Day 2 :
Keynote Forum
Roland Hetzer
Former Medical Director, German Heart Institute Berlin, Germany
Keynote: End-stage Heart Failure
Time : 09:00-09:25
Biography:
Roland Hetzer has completed his cardiothoracic surgery training in Hannover Medical School, Germany and in Stanford University, California. He performed thernfirst heart transplantation in Hannover in 1983 and the first pediatric heart transplantation in Germany in 1985. As the Medical Director and Chairman in DeutschesrnHerzzentrum Berlin from January 1986 to September 2014, he and his team performed more than 1900 heart transplantations and more than 2300 implantationsrnof mechanical circulatory support systems. He has made numerous original contributions in the field of cardiothoracic and vascular surgery particularly in surgicalrntreatment of end-stage heart failure and valve surgery. Presently, he still serves as the Medical Director of Herzzentrum Cottbus and sees his private patients inrnCardio Centrum Berlin.
Abstract:
Heart failure has a rapidly increasing incidence in both men and women and is the most prominent heart disease in thernelderly. This is due to the successful treatment of acute heart disease which later on turns into chronic failure. Whereasrnpharmaceutical and electrophysiological concepts have been constantly improved, end-stage heart failure has been approachedrnby various surgical procedures. The majority of cases depends on ischemic heart disease which we described as LOCIMAN (Leftrnheart failure, Occlusion of the Coronary artery, Incompetence of Mitral valve and Left ventricular Aneurysm or Akinesia), Itrnappears to be mandatory to evaluate the relative contribution of these components to heart failure and the relative importancernof surgical procedures (coronary bypass, mitral valve repair and aneurysmectomy) for cardiac improvement. These proceduresrnplay a major role in less than profound heart failure. In such cases, various external support procedures were introduced whichrnmostly have been abandoned as well as the partial ventricular resection procedure (Batista). Heart transplantation is now a wellestablishedrntreatment for end-stage heart failure, enabling a high degree of physical rehabilitation and a mean survival time ofrn12 to 14years. Some of our patients are now living for more than 30 years after transplantation. However, heart transplantationrnis an option offered to only few patients due to limited availability of donor organs. Mechanical circulatory support systemsrnhave achieved clinical application during the last 30 years. Between 1987 and 2014, more than 2300 ventricular assist devicesrnhave been implanted in Berlin to keep patients alive, after which there were three options: bridge to transplantation, bridge tornmyocardial recovery in myocarditis and in cardiomyopathy, first demonstrated by pump explantation and long-term stabilityrnin Berlin in 1995, and as permanent implants. Originally these ventricular assist devices were extracoporeal connected tornlarge driving units. Thereafter, electrical pulsatile systems were introduced; however, these were noisy and bulky. In 1998, thernauthor implanted the first rotary blood pump with continuous flow (MicroMed DeBakey) worldwide. Such systems, which arernsmall and silent, have become the standard in now 90% of cases. These pumps also qualify for long-term use (up to 10 years).rnThey are developed to support the left ventricle; however, they can be also implanted in the right ventricle when necessary.rnMoreover these systems are very useful in elderly patients. Pulsatile extracorporeal systems, i.e. Berlin Heart EXCOR Pediatric,rnare the only one available for end-stage heart failure in infants and young children. The only available total artificial heart isrnthe CardioWest pneumatic system. However, there are some experimental total artificial heart developmental projects goingrnon in Germany, in France and in USA.
Keynote Forum
Ada Yonath
Weizmann Institute of Science, Israel
Keynote: Towards control of resistance to antibiotics
Time : 14:15-15:00
Biography:
Ada Yonath is focusing on protein biosynthesis and the antibiotics hampering it. In the seventies she established the first structural-biology laboratory in Israel.rnShe is the Director of Kimmelman Center for Biomolecular-Structure. During 1986-2004 she also headed Max-Planck-Research-Unit for Ribosome Structure inrnHamburg. Among others, she is a member of US-National-Academy-of-Sciences; Israel Academy; German Science Academy; PontificiaAccademia-delle-Scienzern(Vatican). She holds honorary doctorates from Oslo, NYU, Mount-Sinai, Oxford, Cambridge, Hamburg, Berlin-Technical, Patras, De-La-Salle, Xiamen, Lodzrnuniversities. Her awards include the Israel Prize; Louisa-Gross-Horwitz Prize; Linus-Pauling Gold Medal; Wolf-Prize; UNESCO/L’Oreal Award; Albert-EinsteinrnWorld Award for Excellence; and Nobel Prize for Chemistry.
Abstract:
Resistance to antibiotics and the spread of antibiotics metabolites are severe problems in contemporary medicine and ecology.rnStructures of complexes of eubacterial-ribosomes with antibiotics paralyzing them illuminated common pathways in inhibitory-actions, synergism, differentiation and resistance. Recent structures of ribosomes from a multi-resistant pathogensrnidentified features that can account for species-specific diversity in infectious-diseases susceptibility. These may lead to designrnof environmental-friendly degradable antibiotics, which will also be species-specific antibiotics-drugs, thus the basis for srnrevolution in the antibiotics field, which its current preference for wide-spectrum drugs. Thus, reducing resistance while protecting the environment and preserving the microbiome.
Keynote Forum
Béla Merkely
Past President of the Hungarian Society of Cardiology
Heart and Vascular Center, Semmelweis University, Hungary
Keynote: Cardiac Resynchronisation: State of the Art
Time : 09:00 - 09:30
Biography:
He is the Chairman of the Heart and Vascular Center, Semmelweis University, Budapest, Hungary. President of the Clinical Center and Vice Rector of the Semmelweis University. Councillor and Member of the Board of the European Society of Cardiology. Chair of the National Cardiac Societies Committee of EHRA. President of the Hungarian Association of Cardiovascular Intervention. Honorary President of the Hungarian Heart Rhythm Association. Past President of the Hungarian Society of Cardiology.
Abstract:
rnCardiac resynchronization therapy (CRT) has become the gold standard device therapy in chronic heart failure patients on optimal medical therapy with ventricular dyssynchrony and reduced ejection fraction. According to the ESC guidelines, CRT is most effective in patients with wide QRS (120-150 msec), left bundle branch block, non-ischemic etiology and female gender. CRT indication is growing across Europe, but CRT penetration is insufficient, thus CRT needs exerts CRT implantations. To compensate, both the numbers of CRT implanting centers and the overall CRT implantations increase rapidly in European countries. In 2013 a total of 51 274 CRT devices were implanted in 1701 national European centers.rnCRT is cost-effective, reduces mortality and morbidity, however non-response to CRT is still the biggest problem. Recent studies have showed no advantage of CRT in patients with narrow QRS or non-left bundle branch block pattern in ECG. Etiology of heart failure has a pivotal role, it has been shown that CRT with implantable cardioverter defibrillator (CRT-D) might be beneficial in patients with ischemic etiology, but not in non-ischemic patients. Device optimization is crucial, physiologic atrioventricular delay (<120 msec), and optimal electrode position (in a postero-lateral vein far away from the scar) reduces mortality. Electroanatomic mapping with right to left ventricular interlead sensed electrical delay measurement improves pacing conditions. Quadripolar lead configuration could avoid phrenic nerve stimulation. Novel implantation techniques have been developed, such as transseptal endocardial lead placement or coronary sinus lead stabilization with stent implantation.rn
- Track 4: Interventional Cardiology Track 5: Echocardiography Track 6: Heart and Blood Vessel Surgeries
Location: Berlin,Germany
Chair
Almasri H. Hatem
Specialized heart center KAMC, Saudi Arabia
Session Introduction
Bernhard Mumm
TOMTEC Imaging Systems, Germany
Title: Echocardiographic methods for preclinical detection of diabetic heart disease and in cardio-oncology
Time : 09:25-09:45
Biography:
Bernhard Mumm has completed his Master of Science in Engineering, Computer Science and Cybernetics at the Technical University Munich / Germany in 1983. Since 1990 he is working at TOMTEC Imaging Systems, located in Munich Germany and holds the position as president. He has done 3D Echocardiography research & developments in cooperation with many university hospitals worldwide. He participated in many publications, book chapters, patents and talks at international scientific conferences on this topic.
