8^th Global Cardiologists and Echocardiography Annual Meeting July 18-20, 2016 Berlin, Germany

To be updated...

Abstract: The mitral–aortic intervalvular fibrosa (MAIVF) 1 is a region of the heart that connects the anterior mitral leaflet to the posterior aortic root and is in communication with the left ventricular (LV) outflow tract, this area contains fibrous, relatively avascular tissue and is the weakest area of the aortic ring. As a consequence of its poor vascularization, this structure is susceptible to injury during aortic or mitral valve replacement or destruction from bacterial infective endocarditis leading to development of an aneurysm or pseudoaneurysm of intervalvular fibrosa (P-MAIVF). This condition is rare in pediatric age group and is usually preceded by aortic valve surgery, active or prior infective endocarditis, and congenital heart disease Case Report: A 7-year old girl previously healthy was referred for evaluation of murmur and abnormal electrocardiogram which was suggestive of biventricular hypertrophy. Transthoracic echocardiogram (TTE) revealed a pulsatile aneurysmal structure (1.1/0.8 cm) posterior to the aortic root and extending to the mitral valve in the intervalvular mitral-aortic fibrosa. There was turbulent flow on color Doppler, filling and expanding the structure during systole and emptying during diastole. (Fig 1). There was no mitral or aortic regurgitation. A cardiac MRI was performed which confirmed the findings of echocardiogram. Her case was discussed with the pediatric cardio-thoracic surgeons and since she was asymptomatic, and her aneurysm size was deemed small, not compressing on adjacent structures or causing regurgitation, it was decided to manage the aneurysm conservatively. She has been followed up for 4 years now with mild increase in her aneurysm to 1.7/1.4 cm. Discussion: We present a congenital mitral-aortic intervalvular fossa aneurysm in a previously healthy 7 year old without any preceding event which reflects a truly congenital nature of the aneurysm. Clinical manifestation may vary from being asymptomatic to shortness of breath, congestive heart failure, cerebral vascular accidents or other embolic events, chest pain, active endocarditis infection. Enlargement of the aneurysm may lead to aortic or mitral regurgitation secondary to failure of leaflet coaptation, compression of adjacent structures including the left atrium, coronary arteries, conduction system and pulmonary artery. Close proximity to the left atrium and aorta may result in fistulous communications with these structures. Rupture into the pericardium resulting in cardiac tamponade is the most dreaded complication, though such an event appears to be very rare. There is a possibility of coexistent aneurysms reinforcing it being a congenital defect. Echocardiography usually establishes the diagnosis. Visualization of the echo-free space with systolic expansion and diastolic collapse of the aneurysmal structure is an important diagnostic feature. However, this phenomenon can be less prominent in a patient with a fistulous communication because the pressure variations within the aneurysm are blunted. Diagnosis is more accurate with a transesophageal echocardiogram than with a transthoracic echocardiogram. Real time 3D echocardiography can also be complimentary to 2D. Computed tomography and MRI both provide excellent multiplanar and 3D images of the aneurysm, its relationship with the coronary arteries, aortic root, and cardiac chambers, which are invaluable to the operating surgeon. The usual recommended treatment is surgery due to potential fatal complications. While there have been some case reports of conservative management and monitoring, there is insufficient data to predict natural course of congenital subvalvular aneurysms. Surgery is technically challenging and associated with high risk of morbidity or mortality The high-risk factors which increase predisposition to rupture include active endocarditis, size of P-MAIVF >3 cm, bicuspid aortic valve, regurgitation, presence of fistula to cardiac chamber or aorta, thrombus in P-MAIVF, compression of adjacent structures(coronary or pulmonary artery). These high risk features would likely contribute to the progression of the pseudoaneurysm and the development of complications. There have been suggestions that patients with thick fibrous and calcific walls might be at lower risk for rupture. Our case is unique in the fact that our patient presented at a young age of 7-yrs as an incidental finding without any prior traumatic or infective insult to the area indicative of a truly congenital weakness of the MAIVF leading to aneurysm formation. She has been closely followed for past 4 years without any significant increase in size of the aneurysm and continues to be asymptomatic. Conclusion: An aneurysm or pseudoaneurysm of the MAIVF in pediatrics age group is a rare disease especially without any preceding infective endocarditis, surgery or congenital heart disease and may be asymptomatic, the region of the MAIVF should be observed carefully by TTE. When necessary, TEE and/or CT scan or MRI should be performed to make a definitive diagnosis. Historically, the usual recommendation has been surgery but there have been case reports of conservative observation in low risk cases.  

