Scientific Program

Day 1 :

Keynote Forum

Dr. Gamal Shaban

MD, FESC, FSCAI FHRS

Keynote: PVC ablation in PVC-related Cardiomyopathy

Time : 10:25-10: 45 AM

Biography:

Head EP unit, Director of Heart Rhythm Service, Egyptian National Heart Institute, Cairo.Consultant of cardiology and critical care. Member of Egyptian Fellowship Board of EP. Member of EHRA and Fellow of Heart Rhythm society. Secretary of Egyptian Cardiac Rhythm Association ECRA. Coordinator of teaching and scientific committee Egyptian National Heart Institute. Goodwill Ambassador Arab Republic Relations Association, Cairo.

Abstract:

Premature ventricular contractions (PVCs) are early repolarizations originating from the myocardium of the ventricles. Pvcs are common phenomenon and they are present  in 1% to 4% on standard 12 lead ECG and 40% to 75% on Holter monitoring. PVCs appear in cardiomyopathies, but also in structurally normal heart. While they might represent a risk factor of sudden cardiac death in cardiomyopathy, PVCs in structurally normal heart usually have a begnin course. However, PVC-induced cardiomyopathy has been a subject of great interest in the last decade. This concept was proposed by Duffee et al. in 1998 when pharmacological suppression of PVCs in patients with presumed idiopathic dilated CMP subsequently improved LV systolic dysfunction. Several factors are identified as risk for developement of PVC-induced CMP and include: PVC burden where several authors put a cut-off value of >10% for PVCs originating from RV, and >20% for PVCs originating from LV. PVCs from RV induce CMP at a lower threshold than PVCs from LV and this is due more dyssynchrony. Also fascicular PVCs can cause more CMP. Longer PVC QRS duration was also associated with more EF deterioration. The mechanism by which PVCs induce CMP is multifactorial and my include: ventricular dyssynchrony, increased oxygen consumption, intracellular calcium abnormalities and several other factors (fig.1). The treatment strategy depends on the symptoms of the patient and the extent of systolic dysfunction: while in asymptomatic patient with preserved systolic function, reassurance and follow-up is enough; in symptomatic patient and/or CMP the first line of treatment is pharmacological suppression of PVCs by the mean of anti-arrhythmic drugs (B-blockers, Verapamil, Class III…). In drug refractory PVCs, ablation has become an effective and alternative therapeutic option, with success rate reaching >85%. Ablation can also be performed as first line of treatment according to the wish of patient.

Biography:

Professor Michael Sacks is the W. A. “Tex” Moncrief, Jr. Simulation-Based Engineering Science Chair and a world authority on cardiovascular biomechanics. His research focuses on the quantification and modeling of the structure-mechanical properties of native and engineered cardiovascular soft tissues. He is a leading international authority on the mechanical behavior and function of the native and replacement heart valves. He is also active in the biomechanics of engineered tissues, and in understanding the in-vitro and in-vivo remodeling processes from a functional biomechanical perspective. Dr. Sacks is currently director of the ICES Center for Cardiovascular Simulation and Professor of Biomedical Engineering.

Abstract:

According to the American Heart Association (AHA), the overall prevalence of any heart valve disease is 2.5%, and clinically diagnosed (moderate or greater) prevalence of 1.8% with an annual mortality of over 22,000. Valve replacement surgery, first performed in 1960, has significantly reduced the mortality rate of patients with valvular heart disease. Of the various types of heart valves, the aortic valve (AV) has been studied most.  While differences exist in the treatment of specific valves, the use of replacement for all types of heart valves continues to grow due to the increased prevalence of valvular heart disease resulting from an ageing population. Since bioprosthetic heart valves (BHVs) continue to be the preferred replacement valve, there continues to be a strong need to develop better and more reliable BHVs through and improved the general understanding of BHV failure mechanisms. The major technological hurdle for the lifespan of the BHV implant continues to be the durability of the constituent leaflet biomaterials, which if improved can lead to substantial clinical impact. In order to develop improved solutions for BHV biomaterials, it is critical to have a better understanding of the inherent behaviors of the leaflet biomaterials, including chemical treatment technologies, the impact of repetitive mechanical loading, and the inherent failure modes. We focus on developing insight on the mechanisms of BHV function and failure. Additionally, this review provides a detailed summary of the computational biomechanical simulations that have been used to inform and develop a higher level of understanding of BHV tissues and their failure modes. Collectively, this information should serve as a tool not only to infer reliable and dependable prosthesis function, but also to instigate and facilitate the design of future valve replacement technologies to clinically impact cardiology.

Biography:

35 years in cardiovascular surgery. Since 1990 full professor for cardiovascular surgery and since 1994 full professor and chairman of the department for cardiovascular surgery at the University Hospital Marburg/Germany. 2 research sabaticals at the Heinemann Research Institute, Carolinas Heart Center, Charlotte NC in 1989 and 1990, electrophysiology and arrhythmia laser surgery Member of the DGTHG (German Society for Thorax, Heart and Vascular Surgery) DIVI ( German Society for Interdisciplinary Intensive Care Medicine), STS, AHA, AAAS.

