Day 2 :
Roland Hetzer has completed his cardiothoracic surgery training in Hannover Medical School, Germany and in Stanford University, California. He performed the first heart transplantation in Hannover in 1983 and the first pediatric heart transplantation in Germany in 1985. As the Medical Director and Chairman in Deutsches Herzzentrum Berlin from January 1986 to September 2014, he and his team performed more than 1900 heart transplantations and more than 2300 implantations of mechanical circulatory support systems. He has made numerous original contributions in the field of cardiothoracic and vascular surgery particularly in surgical treatment of end-stage heart failure and valve surgery. Presently, he still serves as the Medical Director of Herzzentrum Cottbus and sees his private patients in Cardio Centrum Berlin.
Heart failure has a rapidly increasing incidence in both men and women and is the most prominent heart disease in the elderly. This is due to the successful treatment of acute heart disease which later on turns into chronic failure. Whereas pharmaceutical and electrophysiological concepts have been constantly improved, end-stage heart failure has been approached by various surgical procedures.
The majority of cases depends on ischemic heart disease which we described as LOCIMAN (Left heart failure, Occlusion of the Coronary artery, Incompetence of Mitral valve and Left ventricular Aneurysm or Akinesia). It appears to be mandatory to evaluate the relative contribution of these components to heart failure and the relative importance of surgical procedures (coronary bypass, mitral valve repair and aneurysmectomy) for cardiac improvement.
These procedures play a major role in less than profound heart failure. In such cases, various external support procedures were introduced which mostly have been abandoned as well as the partial ventricular resection procedure (Batista).
Neither external restraint procedures have not fulfilled the expectations nor myocardial regeneration and stem cell application.
Heart transplantation is now a well-established treatment for end-stage heart failure, enabling a high degree of physical rehabilitation and a mean survival time of 12 to 14 years. Some of our patients are now living for more than 30 years after transplantation. However, heart transplantation is an option offered to only few patients due to limited availability of donor organs.
Mechanical circulatory support systems have achieved clinical application during the last 30 years. Between 1987 and 2014, more than 2300 ventricular assist devices have been implanted in Berlin to keep patients alive, after which there were three options: bridge to transplantation, bridge to myocardial recovery in myocarditis and in cardiomyopathy, first demonstrated by pump explantation and long-term stability in Berlin in 1995, and as permanent implants.
Originally these ventricular assist devices were extracoporeal connected to large driving units. Thereafter, electrical pulsatile systems were introduced; however, these were noisy and bulky. In 1998, the author implanted the first rotary blood pump with continuous flow (MicroMed DeBakey) worldwide. Such systems, which are small and silent, have become the standard in now 90% of cases. These pumps also qualify for long-term use (up to 10 years). They are developed to support the left ventricle; however, they can be also implanted in the right ventricle when necessary. Moreover these systems are very useful in elderly patients.
Pulsatile extracorporeal systems, i.e. Berlin Heart EXCOR Pediatric, are the only one available for end-stage heart failure in infants and young children.
Complete myocardial recovery has been observed with ventricular assist device support in acute myocarditis and even in dilative cardiomyopathy.
The only available total artificial heart is the CardioWest pneumatic system. However, there are some experimental total artificial heart developmental projects going on in Germany, in France and in USA.
Table 1. Surgical options in advanced cardiac failure
a NYHA=New York Heart Association; b HTX=Heart transplanttation; c LVAD=Left ventricular assist device; d BVAD=biventricular assist device; e TAH=Total artificial heart; f MVR=Mitral valve repair
Gulf Medical University, UAE
Background: The prevalence of obesity and diabetes has reached epidemic proportions, and in terms of the extent of its negative impact on the health has been compared to those of tobacco and hypercholesterolemia. One of the first medical consequences of obesity and diabetes mellitus to be recognized was cardiovascular disease (CVD). Obesity and diabetes are independent predictors of coronary heart disease, heart failure and stroke.
Objective: The aim of the study was to evaluate whether tissue Doppler imaging (TDI) and global longitudinal strain (GLS) detects a pre-clinical impairment of diastolic and systolic functions in obese subjects with Type 2 diabetes with short duration of disease and normal cardiac function with conventional echocardiography (CE), and whether echocardiographic parameters are related to metabolic abnormalities.
Patients and Methods: We studied 240 obese (body mass index (BMI>30 kgm2) , uncomplicated type 2 diabetic subjects with short duration of disease and 93 control subjects. All participants underwent both CE, GLS and TDI echocardiography. With TDI, early mitral annular septal velocity (Ea), pre systolic conventional mitral flow atrial Doppler velocity (Aa), their ratio (Ea/Aa) and systolic velocity (Sa) were measured at the lateral corner of mitral annulus. Glycosylated haemoglobin, fasting plasma glucose and insulin were determined and homeostasis model assessment (HOMA-IR), as an index of insulin resistance, was calculated.
Results: Cardiac function with CE was similar in the two groups. Using TDI, diabetic obese subjects showed a lower Ea velocity (15.5+/-3.9 vs. 19.4+/-3.5 cm/s, P<0.0001), an increased Aa velocity (15.5+/-2.4 vs. 14.1+/-2.4 cm/s, P<0.05) and a reduced Ea/Aa ratio (1.00+/-0.2 vs. 1.39+/-0.3, P<0.0001), compared with control subjects. Interestingly, diabetic women had increased left ventricular (LV) wall thickness (18.8 vs 16.1 mm, p < 0.001).Trans thoracic echocardiography, myocardial Doppler-derived systolic (sm) and early diastolic velocity (em) and strain imaging (GLS) were obtained in obese diabetic subjects and 93 referents (BMI <25 kg/m2). BMI correlated with left ventricular (LV) mass and wall thickness (P<0.001). Severely obese subjects (BMI >35) had reduced LV systolic and diastolic function compared with referents, evidenced by lower average longitudinal peak systolic strain, sm, and reduced em, whereas LV ejection fraction remained normal. Differences in regional and global strain (-14.5% +/- 1.4 ) were identified between the severely obese diabetic (BMI >35) and the referent patients (-17.6% +/- 2.1) ,P<0.001.
Conclusion: An early stage of cardiac dysfunction and dilated cardiomyopathy can be evidenced by TDI and myocardial strain imaging in type 2 diabetic obese subjects even in the presence of a normal cardiac function with CE. This abnormality is associated with cardiac hypertrophy in one third of our studied patients.