Ryan Monti has completed his Medical Degree at the age of 29 years from Avalon University Medical School, graduating at the top of his class and named valedictorian of the class of 2013. Dr. Monti is currently an second year Internal Medicine resident at Hackensack UMC Mountainside Hospital. He currently sits on multiple hospital committees, including Critical Care and The high Value Care Committee.

82 year old African American female from Jamaica with past medical history only significant for hypertension, rheumatoid arthritis, colon cancer status post surgery, chemotherapy and radiation 7 years ago with no current evidence of disease, now presenting with shortness of breath for the past 2 -3 days. Patient states that over the previous two to three days she has been having progressively worsening of dyspnea of exertion. Patient ultimately found to have a left ventricular pseudo-aneurysm and underwent successful cardiac surgery for repair. After extensive workup we were unable to determine the cause of this increasing rare pathology.

Manjusha Hira is a Senior Registrar in Pediatric at Watford General Hospital UK .She has published more than 6 papers in reputed journals.

Introduction: Sengers syndrome is a rare disorder that causes congenital cataract, hypertrophic cardiomyopathy (HOCM), skeletal myopathy and lactic acidosis. HOCM is usually fatal in infancy. It is an autosomal recessive mitochondrial depletion disorder resulting from the mutation of acylglycerolkinase (AGK) gene. This nuclear gene is responsible for the maintenance of mitochondrial DNA (mDNA). Methods: We report a 4 month old boy who had severe lactic acidosis at birth and progressive congenital cataract. Cataract and failure to thrive were missed on his primary examination until he presented with complete loss of vision at 3 months and subsequent heart failure secondary to severe HOCM at 4 months of age. Results: His genetic testing revealed homozygous novel putative splicing mutation of AGK gene, c.1047-2A>G. This substitution has not been previously reported. There are about 40 case reports of Sengers syndrome to our knowledge. The severe form due to homozygous mutation has early onset cataract, lactic acidosis and progressive HOCM leading to death in infancy. The milder form with heterozygous mutation has a better prognosis and develops cardiomyopathy at later stages, with survival into their fourth decade. The mildest form reported had only cataracts. Conclusion: Uncertainty about the red eye reflex in non-Caucasian infants is common in primary examinations. Unexplained and persistent lactic acidosis at birth should not be discounted and should be followed up after discharge. Sengers syndrome should be considered as a differential diagnosis in babies who present with congenital cataracts especially if associated with lactic acidosis and later HOCM. Our patient is currently awaiting a cardiac transplant.

Dr. Shaileshkumar Jagdishchandra Patil has done his MBBS and MD internal medicine from reputed institutions in India with academic excellence. Trained in cardiology for 3 years in one of the high volume centre in India, where highest number of pacemaker implantations are done in asia. Also well trained in thansthoracic and trasesophageal echocardiograph and performed around 5000 femoral and radial angiographies , 1000 angioplasties including complex corornary and peripheral angioplasties, pediatric device implantations and balloon mitral valvuloplasty. Have got 7 national and international publictions to my name. Presently consultant cardiologist at 250 bed tertiary hospital in Pune, India.

