
Methods and Results: In the present study, all the patients undergoing elective PCI between March 2011 and April 2013 at Tehran Heart Center were followed up. Based on our inclusion and exclusion criteria, finally, 2309 patients were qualified for the study. For measuring hs-cTnT, three blood samples were drawn: the first immediately before the beginning of PCI (baseline), the second 6 h after PCI, and the last 12 h after PCI. The hs-cTnT levels were analyzed using Elecsys 2010 analyzer and major adverse cardiac events (MACE) were assessed one month and one year after the procedure. Based on the pre- and post-procedural hs-cTnT levels, the patients were divided into three groups. But, the differences between the three hs-cTnT groups in terms of frequencies of MACE were not significant.
Conclusions: This prospective study demonstrated no association between mild to moderate elevations in hs-cTnT after PCI and one-year MACE.
Siriraj Hospital, Thailand
Title: Prevalence of anatomical aortic arch variants in Thai patients undergoing thoracic aorta computed tomography angiogram
Time : 14:45-15:15
Dr. Nattapong Thaiyanurak graduated his MD from College of Medicine, Rangsit University, Bangkok. He completed his residency in internal medicine and cardiology fellowship training from Siriraj Hospital, Mahidol Universtiy, Bangkok. He is currently the cardiologist at the Lampang Hospital and devotes his time in teaching medical students of Lampang Hospital Medical Education Center, Chiang Mai University.
Queen Alia Heart Institute, Jordan
Time : 15:15-15:45
Yanal Al-Naser is a consultant cardiac surgeon from Amman-Jordan. He graduated from University of Jordan in 1999 and was awarded the Jordanian boards in general surgery (2004) and cardiac surgery (2009). He was trained in Manchester –England as an adult cardiac surgeon and finished his training in 2012. He became a consultant adult cardiac surgeon in 2012 at Queen Alia Heart Institute in Jordan. He has a number of publications, and is a member of the Jordanian Cardiac society and the Royal College of Surgeons in the UK.
A 46 year old female patient, with no medical illnesses was referred to my clinic with effort intolerance and palpitations of four years duration. Her history dates back to when she was 11 when she had an Aortic and Mitral valve replacement due to rheumatic causes, she had a size 19mm bileaflet mechanical aortic valve and a size 27mm bileaflet mechanical mitral valve. She was started on warfarin and took it for three months of her life as documented by her family members and follow up notes till she decided to stop it. She stated that she took no medications at all and was completely asymptomatic, she got married and had three children, all a normal vaginal delivery aided by a mid wife at home. Her 2DECHO showed a grade three para-leaking aortic and mitral valves, and was referred to me for a redo AVR and MVR 35 years later, being off warfarin for all that period and was asymptomatic for 30 years and never had a stuck valve. Her coagulation profile was normal, with an INR of 1, I operated on her and found a rim of pannus surrounding the valves, but the leaflets were mobile. I replaced both valves using St Jude size 21 Aortic Valve and size 29 Mitral valves, both mechanical. There are a few cases described in literature about mechanical valves with no warfarin, but I believe this is one of those with the longest –off warfarin- history.
Hospital Universitari Germans Trias i Pujol, Spain
Title: Creating a new and simply frailty score for predicting postoperative morbidity in cardiac surgery
Time : 15:45-16:15
Elisabet Berastegui completed her studies of Medicine in Barcelona University- Hospital Clinic. She completed her training in Cardiac Surgery in Hospital Vall Hebron where she got her Certificate of research aptitude: Fallot Tetralogy ; Right ventricular remodelling after pulmonary valve replacement in 2010. She works like staff in Hospital Germans Trias I Pujol where is working in areas of frailty and risk, ( Doctoral Programm. Development of Thesis in Autonoma Barcelona University. She is enrolled in differente studys ( PERSIST TRIAL ) and is Coordinator of Spanish PLIAR REGISTER, ( for sutureless prosthesis)
Ageing and elderly people have greater risk. Physical state and frailty status represent an important risk and must be considered before cardiac surgery. More than one third of current surgeries are performed in patients older than 70 years; This is a factor to keep on mind in our routine evaluation. Currently an accepted definition for frailty is not well established. It has been considered as a physiological decline in multiple organ systems, decreasing the patient’s capacity to withstand the stresses of surgery and disease. The aim of our study was to determinate a correlation between preoperative features and the morbidity after cardiac surgery in aortic valve replacement population.
Methods. We selected the 70 years old patients or older who underwent an elective aortic valve replacement. We collected prospectively all preoperative features and frailty traits (Barthel Test; Gait Speed test, Handgrip) also taking into account blood parameters like albumin level and hematocrit previous to the surgery, hospital admissions within 6 months, and we analyze the demographics and medical history of the patients. We compare patients who undergo to stented prosthesis, sutureless or TAVI procedure.
(BMI body mass index, HTA hypertension, DM diabetes mellitus, COPD Pulmonary obstructive disease, IRC chronic renal failure, DLP dyslipidemia, IADL Independence activities daily living)
Results: Two hundred patients were enrolled. The mean age was 78 years all. The predicted mortality with Logistic euroScore I was 12,8% with a real mortality lower than expected (3,5%). Pre-surgery frailty in our population was associated with a Gait Speed higher of 7 seconds, Barthel less of 90%, anemia with Hematocrit <32%, albumin level< 3,4g/dl, chronic renal failure, preoperative re-admission and artery disease. The TAVI group had higher morbidity, no differences statistically significant between Stented and sutureless prosthesis group. Frail individuals had longer hospital stays, readmissions and respiratory/ infectious complications. The mortality at 6 months /one year follow up was 4,1 % /0 % respectively; and morbidity ( pacemaker implant, respiratory events, readmission); at 6 months /one year of follow up was 13,47 % to 3%.
Conclusions: Elderly and frailty population present more complications after a cardiac surgery. A simple frailty score must be considered in cardiac population to avoid increased morbidity.
Poster Presentations 16:30-17:30