Abstract:

Transcatheter aortic valve replacement TAVI has become  a frequently used additional option for elderly and high/intermediate risk patients. The transfemoral approach is mostly preferred. Alternatively, in case of small femoral vessels, severe arterial occlusive disease or other vascular abnormalities, the transapical approach or an access via the subclavian arteries is considered. The decision is such determined by the vascular pathology. However there are also patients with accompanying cardiac or vascular pathologies not amenable for current TAVI techniques and we were looking for alternative techniques which are determined by these patients need. One frequently seen adjunctive disease is the occlusion or severe stenosis of the carotid arteries and many of these patients have already suffered from a stroke or a TIA. So we developed a combination of typical carotid endarterectomy, also under local anesthesia,  and, during the same procedure, a transcarotid aortic valve replacement. To avoid an impairment of blood flow through the newly reconstructed neck vessel, a vascular prosthesis is connected side to side  to the common carotid artery, facilitating the introduction of  the sheaths and avoiding its positioning inside the native vessel. Another problem is created by concommitant heart pathologies additional to the aortic valve disease. As ischemic time matters, especially in this cohort of elderly risk patients, we still operate these patients under extracorporeal circulation and cardioplegic arrest, initially adressing the concommittant pathologies like severe coronary artery or mitral/tricuspid valve disease but finally insert a transcatheter valve prosthesis directly via the ascending aorta. By this hybrid approach, a complete surgical treatment can be achieved and at the same time a significant reduction of the cross clamp time, even compared to new sutureless valves. This is also reflected by lowered mortality among these patients.

We consider these examples a step towards a minimally invasive and at the same time individualized surgical therapy not primarily determined by access site or incision size but by the patients pathologies.

  • Surgical Procedures

Session Introduction

Antonio F. Corno

MD, FRCS, FETCS, FACC

Title: AORTIC VALVE REPAIR
Speaker
Biography:

Antonio F. Corno, MD, FRCS, FETCS, FACC, is Chair in Congenital Cardiac Surgery & Consultant Pediatric and Congenital Cardiac Surgeon at the East Midlands Congenital Heart Center, University Hospitals of Leicester, in Glenfield, Leicester, U.K.

He obtained his Privat-Docent (PhD equivalent) at University of Lausanne, Switzerland, and became Senior Lecturer in University of Liverpool, UK, then Professor of Pediatric Cardiac Surgery, University Sains Malaysia. Antonio F. Corno has more than thirty years’ experience with extensive clinical practice, scientific activity, experimental and clinical research, with authorship of 6 books and 12 chapters for books, 200 publications on peer-reviewed journals, and invited lectures wordlwide.

He has large experience in establishing new programs of pediatric and congenital heart surgery, as well as designing experimental research studies for new surgical techniques and clinical devices

Abstract:

Statement of the problem: The conventional surgery for aortic valve diseases was valve replacement with either biological or mechanical prosthesis, or autotransplantation of the pulmonary valve in aortic position (= Ross procedure). Aortic valve repair was generally limited to commissurotomy to relieve valve stenosis and commissurae and/or leaflets resuspension to reduce the degree of regurgitation. In the last decade several research studies have investigated the morphology of the aortic valve and the structure of its leaflets, while mathematical models combined with computational fluid dynamics revealed the functioning of the aortic valve and its root. In the same time sophisticated research facilities have been studying various biological and bio-engineered materials to replace the aortic valve leaflets. The new knowledge derived from all the above studies allowed the surgeons to perform in vivo evaluations of new techniques of aortic valve repair, followed by experimental studies on animals before moving to the clinical trials.

Methodology and theoretical orientation: The first surgical procedure introduced to repair aortic valve was the mobilization and extension of the three leaflets with strips of various materials. The suboptimal long-term results obtained with this technique prompted the surgeons to look for alternative approaches.

Two different techniques have been used: the replacement of a single aortic valve leaflet, and the replacement of all three ortic valve leaflets (Ozaki procedure). For the success of both this types of aortic valve repairs it is vital to use leaflets of appropriate size and shape, and these come from several mathematical and computational fluid dynamics studies; also various materials have been used to find the one providing the best medium and long-term results.

Conclusions and significance: The progress in the knowledge reached in the last decades, derived from extensive research studies, allowed to perform aortic valve repair with safe and sustainable results, unthinkable before.

Jane Grande-Allen

PhD, Department of Bioengineering, Rice University, Houston, TX, USA

Title: Aortic Valve Leaflet Mechanobiology: Implications for Surgical Repair
Speaker
Biography:

Jane Grande-Allen is the Isabel C. Cameron Professor and Chair of the Department of Bioengineering at Rice University.  Her research group develops experimental and biomaterial platforms to investigate the biomechanics and mechanobiology of soft connective tissues under healthy and diseased conditions, focusing on the extracellular matrix. Dr. Grande-Allen received a BA in Mathematics and Biology from Transylvania University in 1991 and a PhD in Bioengineering from the University of Washington in 1998.  Dr. Grande-Allen has been elected as Fellow of the American Institute of Biological and Medical Engineering, the Biomedical Engineering Society, the American Heart Association, the American Association for the Advancement of Science, and the Society for Experimental Mechanics. She has served on the Board of Directors of the Biomedical Engineering Society and the Society for Experimental Mechanics, and she is Deputy Editor-in-Chief of the Annals of Biomedical Engineering.