Coronary angiography (CAG) is the gold standard for diagnosis of coronary artery disease. Coronary slow flow phenomenon (CSFP) is defined as delayed coronary opacification in the absence of obstructive coronary artery disease. We studied prevalence, clinical presentation and risk factors in 60 patients of coronary slow flow out of total 2018 patients admitted to our tertiary care hospital for a period of 18 months.Statistical Analysis was performed with Epi Info (TM) 3.5.3. We found that CSFP was prevalent in 2.97% of patients, predominantly young male smokers presenting with unstable angina. Traditional risk factors like HTN, DM were not significantly present but positive family history, smoking, increasing low density lipoprotein and triglyceride levels were significant predisposing factors represent coronary slow flow as an early atherosclerosis Elevated hsCRP indicating widespread inflammation and endothelial dysfunction ,resting ECG abnormalities and positive exercise stress tests are more frequent in patients with CSFP. We noticed single vessel involvement more than double and triple vessels, this pattern was different as compared to earlier studies. Significant electrocardiographic changes, positive exercise treadmill test and few patients showing reversible perfusion defect on SPECT imaging strongly indicate that coronary slow flow is not a benign condition and consideration of preventive measures, antiischaemic treatment and proper follow up is required. Though present study projects coronary slow flow as early atherosclerotic and endothelial disease, further large randomized trials are required to prove the exact pathology and definitive treatment.

Zaid Altheeb is currently a Cardiology fellow at New York Medical College. He graduated from Jordan University of Science and Technology (J.U.S.T) in 2009. He has a Medical degree in medicine and surgery. He is in the American board of internal medicine from New York Medical College at St. Joseph’s, Paterson-New Jersey USA. He is a Member in American college of physicians ACP and American College of Cardiology ACC. He has publications in the field of cardiovascular medicine.

BACKGROUND: Bleeding is a common complication of cardiac surgery, accounting for a significant proportion of the total transfusions performed in the United States and Europe. The relationship between platelet reactivity, bleeding and other adverse events after coronary artery bypass graft has been incompletely characterized. In this study we aimed to determine the relationship between platelet reactivity and bleeding as a clinical outcome after successful coronary artery bypass graft (CABG). METHODS AND RESULTS: A total of 238 patients underwent CABG were retrospectively followed for postoperative bleeding. Platelet reactivity unit (PRU) values for all patients were obtained preoperatively to assess the platelet reactivity. The data showed that a range of 150-200 PRU suggests the likelihood of bleeding after CABG (P=0.004), with a statistically significant association only for dual antiplatelet therapy with aspirin and clopidogrel. CONCLUSION: In conclusion, by using PRU values as a method to assess platelet reactivity and antiplatelet responsiveness, our findings suggest that it may be possible to stratify patients undergoing CABG for the risk of postoperative bleeding particularly patients on dual antiplatelet therapy.

Ahmed is a resident physician and a researcher in the department of Thoracic Organ Transplantation at the university hospital of Essen, Germany. He is a graduate of the faculty of Medicine-Alexandria University, 2006, Alexandria, Egypt. He did his Critical Care Medicine residency in Alexandria university hospital. In August 2008 he completed his Master Degree in critical care medicine. He then worked as a specialist in Critical care medicine for 6 years. His most recent study was published in the Transplant International Journal 2015.

Background: Ventricular assist devices (VADs) have been proven to be effective in improving survival and quality of life in patients with refractory heart failure. However, outcomes depend on a variety of preoperative parameters.
Aim of the study: This study evaluates retrospectively the patients’ profiles, clinical outcome, postoperative complications and mortality in patients who underwent VAD implantation in our center taking into account preoperative Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) levels aiming at anticipation of postoperative complications and optimization of the preoperative strategies.
Methods: Between August 2010 and March 2015, 104 patients underwent VAD implantation in our university hospital. INTERMACS profiles were as follow: level 1 in 27 patients, level 2 in 20 patients, level 3 in 27 patients, level 4 in 25 patients, level 5 in 4 patients and level 6 in 1 patients respectively. Patients were divided into 3 groups: Group A included 27 patients at INTERMACS level 1. Group B included 47 patients at INTERMACS level 2/3 and group C included 30 patients at INTERMACS Level 4/5/6. Preoperative clinical, echocardiographic, and hemodynamic and laboratory data were compared between groups as well as the incidence and time of onset of postoperative complications and mortality.
Results: Preoperatively, group A had a significantly lower cardiac index, lower mean arterial blood pressure, lower serum hemoglobin, higher serum blood urea nitrogen, higher serum procalcitonin and higher incidence of metabolic acidosis (p < 0.05). Postoperatively, group A had a higher incidence of respiratory failure, Hemorrhage, multiorgan failure, right ventricular failure and tracheostomy (p < 0.05). Total mortality was higher in group A than in group B (p = 0.017) and in group C (p=0.017) but not between groups B and C (p =0.81). Early mortality (at 30 days after VAD) was higher in group A than in group B (p=0.015) and group C (p=0.010). After 30 days mortality was not statistically different between groups. Sepsis (47.1%), right ventricular failure (37.5%) and respiratory failure (33.7%) were the most common post-operative complications after VAD implantation, whereas renal failure was the most common complication within 1 week after the operation (23.1%). Multiorgan failure was the most common cause of mortality (13.5 % n=10). Predictors of total mortality were preoperative high central venous pressure (HR, 1.077; 95% CI, 1.019–1.138, p=0.008), high systolic pulmonary artery pressure (HR, 1.056; 95% CI, 1.015–1.099 p=0.007), high serum blood urea nitrogen (HR, 1.031; 95% CI, 1.018–1.045; p=0.001), high serum procalcitonin (HR, 1.134; 95% CI, 1.040–1.237; p=0.04), metabolic acidosis (HR, 3.496; 95% CI, 1.708–7.157; p=0.001), low serum Hemoglobin (HR, 0.780; 95% CI, 0.667–0.913; p=0.02).
Conclusion: INTERMACS scale correlates with outcomes after VAD implantation in our single center study. Anticipation of postoperative complications allows for preoperative strategies to minimize these complications. Optimization of preoperative volume status, preload, right heart function, correction of preoperative anemia and management of preoperative sepsis are recommended to lower the total mortality in such patients.