Abstract:
Introduction: Diabetic heart disease or a chemotherapy treatment of a patient in cardio-oncology can have a profound impact on cardiac systolic and or diastolic function and structure. Especially diabetic patients are at a higher risk for developing heart disease than non-diabetic individual. These patients can also have numerous causes of heart related issues and disease. Detecting and monitoring of non-visual changes in cardiac dimensions and function has become very important. Methods: Echocardiography techniques are used for an evaluation of cardiac function and detection of early diabetic myocardial disease. Standard Echo measurements are here LV diameters, wall thicknesses, LV mass, fractional shortening, LV volumes and ejection, measured in 2D or better in 3D. Stress Echocardiography can be another diagnostic tool to evaluate cardiac function. Newer analysis tools feature automatic contour detection in 2D or 3D and myocardial tracking for a fast, accurate and highly reproducible global and regional functional analysis of LV myocardial strain. Conclusion: Automated imaging software that can assist in the management of patients with diabetic heart disease or in chemotherapy is becoming widely accepted over traditional imaging methods. Subclinical markers including the longitudinal strain provide an excellent means of monitoring non visual and regional abnormalities in LV systolic function. Automated software provides a high level of reproducibility which is crucial for the proper management of these patients.
A D John
Johns Hopkins University School of Medicine, USA
Title: PACU update: The cardiac patient undergoing non-cardiac surgery
Time : 09:45-10:05
Biography:
A D John completed BA from Harvard University and MD from New York Medical College. He has done his Internal Medical Residency from Metro West Medical Center; Framingham, MA and Anesthesia and Critical Care Residency from Johns Hopkins Hospital; Baltimore, MD. He has done Cardiac Anesthesia subspecialty in Johns Hopkins Hospital; Baltimore, MD and Cardiac Anesthesiology Fellowship from Massachusetts General Hospital; Boston, MA. He is an instructor at Harvard Medical School; Boston, MA and also at Johns Hopkins School; Baltimore, MD. He is an Assistant Professor of Anesthesiology and Critical Care Medicine at Johns Hopkins University School of Medicine; Baltimore, MD. He served as a Coeditor with Sancho Rodrigues-Villar for Protocols in Critical Care (in Press) and as an Editor for Anesthesia: Essential Clinical Updates for Provider (in Press).
Abstract:
The Post Anesthesia Care Unit (PACU) is a key element in ensuring a successful operative experience. Recovery from surgery is dependent on a transition from intensive focus of the operating room to a safe care in the hospital ward or home after surgery. The key area of transition is the Post-anesthesia Care Unit. It is the PACU that the patient ‘awakens’ from anesthesia. Respiratory function has to be maintained and stable vital signs have to be assured. In addition, pain issues as well as postoperative nausea have to be addressed. In an effort to facilitate throughput, each type of surgery is establishing protocols to aid in rapid recovery, minimize pain, increase ambulation and decrease hospital stay. What are the keys to ensuring patient safety in the PACU? What are the special issues for the cardiac patient undergoing non-cardiac surgery?
Issam A Mikati
Northwestern University Chicago, USA
Title: The use of strain imaging in detection and management of patients with early cardiomyopathy: Focus on diabetic cardiomyopathy
Time : 10:15-10:35
Biography:
Issam Mikati graduated from the American University of Beirut Medical School. He did Cardiology fellowship at Baylor College of Medicine. He complaeted imaging fellowship at the same institution. He is the associate director of the Echocardiography lab at Northwestern Memorial hospital in Chicago Illinois. He has published numerous papers in reputed journals and has served as a reviewer of premier journals.
Abstract:
Cardiomyopathy confers a poor prognosis. Early recognition and intervention is key to improve outcome. Classic methods of assessment of LV systolic dysfunction such Left Ventricular Ejection Fraction (LVEF) suffer from wide variance that limits their utility in detection of minor changes in systolic function on serial testing. In addition, the changes in LVEF appear late after significant myocardial damage has occured. This has been shown to affect prognosis of patients. Strain has been shown to be an accurate sensitive marker of LV function with leass varaiance than traditional methods of LV systolic function. It has been shown to drop early in the natural history of many systemic diease that affect the heart such as diabetic cardiomyopathy. Strain shows great promise in management of cardiomyopathies because its efficacy in early detection and potentially effects of treatment.
Alfredo E Rodriguez
Centro de Estudios en CardiologÃa Intervencionista, Argentina
Title: Cardiac rupture in Takotsubo cardiomyopathy
Time : 10:35-10:55
Biography:
Alfredo E Rodriguez graduated from Córdoba National Medical University, Argentina and completed his PhD from the Cordoba Catholic School of Medicine. He is Director of Centro de Estudios en Cardiología Intervencionista, a premier Research Organization and Head of the Cardiology Department of Sanatorio Otamendi, Buenos Aires, Argentina. He has published more than 250 papers in major peer review journals and also was Editor of four cardiology books the last one published in September 2015 by Springer. He is Editor-In-Chief of the Journal “Revista Argentina de Cardioangiología Intervencionista” and has been serving as an Editorial Board Member of worldwide repute Journals such as Euro-Intervention, JACC Cardiovascular Interventions, World Journal of Cardiology, Drug Designing Journal (2014), Journal of Developing Drugs (2014). He is also frequent reviewer from major cardiology and interventional cardiology Journals.