Abstract:

Statement of the Problem: The treatment of valve disease represents substantial health care costs, yet there are significant limitations in applying the currently available valve repair and replacement technologies to all patients needing treatment. Tissue engineered valves have the potential to improve the quality and range of treatment options for all patients.  The essential function of valves is made possible by the arrangement of extracellular matrix (ECM) within the tissue, but these functional relationships have not been translated into the next generation of valve tissue engineering investigations. Aortic valves are notably anisotropic and their interconnected, layered structure provides valvular interstitial cells (VICs) with heterogeneous environments for substrate adhesion-driven signaling. Our research group is investigating these characteristics to incorporate them into hydrogel biomaterials. Methodology: Porcine aortic valves were characterized using immunohistochemistry, electron microscopy, and biochemical techniques to assess extracellular matrix composition across the valve microstructure.  These characteristics were incorporated as patterns or layers within hydrogel scaffolds prepared from polyethylene glycol (PEG) or crosslinked hyaluronan. Findings: These in-depth investigations have provided new insights into of the layered structure of porcine aortic valves, which we are translating into hydrogel scaffold and combination hydrogel-electrospun mesh models of the valve. These laminate hydrogel scaffolds contain layers with different stiffness, much like the leaflet spongiosa, fibrosa, and ventricularis layers demonstrate unique material behavior. Conclusion & Significance: These investigations have demonstrated that the heterogeneous ECM composition of valves influences their mechanics and local valve cell behavior. This heterogeneity can be translated to scaffold materials for tissue engineered heart valves using patterning or other novel fabrication approaches. Laminate hydrogels can be fabricated with robust interfaces, integrating layers of different mechanical properties, as well as varied biofunctionalization, and thus forming the foundation for a multilaminate scaffold that more accurately represents native tissue.

Mark W. Tibbitt

Macromolecular Engineering Laboratory, Department of Mechanical and Process Engineering, ETH Zürich, 8092 Zürich, CH

Title: What are we learning about aortic valve leaflets?: Materials to better understand and treat disease.
Speaker
Biography:

Mark W. Tibbitt is Assistant Professor of Macromolecular Engineering at ETH Zürich. He is currently the Director of the Macromolecular Engineering Laboratory in the Institute of Process Engineering within the Department of Mechanical and Process Engineering. Prof. Tibbitt received his B.A. in Integrated Science and Mathematics from Northwestern University in 2007. He completed a Ph.D. in Chemical Engineering in 2012 at the University of Colorado Boulder, conducting research in the laboratory of Prof. Kristi S. Anseth. He then trained in the laboratory of Prof. Robert Langer at MIT as a National Institutes of Health NHLBI postdoctoral fellow. Prof. Tibbitt’s research integrates concepts and techniques from chemical engineering, polymer chemistry, materials science, and biology to design and assemble soft matter for biomedical applications. These soft materials are employed to understand fundamental processes in biology as well as translated to address clinical problems in drug delivery, regenerative medicine, and biomedical diagnostics.

Abstract:

The aortic valve is no longer thought of as a passive entity but is now understood to be a biologically complex and active tissue throughout homeostasis and disease. The field is turning to sophisticated materials to further our understanding of aortic valve disease progression and to treat valve disorders. In this vein, this talk will highlight emerging materials for in vitro valve cell culture and in vivo therapy. 

First, a photoresponsive, poly(ethylene glycol) (PEG) based hydrogel has been developed with reversible mechanics to study the (ir)reversibility of myofibroblast activation during cardiac valve fibrosis. Leveraging this system, we have established hydrogel culture conditions that maintain quiescence in isolated valvular interstitial cells (VICs) and identified signalling pathways that regulate VIC myofibroblast activation. This work highlights the importance of considering the culture context when studying valve cell biology outside of the body and when treating valve disease in vivo. In the second part of this talk, an injectable hydrogel for the treatment of valve disorders will be introduced. There is a growing understanding that the valve possesses the innate ability to compensate for pathological states in a range of valve disorders. However, signalling within the valve is often disrupted in the diseased state and positive biological feedback leads to acceleration of pathology. Local delivery of therapeutics or cells in order to modulate valve cell biology has the potential to abrogate or even reverse disease progression as an alternative to valve repair or replacement. This section will specifically focus on how we are leveraging a self-assembled, shear-thinning and self-healing injectable hydrogel for localized delivery of therapeutics and healthy cells. In total, we aim to demonstrate how materials engineering and design can be employed to complement biology and surgical techniques in the understanding and treatment of valve disorders.