Dr. Sonal Tanwar is a general practitioner last 6 years, graduated from rajasthan university of health sciences, jaipur (India) and done master of science in preventive cardiology from Cardiff university (uk). Now she is persuing master in hospital administration fron ICFAI University . She has interest to prevent heart diseases .

Background: Lifestyle intervention in primary healthcare consisting of exercise and education training, yoga, meditation in combination with diet counselling , primary and seconadary prevention with integrated medicine (Allopathy plus alternative medicines). Aim:The Observational study a 3-year outpatient Integrative Medicine program with focus on Integrated Medicine with life style intervention in patients with moderate to high risk for Common cardiovascular Disease and beneficial outcome of integrated approach. Methods: A total of 204 middle-aged men and women, with Hypertension, dyslipidemia, type 2 Diabetes Mallitus, or obesity were enrolled. The usual care (routine allopath medicines) group A(n=108) and the integrated approach( allopathy plus alternative medicines) with life style interventional group B (n=96). For Group B- Behaviour councelling,Education, Exercise: supervised endurance and yoga , meditation,circuit training ,Diet:in groups three times a week for three months with integrated holistic approach for regular 3 year follow up. Results: Proposed lifestyle improved after year 3 in the IP group over UC. There were significant differences between groups, mean changes (and their 95% confidence intervals, CI) in waist circumference pv0.001), in waist–hip ratio p<0.01) , decrease in HR (p<0.01), systolic BP (p<0.01) and diastolic BP(p<0.05) blood cholesterol and sugar, HBA1C level .after 2 year follow up ;ECG st-t changes in group A 20/108, group B 11/96( p <0.03),TMT positive with significant st-t changes in group A 17/108, group B 7/96(p <0.07), 2D Echo- LVH in group A 32/108, group B 12/96( p<0.01), LV Dysfunction in group A 9/108, group B 2/96(p <0.07) Unstable angina in Group A 14/108, group B 3/96( p<0.07) stable angina in group A 15/108, group B 6/96( p<0.07)Myocardial infarction in group A 10/108, group B 2/96( p<0.03).CHF in group A 10/108, group B 2/96( p<0.03) . Atrial fibrillation in group A 8/108, group B 2/96 (p<0.08).Ventricular tachycardia in group A 4/108, group B 1/96( p<0.23). Death in group A 3/108, group B 1/96( p<0.36).Post MI-CHF in group A 3/108, group B 1/96( p< 0.36). Post CABG-CHF in group A 2/108, group B 0/96( p-inf..) Conclusion: Regular 3-year follow-up improvements in cardiac autonomic function, quality of life, decrease stress, symptoms ,decrease incidence of cardio-vascular events in the intervention group improve personality and Exercise Score, better reduction of heart rate, blood pressure, weight, BMI, waist circumference, Waist hip ratio, decrease cholesterol , sugar and HBA1c. three to four time decrease incidence of CVD, Cardiac Arrhythmias and 33% reduction of cardiovascular Moratlity and congestive heart failure in integrated group as compare to usual group.