Abstract:
Takotsubo cardiomyopathy (TCM) was characterized by transient left ventricular dysfunction usually involving antero apical and infero apical regions of the myocardium with ST segment changes or T-wave inversion and minimal release of cardiac enzymes in the absence of significant coronary artery disease (CAD). TCM was in general associated with good prognosis, although a minority of patients develops severe hemodynamic complications, including cardiogenic shock, life threatening arrhythmias and cardiac rupture (CR). Isolated left ventricular impairment is the most common variant of this entity, but right ventricular involvement is also recognized and was associated with poor prognosis. Until January 2015, 14 cases of CR have been reported; included right or left ventricular wall rupture or ventricular septal perforation (VSP) VSP was reported in 4 cases 2 of them who survived were treated with open heart surgery. We are reporting the case of a female patient with acute T waves changes in antero-lateral leads in basal ECG, minor enzymes elevation; anterior and apical hipokinesia of the left ventricle and hipokinesia of the right ventricle observed at admission with trans-thoracic echocardiography (TE) and without significant CAD in the coronary angiogram, four days later she develop cardiogenic shock with left and right severe heart failure and in a new TE a VSP was observed and was located at 10mm of the left ventricular apex. The VSP was repaired successfully percutaneously using an Amplatzer device. Patient had a rapid improvement of her ventricular function and had hospital discharge three days later. TCM can be associated with severe complications including cardiac rupture and VSP. At our knowledge, this is the first reported case in the literature using a percutaneous endovascular technique to repair it.
Flavia Ventriglia
Sapienza University of Rome, Italy
Title: Early fetal echocardiography for congenital heart disease detection: A preliminary experience and outcome analysis of 102 fetuses to demonstrate the value of a clinical flow-chart designed for at-risk pregnancy management
Time : 10:55-11:15
Biography:
Flavia Ventriglia graduated and specialized in Pediatrics and Cardiology at the “Sapienza” University of Rome. He has done his PhD in Congenital Heart Disease at the University of Padua. He works as a Researcher Aggregate Professor of Pediatric Cardiology at the “Sapienza” University of Rome, first level manager at the UOC of Pediatric Cardiology at the Policlinico Umberto I in Rome and is responsible for the ECHOLAb of Fetal Echocardiography. He has published numerous scientific international papers in the field of pediatric cardiology and fetal cardiology.
Abstract:
Early fetal echocardiography (EFEC) is a fetal cardiac ultrasound analysis performed between the 12th and 16th week of pregnancy (compared with the usual 18-22 weeks). In the last 10 years, the introduction of “aneuploidy sonographic markers” in screening for cardiac defects has led to a shift from late second to end of the first trimester or beginning of the second trimester of pregnancy for specialist fetal echocardiography. In this prospective study, early obstetric screening was performed between January 2014 and October 2015, using “aneuploidy sonographic markers” following SIEOG Guidelines 2014. These parameters were then collected and strategically combined in an evaluation score to select the group of pregnancies for performing EFEC, in accordance with the American Society of Echocardiography guidelines for fetal Echocardiography. All second-level examinations were performed trans-abdominally using a 3D convex volumetric probe with frequency range of 4-8 MHz (Accuvix–Samsung). The outcome data included trans-abdominal fetal echocardiography from 18 weeks to term and after birth. Overall, 99 pregnant women in the first trimester underwent EFEC (95 singleton and 4 twin pregnancies). Specifically, 30 fetuses were evaluated for extra-cardiac anomalies evidenced by obstetric screening (30%), 25 for family history of congenital heart diseases (25%), 8 for family history of genetic-linked diseases (8%), 4 for heart diseases suspected by obstetric screening (4%) and 19 by normal screening (19%). EFEC detected 11 cases of CHD (10.7%); when EFEC CHD assessments were compared to those performed later in pregnancy (18 weeks GA-term), a high degree of diagnosis correspondence was evidenced. The higher sensitivity value of EFEC vs. late-FE, in comparison with the post-natal value, coupled with the high EFEC specificity shown vs. both the end points, enabled us to consider it as a really reliable diagnostic technology, at least in experienced hands. The introduction of a key combination of the more sensitive obstetric and cardiologic variables should facilitate the formulation of a possible flow-chart as a guide for CHD at-risk pregnancies.
Marco Picichè
San Camillo-Forlanini Hospital, Italy
Title: The evolution of surgical myocardial revascularization
Time : 11:15-11:35
Biography:
Marco Piciche MD, PhD graduated with a degree in Medicine in Florence in 1995 and completed his cardiac surgery residency in Rome in 2000. He earned his research master in Surgical Science (Paris, 2007) and a university diploma in vascular surgery (Paris, 2007). In 2009 he opened the 44th Congress of the European Society for Surgical Research. He has written many publications and worked as a guest reviewer for many international leading journals. He is a Member of the Editorial Board of several English language Journals. He received a Doctor of philosophy (PhD) in Paris. He is the Editor-in-Chief of the multi-author book "Dawn and Evolution of Cardiac procedures-Research Avenues in cardiac Surgery and Interventional cardiology”. Currently he is a cardiac surgeon in Rome.
Abstract:
Prior to the advent of cardiopulmonary bypass, myocardial revascularization strategies fell into three categories: Extracardiac procedures, cardiac operations on non-coronary artery structures and direct coronary artery surgery. After the invention of the heart-lung machine by John Gibbon in the fifties, coronary artery by-pass grafting spread all over the world. Since the nineties, the methods of surgical revascularization fell into two main categories, namely on-pump and offpump procedures. Progresses in techniques not with-standing, there are still a significant number of patients who may not benefit from conventional techniques of myocardial revascularization due to diffuse coronary artery disease. Since a certain level of morbidity and mortality is associated with direct surgical or endovascular coronary procedures, the search is on for less invasive and less costly alternatives that ensure myocardial blood supply. Researchers are on the lookout for new revascularization methods also because of the many patients suffering from diffuse coronary artery disease that may not benefit from conventional techniques. Some alternative myocardial revascularization methods attempted in recent years bear a resemblance to techniques tried andabandoned in the first half of the last century. Earlier attempts to achieve myocardial revascularization may constitute a fertile pool of ideas. In the era of coronary stenting, research still needs todraw some old ideas to elaborate derivative strategies that employ the tools of modern technology. It is important for clinicians and researchers to know the historical steps which paved the way to current practice.
Robert Skalik
Wrocław Medical University, Poland
Title: Screening of athletes – Should we go beyond standard electrocardiogram?
Time : 11:35-11:55
Biography:
Robert Skalik, MD, PhD is a consultant in cardiology, exercise physiologist. He completed his PhD in echocardiography from Medical University of Wrocław. He covered internship in the Department of Cardiology at Free University of Amsterdam, the Netherlands. He is a lecturer in Post-graduate School of Cardiology, University of Perugia and an academic teacher and researcher in Department of Physiology, former consultant in cardiology in Department of Cardiac Surgery and Cardiology, Medical University of Wrocław, former Head of Department of Cardiac Rehabilitation, Wrocław, private practice in cardiology, Wrocław, research projects evaluator for EU. He has published 103 papers on cardiology and human physiology.