Speaker
Biography:

Paolo Magagna, MD, Gian Domenico Cresce MD, Loris Salvador MD, Dept CardioVascular Surgery San Bortolo Hospital, Vicenza. M.B.B.ch Faculty of Medicine University of Verona , Italy  1992, Postgraduate degree in Cardiac Surgery, Faculty of Medicine, University of Verona , Italy 1998. Registered medical practitioner Chirurghi e Odontoiatri of Verona (Italy) number 06150; 22 February 1993. More than 1622 cardiac operations for adult heart disease with particular field of interest: (1 operator): Stentless aortic bioprosthesis: 507 pts, CABG: 603pts, endovascular procedure; arch, descending aorta, aorta dissection 151 pts, debranching epiaortic vessels, Frozen elephant trunk (experience with evita open plus) hybrid procedure: 252 pts, TAVI: trans femoral, trans axillary (percutaneous approach), trans apical: 128 pts, Valve in Valve procedure: 21 pts, Mitraclip: 13 pts, As 2 operator more 5100 procedure, ability to carry out team projects, gained through experience, belong of the local heart team for four years.

Abstract:

INTRODUCTION: The management of the left subclavian artery during a debranching procedure is controversial and sometimes challenging, especially during an emergency life-saving procedure, such as a type A acute aortic dissection

CASE REPORT: A 64-year-old man, with a history of hypertension and smoking, was admitted to the I.C.U. for Type A Acute Aortic Dissection and underwent emergency surgery. Surgical technique: surgical access through a median sternotomy, right axillary artery cannulation, moderate hypothermia, rain protection with selective antegrade cerebral perfusion, Frozen Elephant Trunk (E-vita open plus), ascending aorta and aortic arch replacement with debranching of the innominate and left common carotid arteries (Lupiae™ Branched Arch Graft 30/10/10/8); closure of the origin of the left subclavian artery and its revascularization using the in situ LIMA anastomized to the prosthesis branch; aortic Valve Replacement with Stentless Edwards Prima Plus 25 mm. using the inclusion technique; CPB time: 314 minutes, Aortic Cross Clamp time: 122 minutes: circulatory arrest time: 33 minutes ; cerebral perfusion time: 53 minutes

RESULTS: The postoperative course was uneventful and the patient was discharged from the ICU on the fifth postoperative day and from the hospital on the tenth postoperative day in satisfactory clinical conditions. Follow-up: six months after the operation, the patient underwent and Angio CT-scan that showed a good result of the procedure and a well perfused left subclavian artery.

CONCLUSION: This procedure is easy and safe.

Michael S. Sacks

ICES and the Department of Biomedical Engineering, The University of Texas at Austin, Austin TX.

Title: Simulation of the aortic heart valve
Speaker
Biography:

Professor Michael Sacks is the W. A. “Tex” Moncrief, Jr. Simulation-Based Engineering Science Chair and a world authority on cardiovascular biomechanics. His research focuses on the quantification and modeling of the structure-mechanical properties of native and engineered cardiovascular soft tissues. He is a leading international authority on the mechanical behavior and function of the native and replacement heart valves. He is also active in the biomechanics of engineered tissues, and in understanding the in-vitro and in-vivo remodeling processes from a functional biomechanical perspective. Dr. Sacks is currently director of the ICES Center for Cardiovascular Simulation and Professor of Biomedical Engineering

Abstract:

The analysis of aortic valve mechanics has been extensively conduced in silico through computational simulations with the aid of the finite element method. Although most studies have initially been conducted with simplified geometries and basic material models, and sometimes, with idealized physical settings, finite element modeling studies have been able to guide design and manufacturing techniques with relative success. Simply by changing leaflet shapes, the stress distribution pattern acting on the leaflets is altered. Even from a purely mechanical standpoint, computational simulations of functioning heart valves are not at all trivial.  The realistic geometry of the aortic heart valve is quite complex, and in particular, leaflets are very. Moreover, while the unpressurized geometry of an aortic heart valve can be characterized on the bench, translation to the in-vivo state is hampered by a lack of knowledge of the in-vivo pre-strain state. Most importantly, segmentation of medical images is difficult to conduct for such thin and complex structures, which presents challenges for patient-specific modeling. We present our comprehensive approaches to modeling the aortic valve to both understand normal heart valve function, insights into disease processes, and to inform methods of repair and replacement.

Speaker
Biography:

Intervention Cardiologist- Egypt

Abstract:

Objectives The purpose of this study was to compare the early and late results of percutaneous and surgical revascularization of left main coronary artery stenosis.

Background Unprotected left main coronary artery (ULMCA) stenting is being investigated as an alternative to bypass surgery.

Methods We randomly assigned 105 patients with ULMCA stenosis to percutaneous coronary intervention (PCI; 52 patients) or coronary artery bypass grafting (CABG; 53 patients). The primary end point was the change in left ventricular ejection fraction (LVEF) 12 months after the intervention. Secondary end points included 30-day major adverse events (MAE), major adverse cardiac and cerebrovascular events (MACCE), length of hospitalization, target vessel failure (TVF), angina severity and exercise tolerance after 1 year, and total and MACCE-free survival.

Results A significant increase in LVEF at the 12-month follow-up was noted only in the PCI group (3.3 ± 6.7% after PCI vs. 0.5 ± 0.8% after CABG; p = 0.047). Patients performed equally well on stress tests, and angina status improved similarly in the 2 groups. PCI was associated with a lower 30-day risk of MAE (p < 0.006) and MACCE (p = 0.03) and shorter hospitalizations (p = 0.0007). Total and MACCE-free 1-year survival was comparable. Left main TVF was similar in the 2 groups. During the 28.0 ± 9.9-month follow-up, there were 3 deaths in the PCI group and 7 deaths in the CABG group (p = 0.08).