Zaid Altheeb is currently a Cardiology fellow at New York Medical College. He graduated from Jordan University of Science and Technology (J.U.S.T) in 2009. He has a Medical degree in medicine and surgery. He is in the American board of internal medicine from New York Medical College at St. Joseph’s, Paterson-New Jersey USA. He is a Member in American college of physicians ACP and American College of Cardiology ACC. He has publications in the field of cardiovascular medicine.

Background Thyroid disease is quite common, and since thyroid hormone has both inotropic and chronotropic effects on the heart, variations in thyroid hormone among the general public has demonstrated EKG changes.Hypothyroidism has been shown to be associated with AV blocks,QTc interval prolongation, and heart rate variability as well. The goal of this study is to observe PR interval changes on EKGs and investigate their correlation with TSH in hypothyroid patients being treated with levothyroxine. Methods and results This is a retrospective study looked at 504 admissions of hypothyroid patients who had an EKG and a TSH within three months of each other. Exclusion criteria were patients with atrial fibrillation, atrial flutter, and patients not on levothyroxine, which left the study with 455 admissions. Each admission was stratified based on TSH with low TSH (<0.4) had 85 admissions, normal TSH (0.5-5.0) had 269 admissions, and high TSH (>5.0) had 101 admissions. The mean PR intervals were 152.2,163.0,and 158.8 for the low TSH, normal TSH, a nd high TSH groups, respectively. Our data demonstrated that the low TSH group compared to normal TSH group had a lower mean of PR intervals (P value <0.05); however this analysis is not practical, as risks of over treating hypothyroid patients in order to treat or prevent 1st degree AV block would likely outweigh the benefits, while comparing the low TSH group with the high TSH group and normal TSH group compared to high TSH group did not show statistical significance (P value >0.05). This potentially shows that as long as a patient is getting thyroid hormone replacement in these subgroups, they will not have a higher chance of increasing PR intervals and subsequent blocks regardless of their TSH level. Conclusion In conclusion, as long as patients with normal or high TSH level are getting thyroid hormone replacement, they will not have a higher chance of increasing PR intervals and subsequent atrioventricular blocks, giving that benefits of over treating hypothyroid patients in order to treat or prevent first degree AV block would likely outweigh the risks of developing thyrotoxicosis.

Introduction: Diabetic patients with normal left ventricular ejection fraction are frequently associated with diastolic dysfunction. Speckle tracking is more sensitive than LVEF in detection subclinical LV systolic dysfunction.
Aim: Detection of different patterns of global longitudinal strain in diabetic patients using global longitudinal strain by speckle tracking.
Methods: fifty two diabetic patients had been referred from internal medicine clinic after they had been tested for HBA1c test and stratified into two groups
Group І: it include26 DM patients with controlled blood sugar.
Group II it include26 DM patients with uncontrolled blood sugar
The two groups had been subjected to the following diagnostic workup: Full medical history, full clinical examination, laboratory assessment, twelve lead resting ECG, Stress ECG, Echocardiography study, Traditional Tissue Doppler imaging, Assessment of global longitudinal strain.
Patients with IHD, Systolic dysfunction, CHD ,Valvular, Arrhythmia, HOCM ,Pericardial, major systemic disease had been excluded.
Result: there was significant statistical difference in GLS, Age, Diabetic Type, Diabetic Duration, 2HPP Blood sugar level, E/é ratio in controlled DM compared to uncontrolled DM (p<0.05), there was no significant difference in Gender, FBS. EF, E/A in controlled DM compared to uncontrolled DM.
Conclusion: Diabetic duration was strongly correlated with reduction of global Longitudinal strain. Poor blood glucose control, as indicated by HbA1c>6.5%, leads to reductions in LV global longitudinal systolic strain, which is associated with preclinical LV dysfunction.