Abstract:
Professional and amateur athletic training can cause tremendous overload of the cardiovascular system and thus become a trigger for fatal cardiac events in athletes with previously undetected underlying heart diseases. Subsequently, every athlete should undergo a specialized diagnostic and qualification screening process before a training program is prescribed or continued. However, it is still unresolved issue which of the diagnostic tools should be routinely applied in order to increase the safety of extreme physical training and reduce the risk of sudden cardiac death. Pre-participation athlete evaluation including resting electrocardiography (EKG), physical examination and familial history of cardiovascular diseases is important, but does not always guarantee high diagnostic accuracy. The permanently growing interest in the sport activities raises serious and justified concerns about health and safety of extreme physical training and sport-related risk of sudden cardiac death (SCD). In recent years there are more and more press reports on cases of sudden cardiac death in young athletes during sport events. EKG is recommended by national and international medical associations as a basic tool to screen athletes. EKG is one of the oldest and simplest diagnostic instruments to diagnose cardiac diseases, but the main drawback of resting EKG is its interpretational ambiguity and controversial accuracy for the diagnosis of cardiovascular diseases. Hence, the complex and reliable evaluation of cardiovascular health status in athletes or athlete candidates should always include more sophisticated diagnostic techniques including echocardiography, exercise testing and cardiac magnetic resonance or in some selected cases cardiac computed tomography.
Noemi Csaszar-Nagy
National Center for Spinal Disorders, Hungary
Title: Psychological conditions, examination and evaluation of suitability for heart transplantation
Time : 09:00 - 09:20
Biography:
Császár Noémi Ph. D., ECP, is the Head of the Education Board of the Hungarian Association of Hypnosis (H.A.H), clinical psychologist, supervisor hypnotherapist, psychotherapist, Head of Psychotherapy Department and Psychosomatic Out-Patient Department at the National Center for Spinal Disorders in Budapest. She is the author of the special issue chapter: Császár N., Ganju A., Mirnics Zs., Varga P.P.: Psychosocial Issues In The Cancer Patient. Spine, 15:34 (22 Suppl):26−30, 2009. And the book chapter: Császár N.: Hypnotherapy treatment of chronic Pain. In: Vértes, G. (ed.): Hypnosis─Hypnotherapy. Budapest, Medicina Könyvkiadó Rt., 2006, 31–62.
Abstract:
There are increasing number of patients needing medical care for medication resistant, chronic cardiac failure. Heart transplantation is a multidisciplinary area, where cooperation of well-organized professional team is required in every stage of the procedure. Patient suitability is a crucial point in transplantation; adequate patient selection is therefore a key stage regarding long-term success. Evaluation of suitability for heart transplantation must be carried out in the following domains: 1. Severity of heart disease and prognosis for conservative treatment 2. Overall health of other organs and organ systems. Is general condition of the patient sufficient enough to tolerate surgical stress and the side effects of prolonged immunosuppressive treatment? Is there any comorbidity influencing chance of survival or endangering the new heart? 3. Psychosocial suitability The aim of this presentation is to summarize the most important psychological and psychiatric diagnostic aspects of patient evaluation. Certain diseases of the central nervous system, mental disorders, psychiatric conditions, substance abuse and noncompliance are all to be considered in the screening process. Complex psychodiagnostics provides a tool for clinicians to identify potential risk factors so that adequate therapy can be started or optimized accordingly. Absolute contraindications include: - Acute psychosis where – regardless of treatment - sufficient compliance cannot be achieved. - Suicidal ideation, urges, motivation, or attempted suicide in patients’ history – which implies insufficient coping. - Acute bereavement, severe depression with or without psychotic symptoms and untreated recurrent depression. Acute bereavement and depression are important risk factors of morbidity and mortality, hostility and PTSD symptoms in the postoperative period, serving as a predictor of poor compliance. - Mental and behavioral disorders caused by psychoactive substance abuse, such as nicotine, alcohol or drugs. Relative contraindications that may lead to insufficient compliance include dissocial and unstable affective personality disorders, organic and symptomatic mental disorders (mental retardation and dementia), schizophrenia, schizotypal and paranoid disorders and bipolar affective disorders. Some other conditions must be considered as risk factors that can contribute to developing postoperative complications and prolonged hospitalization. These include adjustment disorders triggered by severe stress, neurotic, stress related and somatoform disorders, mild- and moderate levels of depression and dysthymia. Scientific background and clinical practice of risk assessment guided by national guidelines will be reviewed in the presentation.
Amballur David John
Johns Hopkins University School of Medicine, USA
Title: The cardiac patient undergoing non-cardiac surgery
Time : 09:20 - 09:40
Biography:
A D John completed BA from Harvard University and MD from New York Medical College. He has done his Internal Medical Residency from Metro West Medical Center; Framingham, MA and Anesthesia and Critical Care Residency from Johns Hopkins Hospital; Baltimore, MD. He has done Cardiac Anesthesia subspecialty in Johns Hopkins Hospital; Baltimore, MD and Cardiac Anesthesiology Fellowship from Massachusetts General Hospital; Boston, MA. He is an instructor at Harvard Medical School; Boston, MA and also at Johns Hopkins School; Baltimore, MD. He is an Assistant Professor of Anesthesiology and Critical Care Medicine at Johns Hopkins University School of Medicine; Baltimore, MD. He served as a Coeditor with Sancho Rodrigues-Villar for Protocols in Critical Care (in Press) and as an Editor for Anesthesia: Essential Clinical Updates for Provider (in Press)
Abstract:
The Post Anesthesia Care Unit (PACU) is a key element in ensuring a successful operative experience. Recovery from surgery is dependent on a transition from intensive focus of the operating room to a safe care in the hospital ward or home after surgery. The key area of transition is the Post Anesthesia Care Unit. It is the PACU that the patient ‘awakens’ from anesthesia. Respiratory function has to be maintained and stable vital signs have to be assured. In addition, pain issues as well as postoperative nausea have to be addressed. In an effort to facilitate throughput, each type of surgery is establishing protocols to aid in rapid recovery, minimize pain, increase ambulation, and decrease hospital stay. What are the keys to ensuring patient safety in the PACU? What are the special issues for the cardiac patient undergoing non-cardiac surgery?
Robert Skalik
Medical University of Wroclaw, Poland
Title: Screening of athletes should we go beyond standard electrocardiogram?
Time : 10:20 - 10:40
Biography:
Robert Skalik, MD, PhD, consultant in cardiology, exercise physiologist. He completed his PhD in echocardiography from Medical University of Wrocław. He covered internship in Department of Cardiology, Free University of Amsterdam, the Netherlands, lecturer in Postgraduate School of Cardiology, University of Perugia, academic teacher and researcher in Department of Physiology, former consultant in cardiology in Department of Cardiac Surgery and Cardiology, Medical University of Wrocław, former Head of Department of Cardiac Rehabilitation, Wrocław , private practice in cardiology, Wrocław, research projects evaluator for EU. He has published 103 papers on cardiology and human physiology.