Surgical revascularization

Operations were performed using standard anesthetic techniques. All but 1 operation were performed through a median sternotomy, with standard cardiopulmonary bypass and moderate systemic hypothermia. One patient underwent off-pump CABG. Left internal mammary artery grafts were used in 72% of CABG patients, and radial artery grafts were used in 9%.

Pharmacologic treatment after revascularization

All patients stayed on double antiplatelet treatment for at least 12 months. Other pharmacological treatments (e.g., statins, angiotensin-converting enzyme inhibitors, beta-blockers) were recommended based on current practice and were left to the discretion of a supervising physician.

Conclusions

Based on the results of our study, we conclude that patients with ULMCA disease treated with stent-supported PCI have favorable early outcomes in comparison with CABG. At 1 year, LVEF improved only in the PCI group. Both procedures resulted in similar angina relief at 1 year and equal risk of left main TVF. Freedom from MACCE was comparable after more than 2 years of follow-up, and there was a trend for better survival in the PCI group. These findings support the need for larger randomized trials with clinical primary end points.

  • Heart Repair or Transplant

Session Introduction

Dr. Hamid Ahmad

Gov. Lady Reading Hospital, Peshawar, Pakistan

Title: Comparative study of Standard Median Sternotomy (SMS) VS Right Anterolateral Thoracotomy (RALT) for Mitral Valve Replacement
Speaker
Biography:

Hamid Ahmad is graduate in Medicine & surgery from Khyber Medical College, Peshawar Pakistan. He started his practical life in Basic health unit and then worked in Khyber medical college as lecturer in Biochemistry. He opted cardiac surgery and working in Department of cardiovascular surgery in Lady Reading Hospital Peshawar. He has special interest in Adult cardiac surgery. He play pivotal role in development of his department under the supervision of his Professor Dr Riaz Anwar Khan. He is member of Pakistan Society of Cardiovascular and Thoracic Surgeons and worked as Public Relation secretary and Joint Secretary. He attended many national and international conference and presented papers. He has hobby of Mountaineering & Hiking.

Abstract:

Objective: to compare the outcome in mitral valve replacement done through standard median sternotomy versus right anterolateral thoracotomy

Methodology: Retrospective study from Jan 2010 to Dec 2016 at Department of Cardiovascular Surgery, Govt. Lady Reading Hospital Peshawar, Pakistan. Total 281 cases of mitral valve replacement (MVR) done among them 229 were operated through Standard Median Sternotomy (SMS) and 157 were operated through Right Anterolateral thoracotomy (RALT). Ethical committee approval was taken. An informed consent was taken for all patients. Age, sex, mortality, total cardiopulmonary bypass CPB time, time to establish CPB, mediastinal /chest drainage, post op blood transfusion, total hospital stay, ICU stay were analyzed and compared in the two groups. Statistical analysis done by SPSS version 17 and paired t test were applied to get p value. P value less than 0.05 was considered significant.

Results: Females were predominant in both the groups (SMS 73.03 % and RALT 77.07 %). Mean body surface area was 1.34 meter square. Mean age was 28.65 years in SMS and 26.42 years in RALT. There

was no significant difference in mortality, cardiopulmonary bypass time, cross clamp time, ventilator time, in the two groups. There was significant difference in post op blood transfusion, chest drainage, ICU stay and in total post op hospital stay.

Conclusion: Sternum Sparing Mitral Valve Replacement can be done safely in selected cases. It gives better cosmetic results in females. RALT approach reduces hospital stay of patients and he can return to work early. Besides less pain, shorter skin incision and lower blood loss, it has more advantages as reduced sternal infection and sternal disruption.

Speaker
Biography:

Abstract:

Background: In this study we determine how surgical desisions (repair or replacement) affects and whether a one-time application of concomitant techniques would be efficient in the restoration of sinus rhythm after mitral valve surgery.

Methods: Overall 273 patients included in the study. They were divided into 3 groups: in group 1 only correction of the mitral valve diseases – 93 cases, in grouop 2 mitral valve correction combined with atrioplasty –126 cases and in group 3  mitral valve correction with atrioplasty and irrigated radio-frequency ablation  – 54 cases

Results: We revealed that after mitral valve repairs the sinus rhythm restoration at the time of discharge was 40%, in 6 months it decreased till 34%, but by the time of 3 years it increased till 47%. At the same time after mitral valve replacements the restoration of sinus rhythm at the discharge time was 47%, in 6 months it was 39% and in 3 years it was 45%. Application of atrioplasty methods reduces risk of AF recurrence at 17,5%. After biatrial ablation the restoration and maintenance of sinus rhythm at the time of discharge was 69%, and at 3 years it reached 78%, while in the left-atrial ablation sinus rhythm at discharge time was restored in 61%, but at 3 years it retained only in 67% of patients. Restoration of the sinus rhythm in group 3 was 2.3 times higher than in group 2 and 3.6 times higher than in group 1. Quality of Life (SF-36) were improved in 74% of patients after concomitant surgery, whereas only in 57% of patients undergoing only mitral valve surgery.