Abstract:
Professional and amateur athletic training can cause tremendous overload of the cardiovascular system and thus become a trigger for fatal cardiac events in athletes with previously undetected underlying heart diseases. Subsequently, every athlete should undergo a specialized diagnostic and qualification screening process before a training program is prescribed or continued. However, it is still unresolved issue which of the diagnostic tools should be routinely applied in order to increase the safety of extreme physical training and reduce the risk of sudden cardiac death. Pre-participation athlete evaluation including resting electrocardiography (EKG), physical examination and familial history of cardiovascular diseases is important, but does not always guarantee high diagnostic accuracy. The permanently growing interest in the sport activities raises serious and justified concerns about health and safety of extreme physical training and sport-related risk of sudden cardiac death (SCD). In recent years there are more and more press reports on cases of sudden cardiac death in young athletes during sport events. EKG is recommended by national and international medical associations as a basic tool to screen athletes. EKG is one of the oldest and simplest diagnostic instruments to diagnose cardiac diseases, but the main drawback of resting EKG is its interpretational ambiguity and controversial accuracy for the diagnosis of cardiovascular diseases. Hence, the complex and reliable evaluation of cardiovascular health status in athletes or athlete candidates should always include more sophisticated diagnostic techniques including echocardiography, exercise testing, and cardiac magnetic resonance or in some selected cases cardiac computed tomography.
Marco Piciche
San Camillo Hospital Rome, Italy
Title: The evolution of surgical myocardial revascularization
Time : 10:00 - 10:20
Biography:
Marco Picichè (MD, Ph.D.) graduated with a degree in medicine in Florence in 1995 and completed his cardiac surgery residency in Rome in 2000. He earned his research master in Surgical Science (Paris, 2007), and a university diploma in vascular surgery (Paris, 2007). In 2009 he opened the 44th Congress of the European Society for Surgical Research. He has written many publications and worked as a guest reviewer for many international leading journals. He is a member of the Editorial Board of several English language Journals. He received a doctor of philosophy (Ph.D.) in Paris. He is the Editor in Chief of the multi-author book "Dawn and Evolution of Cardiac procedures-Research Avenues in cardiac Surgery and Interventiontional cardiology" (Springer Verlag 2012). Currently he is a cardiac surgeon in Rome.
Abstract:
Prior to the advent of cardiopulmonary bypass, myocardial revascularization strategies fell into three categories: extracardiac procedures, cardiac operations on noncoronary artery structures, and direct coronary artery surgery. After the invention of the heart-lung machine by John Gibbon in the fifties, coronary artery bypass grafting spread all over the world. Since the nineties, the methods of surgical revascularization fell into two main categories, namely on-pump and off-pump procedures. Progresses in techniques not withstanding, there are still a significant number of patients who may not benefit from conventional techniques of myocardial revascularization due to diffuse coronary artery disease. Since a certain level of morbidity and mortality is associated with direct surgical or endovascular coronary procedures, the search is on for less invasive and less costly alternatives that ensure myocardial blood supply. Researchers are on the lookout for new revascularization methods also because of the many patients suffering from diffuse coronary artery disease who may not benefit from conventional techniques. Some alternative myocardial revascularization methods attempted in recent years bear a resemblance to techniques tried and abandoned in the first half of the last century. Earlier attempts to achieve myocardial revascularization may constitute a fertile pool of ideas. In the era of coronary stenting, research still needs to draw some old ideas to elaborate derivative strategies that employ the tools of modern technology. It is important for clinicians and researchers to know the historical steps which paved the way to current practice.
Almasri H. Hatem
Specialized heart center KAMC, Saudi Arabia
Title: Coronary artery reconstruction with internal mammary artery and vein patch grafting with or without endarterectomy
Biography:
Dr. Hatem Al-Masri is a cardiac critical care intensivist and consultant of cardiac surgery. Dr. Al-Masri completed his medical degree (M.D.-Doktorate) at Charles University – Faculty of Medicine, holds a degree in biochemistry from the University of Waterloo - Canada, completed his residency training in Germany (Leading Facharzt) and holds training fellowships in Cardiac Surgery from IJN KL Malaysia, Switzerland, and Canada. Dr. Al-Masri is the author of an award-wining medical research paper titled “Hemodynamic Support Requires Integrated Approach Comparing pl.VAD vs. IABP in Patients Experiencing Left Venticular Failure” (Best Paper of Young Cardiac Surgeon) at the 8th International Congress of Update in Cardiology and Cardiovascular Surgery (UCCVS 2012) awarded by European Society for Cardiovascular Surgery, World Society of Arrhythmias (WSA ) and the Society of Cardiology and the International Academic of Vascular and Endovascular Surgery (ISCP). Dr. Al-Masri is a member of the Medical German Association, Malaysian Medical Association and the Saudi Medical Council.
Abstract:
BACKGROUND: An increase in the numbers of patients with diffuse coronary artery disease who are referred to cardiac surgeons had necessitated the need of developing new techniques to establish the revascularization of specially young patients or elderly with high risks to undergo future re-do surgeries. Long-segmental reconstruction of the diffusely diseased left anterior descending (LAD) coronary artery with the left internal thoracic artery (LITA) and or venous patch has been shown to be beneficial for patients with diffuse coronary artery disease. In this retrospective study, we analysed the long-term outcomes obtained with this technique. METHODS: Between Jan 2003 and October 2007, 1500 coronary artery bypass grafting (CABG) operations were performed by our team. Of these cases, a number of patients were found to have diffusely diseased coronary arteries (mainly LAD) underwent a r long-segmental reconstruction procedure with a LIMA graft or saphenous venous patch with or without endarteriectomies. CONCLUSIONS: Patients with diffuse coronary artery disease present a major challenge for cardiovascular surgeons. The long-term results of long-segmental coronary artery reconstruction are very encouraging, and this approach may be used safely in this subgroup of patients. Coronary artery reconstructions with exclusion of plaques or associated with endarterectomy when plaques are too calcified or stiff produce good stable results in the long run. Coronary endarterectomy should be reserved for arteries that are truly inoperable by other procedures including exclusion of plaques out of the lumen of a new reconstructed coronary vessel using coronary artery reconstruction technique.
Alfredo Rodriguez
Sanatorio Otamendi hospital, Argentina
Title: Cardiac rupture in takotsubo cardiomyophaty
Time : 10:40 - 11:00
Biography:
Alfredo E. Rodriguez graduated from Córdoba National Medical University, Argentina at the age of 22, and has completed his PhD at 30 from the Cordoba Catholic Shool of Medicine. He is Director of Centro de Estudios en Cardiología Intervencionista, a premier Research Organization and Head of the Cardiology Department of Sanatorio Otamendi, Buenos Aires, Argentina. He has published more than 250 papers in major peer review journals and also was Editor of four cardiology books the last one published in September 2015 by Springer. He is editor-in-chief in the Journal “Revista Argentina de Cardioangiología Intervencionista” and has been serving as an editorial board member of worldwide repute Journals such as EuroIntervention, JACC Cardiovascular Interventions, World Journal of Cardiology journal, Drug Designing Journal (2014); Journal of Developing Drugs (2014). He is also frequent reviewer from major cardiology and interventional cardiology Journals
Abstract:
Takotsubo cardiomyopathy (TCM) was characterized by transient left ventricular dysfunction usually involving antero apical and infero apical regions of the myocardium with ST segment changes or T-wave inversion and minimal release of cardiac enzymes in the absence of significant coronary artery disease (CAD). TCM was in general associated with good prognosis, although a minority of patients develops severe hemodynamic complications, including cardiogenic shock, life-threatening arrhythmias and cardiac rupture (CR).Isolated left ventricular impairment is the most common variant of this entity, but right ventricular involvement is also recognized and was associated with poor prognosis. Until January 2015, 14 cases of CR have been reported; included right or left ventricular wall rupture or ventricular septal perforation (VSP) VSP was reported in 4 cases 2 of them who survived were treated with open heart surgery. We are reporting the case of a female patient with acute T waves changes in anterolateral leads in basal ECG, minor enzymes elevation; anterior and apical hipokinesia of the left ventricle and hipokinesia of the right ventricle observed at admission with transthoracic echocardiography (TE) and without significant CAD in the coronary angiogram, four days later she develop cardiogenic shock with left and right severe heart failure and in a new TE a VSP was observed and was located at 10mm of the left ventricular apex. The VSP was repaired successfully percutaneously using an Amplatzer device. Patient had a rapid improvement of her ventricular function and had hospital discharge three days later. TCM can be associated with severe complications including cardiac rupture and VSP. At our knowledge, this is the first reported case in the literature using a percutaneous endovascular technique to repair it.