Conclusions: During  mitral valve surgery  using irregeted radiofrequency ablation techniques restores more regular sinus rhythm, but concomitant atrioplasty techniques is more benefitial for patients. Repair or replacement depends on mitral valve pathology, not to restotarion rate.  

  • Miscellaneous

Session Introduction

Dr. Abdullah Al Jamil

Skilled Interventional Cardiologist and Electrophysiologist

Title: Venoplasty: A Less Frequent But Essential Procedure
Speaker
Biography:

He graduated from Sher-E-Bangla Medical College, under Dhaka University, Bangladesh in 1988. He started career as House Physician in Department of Medicine, IPGMR, Dhaka. Then he served in CCU and Internal Medicine, Dhaka Medical College Hospital as Assistant Registrar and Registrar. He obtained Fellowship in Medicine from Bangladesh College of Physicians and Surgeons in 1997. Subsequently he worked as Junior Consultant, Medicine, Shaheed Suhrawardy Hospital, Dhaka for 3 years. He obtained MD Cardiology from Dhaka University in 2001. He worked as Assistant & Associate Professor of Cardiology, Bangabandhu Sheikh Mujib Medical University, Dhaka over 3 years. Then he joined at Square Hospital as Consultant, Interventional Cardiology in January 2007. He joined the present working place in June 2016. He attended several International Conferences as faculty, and presented papers in USA, Switzerland, Japan and Singapore. He performed 2130 procedures including PCIs, Device Implantations, Balloon Valvuloplasties, Peripheral Angioplasties and EPS & RFA.

Abstract:

Statement of the Problem: Balloon venoplasty and stenting of venous obstruction was introduced in late 1980s and 1990s. Earliest venous stenting was done in 1997.1 It is less frequent but recognized essential procedure. Its clinically significant is more common in upper than lower extremities. Most commonly affected sites include axillary, brachial, cephalic, Subclavian, Superior vena cava, Femoral and Iliac veins. Majority of cases are hemodialysis catheter related from intimal hyperplasia and fibrosis due to intimal trauma secondary to catheter movement during cardiac cycle or due to propagating infection along the venous wall from entry point. Other causes include central venous catheter, pacemaker leads, radiation, trauma or external compression. Venous stenosis presents with swelling of affected area of drainage. Duplex scanning is less reliable in subclavian vein whereas venography is less reliable in femoral and iliac vein obstruction.2 Endovascular therapy is the effective modality of treatment. Balloon angioplasty preferred in subclavian veins and stenting preferred in femoral or iliac veins. Outcome: In subclavian balloon angioplasty luminal diameter improvement in 70%, elastic recoil in 23% and failed in 7%.3 Restenosis develops in 81% at 7.6 months; one-year patency 35% and two-year patency 6%.4 Primary patency in subclavian stenosis varies from 20% to 70%.5 Repeat procedure is needed in large number of patients. Femoral or iliac vein stenting has no in-stent restenosis at 27±4 months but stent thrombosis in 4%.6 Conclusion & Significance: Majority of venous obstructions are iatrogenic mostly hemodialysis patients. It’s a less frequent procedure but essential to keep open the vein related to dialysis, the lifeline for the patient. Need for repeat procedure is very high.

Speaker
Biography:

Lecturer of Department of Biochemistry, University of Medicine Mandalay. I have finished PhD (Biochemistry) in the recent year, 2017. My research title is “Association between angiotnsinogen gene M235T polymorphism and plasma angiotensinogen level in essential hypertension”. I am doing ongoing departmental research concerned with the Renin Angiotensin System genes polymorphism in essential hypertension in Myanmar.

Abstract:

Introduction: This case control study is such an effort to determine whether or not this AGT polymorphism of this gene is presenting at here, Myanmar understands this relationships and the context in which it occurs.

Method: There were 144 subjects, 72 hypertensives and 72 normotensives. After getting informed consents, determination of blood pressure and BMI were done. The AGT M235T genotypes were determined by polymerase chain reaction followed by digestion of the products with Tth111I. The determination of plasma angiotensinogen level was done by ELISA method.

Results: In a total of 72 hypertensives, the frequency of the homozygous (TT) genotype, the heterozygous (MT) genotype and the homozygous (MM) genotype for AGT M235T were (34.72%), (62.50%) and (2.78%).  In a total of 72 normotensives, the frequency of the homozygous (TT) genotype, the heterozygous (MT) genotype and the homozygous (MM) genotype for AGT M235T were (9.72%), (66.67%) and (23.61%) respectively. Homozygous (TT) genotype was significantly associated between AGT M235T polymorphism and essential hypertension χ2 =13.01 and ρ value was <0.001.

In this present study, TT homozygous genotype of AGT M235T has about five folds higher risk of essential hypertension [OR = 4.93 (95% CI = 1.97-3.40)]. The frequency of homozygous TT genotype was more common in hypertensives than normotensives. The odd ratio for hypertension with subjects carrying “T” allele was [OR= 2.56 (95% CI) 1.59 to 4.13]. Subjects carrying TT genotypes have the higher level of plasma angiotensinogen level than other genotypes MT and MM (p=0.005 and p < 0.001) in both hypertensives and normotensives.