Mohamed Ahmed-Nasr
National Heart Institute, Egypt
Title: Emergency surgery for cardiac valve prostheses obstruction Experience of a teaching hospital institution
Time : 11:00 - 11:20
Biography:
Mohamed AHMED-NASR is the Emeritus Professor of cardiac surgery and Ex Head of Surgery of The Egyptian Heart Institute Head of the department 1999-2005 and 2009 – until July 31st 2011 that performs around 3000 open heart procedures per year in addition to another 1000 cases in the different private Cairo clinics. He does perform by himself around 250 cases per year. He is still of the old generation that performs both adult and pediatric cardiac surgery. He is the Consultant of Cardio-Thoracic Surgery Misr International & Dar El Shefa Hospitals. He is the Minister of Health of the shadow cabinet of Al Wafd Party.
Abstract:
Aim of the work: Emergency valve prostheses obstructions are becoming increasingly common. Analysis of causes and results are shown Patients and Methods: Between January 2004 and December 2013, 885 cases of cardiac valve prostheses obstruction were done. 617 (69,7%) MVR; 147 (16,6%)AVR; 121 (13,6%) DVR. Out of the 617 MVR 9 (1,4%) were due to endocarditis ,608 cases were due to valve thrombosis out of them 316 (52%) were pregnant women. In Aortic postion 7 cases (4,7%) were due to endocarditis and 140 case due to thrombosis out of them 22 cases were pregnant women. DVR 110 were due to valve thrombosis and 11 (9%) due to endocarditis in aortic position. Total mortality 118/885 (13,3%)(13,3%)(13,3%) 338 cases were pregnant women out of them 310 cases (92%) continues preganacy. 16 cases had immediate caesarian section in the immediate post-operative with 6 infant mortalities. Conclusion: Endocarditis represents 1,4% in Aortic position; 9% in DVR; and 4,7% in mitral position. Pregnancy represents a major factor in valve prostheses thrombosis due to anticoagulation program shifting from oral anticoagulation to Heparine.
Ahmed A
University Hospital of Essen, Germany
Title: Survival analysis and postoperative complications after ventricular assist device implantation; prognostic value of intermacs scale
Time : 11:20 - 11:40
Biography:
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.
Abstract:
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.
- Workshop
Location: Berlin, Germany
Session Introduction
Fabiola B Sozzi
University of Milan, Italy
Title: Stress echocardiography: Clinical value and prognosis
Time : 11:55-12:40
Biography:
Fabiola B Sozzi works as a practicing cardiologist at the University Hospital Policlinico of Milan, IT. She worked in the Echolab of the Thoraxcentre, Rotterdam, NL where she defended her PhD thesis on cardiac imaging under the supervision of Professor Roelandt. She reached a high expertise in the non-invasive diagnosis of CAD using all the different available techniques: cardiac CT and MRI integrated with stressecho and nuclear. She also works in the acute clinical setting treating the acute cardiac disease. She is visiting professor at the University of Milan where she teaches and leads several research projects.
Abstract:
Stress echocardiography is a noninvasive cardiovascular diagnostic test that provides functional and hemodynamic information in the assessment of a number of cardiac diseases. Performing stress echocardiography with a pharmacologic agent such as dobutamine allows for simulation of increased heart rate and increased myocardial physiologic demands in patients who may be unable to exercise due to musculoskeletal or pulmonary comorbidities. Dobutamine stress echocardiography (DSE), like exercise echocardiography, has found its primary application in ischemic heart disease, with roles in identification of obstructive epicardial coronary artery disease, detection of viable myocardium, and assessment of the efficacy of anti-ischemic medical therapy in patients with known coronary artery disease. DSE features prominently in the evaluation and management of valvular heart disease by helping to assess the effects of mitral and aortic stenoses, as well as a specific use in differentiating true severe valvular aortic stenosis from pseudostenosis that may occur in the setting of left ventricular systolic dysfunction. DSE is generally well tolerated, and its side effects and contraindications generally relate to consequences of excess inotropic and/or chronotropic stimulation of the heart.
Guy Hugues Fontaine
Universite Pierre et Marie Curie, France
Title: Electrogenesis of Epsilon wave - A comprehensive review of this new ECG waveform
Time : 13:25-14:15
Biography:
Guy H Fontaine MD PhD HDR has made 15 original contributions in the design and the use of the first cardiac pace makers in the early 60s. He has serendipitously identified ARVD during antiarrhythmic surgery in the early 70s. He has developed the technique of Fulguration to replace surgery in the early 80s. He has been one of the 216 individuals who have made a significant contribution to the study of cardiovascular disease since the 14th century and one of the 500 greatest geniuses of the 21st Century (USA Books), one of the 100 life time of achievement (UK Book). He has > 900 publications including 201 book chapters. He is a reviewer of 17 scientific journals both in basic and clinical science. He has given 11 master lectures of 90 minutes each in inland China in 2014. He is now developing new techniques for brain protection in OHCA, stroke and spinal cord injury by hypothermia.
Abstract:
Epsilon wave was the name given to the second of double epicardial potentials recorded in patients with resistant ventricular tachycardia treated by antiarrhythmic surgery (Fontaine AHA abstract 1976). The timing of the first normal potential fell inside the QRS complex of the surface tracing; the second abnormal potential occurred after the end of the QRS complex. Other approaches were used to detect this delayed electrical activity which showed a spectrum of morphologies including fragmented potentials after the end of QRS complexes on the surface ECG, also called “Epsilon waves”. This anomaly was also recorded from an endocardial catheter, as well as on the standard ECG; more precisely on a bipolar precordial lead for Holter recording. It was also extracted by the summation averaging technique in patients who did not have Epsilon waves on the standard ECG despite the presence of epicardial Epsilon waves (Fontaine Kulbertus book 1977). Their behavior in sinus rhythm during stimulation and during VT has been described. Particular techniques have been studied to improve their detection on the surface ECG by increasing the sensitivity of the ECG recording, as well as filtering of the signal from an optimal bipolar precordial lead position (Fontaine Parmley book 1991). Detailed descriptions of these potentials suggest a post-excitation phenomenon due to an intramyocardial conduction defect well understood by the pathology of ARVD. This was consistent with a reentrant phenomenon. Finally, standardization of this approach led to the “Fontaine Lead System” (FLS) according to Dr. Willis Hurst who published in Circulation 1998 his discussion about “The naming of the waves in the ECG, with a brief account of their genesis”. The quantitative aspects on a new series of 43 patients were reported (Fontaine Ann Cardiol Angeiol 1993). We now present for the first time recording of Epsilon waves that are present before as well as after spontaneous episodes of ventricular tachycardia with an insertable loop recorder (Medtronic “Reveal”) in a patient with ARVD discovered after multiple episodes of acute myocarditis (Fontaine Europace in press). The brand new Schiller ECG High Definition machine will be able to detect more precisely fragmented potentials in the Epsilon wave and even inside the QRS complex in cardiomyopathies in general as well as in CAD. Conflict of interest: GF is a consultant for ECG machines, Defibrillators, new Chest compressor, Hypothermia for brain protection in OHCA and Stroke for the Schiller Company, Baar, Switzerland.
- Track 4: Interventional Cardiology Track 5: Echocardiography Track 6: Heart and Blood Vessel Surgeries
Location: Berlin, Germany
Session Introduction
Peter P Karpawich
The Children's Hospital of Michigan, USA
Title: Contractility (dP/dt-max)-guided determination of resynchronization pacing therapy for heart failure among patients with congenital heart
Time : 15:00-15:20
Biography:
Peter P Karpawich completed his Masters in Science degree from The University of Detroit and his Medical Degree from Hahnemann/Drexel University in Philadelphia, PA. He completed his Post-doctoral 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 the Founder and 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 250 scientific papers, textbook chapters and textbooks and is on the Editorial staff of several internationally-recognized medical journals.
Abstract:
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 patients 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, patients 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 improves patient selection and responder rates.
Almasri H Hatem
Specialized Heart Center KAMC, Saudi Arabia
Title: Coronary artery reconstruction with internal mammary artery and vein patch grafting with or without endarterectomy
Time : 15:20-15:40
Biography:
Al-Masri H Hatem is a cardiac critical care intensivist and consultant of cardiac surgery. He completed his medical degree (MD-Doktorate) at Charles University – Faculty of Medicine and holds a degree in Biochemistry from the University of Waterloo – Canada. He completed his residency training in Germany (Leading Facharzt) and holds training fellowships in Cardiac Surgery from IJN KL Malaysia, Switzerland and Canada. He is the author of an award-wining medical research paper titled “Hemodynamic Support Requires Integrated Approach Comparing pl.VAD vs. IABP in Patients Experiencing Left Venticular Failure” (Best Paper of Young Cardiac Surgeon) at the 8th International Congress of Update in Cardiology and Cardiovascular Surgery (UCCVS 2012) awarded by European Society for Cardiovascular Surgery, World Society of Arrhythmias (WSA) and the Society of Cardiology and the International Academic of Vascular and Endovascular Surgery (ISCP). He is a member of the Medical German Association, Malaysian Medical Association and the Saudi Medical Council.
Abstract:
Background: An increase in the numbers of patients with diffuse coronary artery disease who are referred to cardiac surgeons had necessitated the need of developing new techniques to establish the revascularization of especially young patients or elderly with high risks to undergo future redo surgeries. Long-segmental reconstruction of the diffusely diseased left anterior descending (LAD) coronary artery with the left internal thoracic artery (LITA) and or venous patch has been shown to be beneficial for patients with diffuse coronary artery disease. In this retrospective study, we analyzed the long-term outcomes obtained with this technique. Methods: Between Jan 2003 and October 2007, 1500 coronary artery bypass grafting (CABG) operations were performed by our team. Of these cases, a number of patients were found to have diffusely diseased coronary arteries (mainly LAD) underwent a long-segmental reconstruction procedure with a LIMA graft or saphenous venous patch with or without endarteriectomies. Results & Conclusion: Patients with diffuse coronary artery disease present a major challenge for cardiovascular surgeons. The long-term results of long-segmental coronary artery reconstruction are very encouraging and this approach may be used safely in this subgroup of patients. Coronary artery reconstructions with exclusion of plaques or associated with endarterectomy when plaques are too calcified or stiff produce good stable results in the long run. Coronary endarterectomy should be reserved for arteries that are truly inoperable by other procedures including exclusion of plaques out of the lumen of a new reconstructed coronary vessel using coronary artery reconstruction technique.
Alfredo E Rodriguez
Centro de Estudios en CardiologÃa Intervencionista, Argentina
Title: Modifying syntax score according to PCI strategy: Lessons learnt from ERACI IV study
Time : 15:40-16:00
Biography:
Alfredo E Rodriguez graduated from Córdoba National Medical University, Argentina and completed his PhD from the Cordoba Catholic School of Medicine. He is Director of Centro de Estudios en Cardiología Intervencionista, a premier Research Organization and Head of the Cardiology Department of Sanatorio Otamendi, Buenos Aires, Argentina. He has published more than 250 papers in major peer review journals and also was Editor of four cardiology books the last one published in September 2015 by Springer. He is Editor-In-Chief of the Journal “Revista Argentina de Cardioangiología Intervencionista” and has been serving as an Editorial Board Member of worldwide repute Journals such as Euro-Intervention, JACC Cardiovascular Interventions, World Journal of Cardiology, Drug Designing Journal (2014), Journal of Developing Drugs (2014). He is also frequent reviewer from major cardiology and interventional cardiology Journals.
Abstract:
Recently, an angiographic score was introduced in clinical practice to stratified different levels of risk after PCI. The SYNTAX score (SS) classified patients in three different risk levels. Patients allocated with low SS could be equally treated with either PCI or CABG, whereas those with intermediate or high SS were better off with CABG. However, using original SS each coronary lesion with a diameter stenosis ≥50% in vessels ≥1.5 mm was scored. In contrast, in ERACI IV study, which included patients with multiple vessel disease and unprotected left main stenosis treated with 2nd generation DES, we used a revascularization strategy during PCI where operators were advised to only treat lesions ≥ than 70% in a ≥ 2.0mm reference vessel; therefore, no intermediate lesions should be treated and severe stenosis in vessels ≤ 2.0 mm was discouraged as well. If we recalculated SS using the above-mentioned operators' advices all intermediate lesions were not scored and severe stenosis in vessels < 2.0 mm were excluded for the analysis; after this new scoring, the original SS dropped from 27.7 to 22. More over after this new scoring in ERACI IV, low SS rose to 54.8%, intermediate dropped to 27.9% and only 17.2% of ERACI’s patients scored a high SS. At 24.5 months of follow up, MACCE rate was only 6.7%, composite of death/MI and stroke was 3.6% and unplanned new revascularization 4%. In conclusion, if we performed a SS scoring only severe stenosis in vessels with a reference diameter ≥ 2.0 mm would allow a more rational assessment of coronary anatomy which was associated with low events rate at 2 years of follow up.