Conclusion: Therefore, this study gave information about AGT M235T is an important gene for determining susceptibility to essential hypertension. By studying the AGT M235T gene, subjects with risk allele carrier have higher plasma angiotensinogen level and increased risk to essential hypertension in Myanmar.

Mrs. Onaseso Adeola Temitope

Nurse

Title: Various Surgery Procedures
Speaker
Biography:

Nurse at Health Service Commission under Lagos state, Nigeria. She was born on the 5th of December, 1982 in ila-orangun, osun state, am a Christian, dark in complexion and of average  height and size. I obtained my primary school leavin certificate  in the year 1993 . And o level in the years 2000, aslo  general  nursing certificate in osun state of nursing, osogdo ,2005. Presently living In Lagos and working with health service commission under Lagos state (general hospital mushin) unit as a nursing sister,since about 7year ago till date and I have received about two to three award in a different year back and I have also, represents unit /local government  cme/cne , and am undergoing ophthalmic nursing program at Lagos university teaching hospital (luth).

Abstract:

Surgery is an invasive operative procedure in which a more extensive resection is performed e.g body cavity is entered. Organs are removed or normal anatomy is altered. In general, if a mesenchymal barrier is opened [Pleural cavity, peritoneum, meninges]. Surgery facilities must be provided, designed and managed to insure a level of sanitation being performed. In general the standards for major surgery apply only to non-rodent species. However, if micro contamination proves to be a significant problem with procedure carried out in rodents. Virtual reality is just beginning to come to that threshold level where we can begin using simulators in medicine the way the Aviation industry has been using it for the past 50 years to avoid errors. In surgery, the life of the patient is of utmost important and surgeon cannot experiment on the patient body. VR provide a good tool to experiment the various complications aring during surgery.  Method: According to the American Medical Association and the American College of Surgeons, some of the most Surgical operation performed in the united state include the following.

1. Breast Biopsy is a diagnostic test involving the removal of tissue or cell for examination under a microscope. This procedure is also used to removed abnormal breast tissue. A biopsy may be performed using a hollow needle to extract tissue [needle aspiration], or a lump may be partially or completely removed [lumpectomy] for examination and/or treatment.

2. Cataract Surgery:These cloud the normally clear lens of the eyes. Cataract surgery involve the removal of the cloudy content with ultra sound waves. In some case, the entire lens is removed.

3. Appendectomy is the surgical removal of the appendix, a small tube that branches off the large intestine, to treat acute appendicitis. Appendicitis is the acute inflammation of this tube due to infection.

4. Cartoid endarterectomy is a surgical procedure to remove blockage from cartotid ateries that supply blood to the brain. Left untreated a block cartoled can lead to stroke.

5. Surgery assists in preventing any cell that can damage the intestine.

6. Surgery also assists in preventing stroke.

CONCLUSION: All major surgical procedure must use appropriate surgical techniques and must be conducted in facilities intended for survival surgery and used for that purpose. The facilities must be designed and managed to insure a level of sanitation appropriate for aseptic surgery. The operating room should contain only the equipment and supplies required to support the procedure being performed.

  • Coronary Artery Bypass Grafting

Session Introduction

Maha Hassan

MSc. Cardiology specialist at Helwan University

Title: Evaluation of Right ventricular dysfunction post On-pump vs Off-pump coronary artery bypass grafting by Echo, is there a difference?
Speaker
Biography:

Maha Hassan, MSc. Cardiology specialist at Helwan University. Master degree and MD candidate at Kasr El-Aini medical school-Cairo University (Egypt). Received clinical training in the cardiology department since 2007. Echo operator since 2010 and vascular Doppler operator since 2013 at ASSalam international hospital-Maadi and private centers. Participated in the conference of the European Society of Cardiology (ESC 2014) in Spain as speaker (poster presentation). Participation at Cardioegypt conferences as a speaker (oral presentation) 2014, 2015 & 2017. Participation in Cardioalex conferences by oral presentation in 2014 & 2017

Abstract:

Background: The right ventricle (RV) may be selectively impaired following coronary artery bypass graft (CABG).

Methods: We tested this hypothesis by prospective study. We examined two groups of patients. Group A (30) patients had Off-pump CABG and group B (30) patients had On-pump CABG. All patients were subjected to preoperative, early post-operative and 6 months follow up, full clinical and ECHO-Doppler studies. All patients had preoperative diagnostic coronary angiography (CA).

Results: There was insignificant difference comparing the clinical picture of right side heart failure (RSHF) in both groups. Preoperative characteristics and RV function by ECHO did not differ significantly between the 2 groups (mean±SD): Tricuspid annular plane systolic excursion (TAPSE) was 1.83±0.7 cm, 1.47±0.51 cm and 1.87±0.34 cm in preoperative, early post-operative and 6 months follow up respectively in group A (Off-pump patients), while in group B (On-pump patients) was 1.99±0.65 cm, 1.63±0.49 cm and 1.97±0.41 cm in preoperative, early post-operative and 6 months follow up respectively.

The tricuspid annulus pulsed wave tissue Doppler (TDTA) was 11.98±3.0 cm/sec, 9.77±1.73 cm/sec and 11.9±1.72 cm/sec in preoperative, early post-operative and 6 months follow up in group A, while in group B it was 12.83±3.0 cm/sec, 10.77±2.12 cm/sec and 12.27±1.68 cm/sec. The parameters of RV function including PASP, RV dimension, TAPSE and TDTA were significantly impaired early post-operative in both groups and completely improve after 6 months.

Conclusion: The RV function significantly impaired early post-operative in both modalities of CABG irrespective to the surgical technique and completely improved to normal after 6 months. Both surgical techniques produced equivalent results on the RV function with or without significant disease of RCA

Dr. Prof. Sushil Kumar Singh

MS, MCh , FIACS

Title: Intermittent Pump Supported Beating Heart CABG
Speaker
Biography:

Professor in Department of CTVS, King George’s Medical University, Lucknow ( INDIA )

Abstract:

OBJECTIVE :. ‘Intermittent on pump beating heart CABG’ is a more reliable method of coronary revascularization which  takes the advantage of off and on pump CABG while eliminates the disadvantage of both the technique.

METHODS: From January 2015 to October 2016 a new technique “Intermittent On pump beating heart CABG” using suction stabilizer  was used  by putting aortic and venous canula electively  in all the patients. Patients were supported  by pump intermittently, as and when required ( Group 1, n = 54 ). A retrospective data was collected from our record of  the patients who underwent  off pump CABG electively by the same surgeon ( Group 2, n= 54 ).

RESULTS : Significant advantage was noted in Group 1 patients in terms of number of graft ( 3.31 ± 1.16  vs 2.30 ±0.66 ), grafting of lateral vessels ( 68 vs 22), mean operating time ( 1.37 ± 0.23 hrs vs 2.22 ± 0.45 hrs ) and post operative blood loss (  406.30 ± 257.90 ml vs  567.41 ± 265.20 ml ).  CPB support time was less than 15 minutes in majority of patients (n = 38, 70.37 % ) with a mean of 16.81 minutes. It was required particularly during grafting of lateral vessels. A rise in enzymes level ( CRP , CKMB, Trop I and  NT Pro BNP) was noted in  Group 1 patients . But, these did not affected the postoperative course in patients. There  was no mortality in Group 1 patients while 4 of patients in Group 2 died.      

COCLUSIONS: Intermittent on pump CABG technique is promising method of surgical revascularization for all the patients requiring CABG. It has shown its superiority in terms of safety, number of grafts, operating time and better perioperative course.

  • Cardiomyopathy
Speaker
Biography:

Cardiovascular Disease Research Center, Ahvaz Jundishapur University of medical sciences, Ahvaz, Iran

Abstract:

Background: CHF (Congestive Heart Failure) is one of the most important causes of mortality and morbidity in the world.  Diuretics such as spironolacton can decreases pulmonary congestion and reduce the amount of fibrosis in CHF patients. The primary end point was to assess the effect of spironolacton on airway resistance with impulse oscillometry, the secondary goal was to localize the site of the lung that may be affected more by spironolactons.

Methods: It was clinical trial that 24 patients with congestive heart failure (CHF) that had functional class II-IV and EF< 40%, were assessed by impulse in Ahwaz teaching hosipals. All patients were filled questionnaire and none of them taken spironolactone before.  Spironolactone was given to them and they evaluated by IOS 1month later. All data were analyzed by SPSS soft ware .

Result: The age of patient was 61 ± 10 and the age of control was 57 ± 7 years old. The data of oscillometry before and after spironolacton were X5( 0.14 ± 0.05 VS 0.14 ±0.05 , P: 0.93)  , R5(  0.39 ± 0.21 VS 0.39 ±0.15 , P: 0.35) , X20(0.04 ± 0.06 VS 0.06 ±0.06 , P: 0.37) , R20(0.04 ± 0.03 VS 0.06 ±0.06 , P: 0.37) , Zrs (0.39 ± 0.21 VS 0.39 ±0.15 , P: 0.35).

Conclusion:  There was a trend toward reduction of peripheral airway resistances in CHF patients than controls with use of 1 month of spironolactone.

Key words: Spironolactone, oscillometry, Congestive Heart Failure

Speaker
Biography:

Applied Biotechnology Research Center,Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran

Abstract:

Morbidity and mortality are mainly rooted in valvular heart disease which is also associated with the result of congenital malformations. In fact, it is important to pay a precise attention to the fact that by the amalgamation of human being increased understanding of heart valve development and major advances in genetic technologies, and also by considering the success of the Human Genome Project, heart valve diseases rooted in numerous genetic contributions have been discovered. The present paper will summarize the review of the related literature regarding the two common familial VHDs which have the genetic basis, namely such as mitral valve prolapse and bicuspid aortic valve; it also highlights some of the recent findings that boosts our understanding of pathogenesis in such diseases. The main objective of the present paper is to meet the needs of clinicians by providing a good command of knowledge on elaborating the notion of genetic contributions as one of the main sources in valvular heart diseases

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