Ehab E El-Hefny
Al-Azhar University, Egypt
Title: Role of 2-dimensional speckle tracking echocardiography in diagnosis of coronary artery disease instable angina pectoris patients
Time : 16:00-16:20
Biography:
Ehab E El-Hefny is a Graduate of Al-Azhar University in Cairo, Egypt and specialized in Cardiology since being a resident in the Department of Cardiology. He did his international training in the University of Pittsburgh Medical Center, USA (Preventive Cardiology) and later in the University of Britania Occidentale in France (Interventional Cardiology). He is the Full Professor of Cardiology and Director of the Cath lab, Al-Azhar University Member of the post graduate teaching and examining board. He supervised and evaluated more than 40 research projects for Master and Doctorate degrees in national universities in Egypt. He is the consultant of the National health organization in Egypt and also Reviewer in the Egyptian Journal of Hospital Medicine.
Abstract:
In this work 120 patients suspected of having stable angina pectoris were included, they were presented for evaluation of chest pain and to whom clinical evaluation, echocardiography, nuclear scanning and coronary angiography were done. They were classified into group (A) 40 control patients considered as control group with normal coronaries, and group (B) 80 patients with significant CAD. The study showed that regarding the echo parameters, there were statistically significant differences between the 2 groups regarding the A wave, E/A ration, DT, Em and E/EM also regarding SLSS and GLS 17 and GLS 12 as well as SLSr, GLSr 17 and GLSr 12. Significant difference was present regarding number of vessels affected as regard GLS 12, GLSr 12 and GLSr 17. In comparison with the results of MPI, there were positive correlation between the number of segments affected in MPI and GLS 12 and GLSr 12. A statistically significant correlation was also found between the 17 segments in MPI, SLSS and SLSr parameters. Myocardial strain by speckle tracking is superior to conventional echo. Parameter measurements of global and segmental LS using 2DSE and it is more sensitive tool in the identification of WMA at rest than visual analysis and that support its use to risk stratifies atherosclerotic CAD. It is found that 2DSE is not inferior to the MPI in the non-invasive diagnosis of CAD.
Krasimira Hristova
National Heart Hospital, Bulgaria
Title: Three dimensional right ventricle function
Time : 16:20-16:40
Biography:
Krasimira Hristova is a consultant cardiologist and expert in echocardiography at National Cardiology Hospital and a consultant in cardiology at University Women Hospital "Nadejda". She has defended a Doctorate on the application of new echocardiographic methods for assessing myocardial deformation in patients after acute myocardial infarction. She has specialized in prestigious universities in Austria and Belgium. She received Master's degree in the field of Advance Medical Imaging in Cardiology at the Catholic University in Leuven, Belgium. She is an author of many scientific articles and is a prize winner for a young investigator award of the International Society of Hypertension in 2006, as well as a number of awards at national and international organizations. She was a secretary and currently the President of the working group on echocardiography in Bulgarian Society of Cardiology, Member of the Board of the European Association of Echocardiography and the Scientific Committee of the American Society of Echocardiography. She is the Visiting Professor in Creighton University- Omaha, Nebraska, USA. Sinse December 2013, she is a member of the Board of Directors of the World Hypertension League.
Abstract:
Noninvasive assessment of RV function nowadays, is mainly priority on 3-Dimensional echocardiography. 3D Echocardiography overcomes the difficulties in estimating RV volumes and function in different diseases. RV is systemic pumping chamber, facing increasing after load in CHD, cardiomyopathies, pulmonary hypertension. Difficult anatomy on the RV with heavy trabecularization make determination of blood-endocardial border difficult, missing of axis of symmetry complicate the task of geometry remodeling. Despite all these difficulties assessing RV volumes and function is crucial in the clinical management in patients with CHD. The Recommendations suppose assessing on RV function- volumes and EF to perform with 3D echocardiography. The results from different studies showed very high correlation on the results from MRI data assessing. The method is very simple, fast and with high accuracy to perform RV volumes and EF.
Aldo Pietro Maggioni
ANMCO Research Center, Italy
Title: The real world evidence of heart failure: A model of epidemiological research using of administrative big databases.
Time : 11:40 - 12:00
Biography:
Aldo Maggioni received his medical degree from the University of Milan, School of Medicine, where he also completed a fellowship in internal medicine. He performed a residency in cardiology at the University of Padua before becoming a clinical cardiologist in the Division of Cardiology at General Hospital “G. Fornaroli” in Magenta, Milan, then at General Hospital Fatebenefratelli ed Oftalmico, also in Milan. Aldo Maggioni is Member of the Steering Committee of the GISSI studies and Director of the Research Center of the Italian Association of Hospital Cardiologists in Florence. Since 2010 Dr Maggioni is the Scientific Coordinator of the EURObservational Research program of the European Society of Cardiology. Aldo Maggioni served as a member of the Steering Committee, Event Evaluation Committee, Data and Safety Monitoring Board of more than 50 clinical studies in areas including myocardial infarction, secondary prevention, diabetes, stroke, and acute and heart failure. Dr. Maggioni is author of about 500 peer reviewed papers and has been included in the list of the highly cited researchers over the last 11 years (2002-2013) by Thomson Reuters.
Abstract:
Aims: Patients with heart failure (HF) randomized in controlled trials are generally selected and do not fully represent the “real world”. The purpose of this presentation is to better describe the characteristics of HF analyzing administrative data of a population of nearly 2,500,000 subjects. Methods: Data came from the ARNO Observatory including in-habitants of 5 Local Health Units of the Italian National Health Service (INHS). Patients were selected when discharged for HF (January 1, 2008 - December 31, 2012). Clinical characteristics, pharmacological treatments, rate and reasons for re-hospitalization and direct costs for the INHS occurring during 1 year follow-up (FU) were described. Results: Of the 2,456,739 subjects included in the database, 54,059 (2.2%) were hospitalized for HF: 41,413 were discharged alive and prescribed on HF treatments. Mean age was 78±11 years, females accounted for 51.4%. Just 26.6% were managed in a cardiology setting. The more frequent co-morbidities were diabetes (30.7%), COPD (30.5%) and depression (21%). ACE-inhibitors/Angiotensin Receptor Blockers, Beta-Blockers and Mineralocorticoid antagonists were prescribed in 65.8, 49.7 and 42.1% of patients. During 1-year FU at least one re-hospitalization occurred in 56.6% of patients, 49% of them were due to non-cardiovascular causes. INHS’s direct cost per patient per year was 11,867€ of which 76% related to hospitalizations. Conclusions: Real world evidence provides a description of patients’ characteristics and treatment patterns that are very different from those reported by randomized clinical trials. Costs for the INHS are mainly driven by hospitalizations which are often due to non-cardiovascular reasons.
Robert Skalik
Medical University of Wroclaw, Poland
Title: Neglected mechanisms of cardiopulmonary capacity in health and heart failure - Why brain and heat stress really matter ?
Time : 12:00 - 12:20
Biography:
Robert Skalik, MD, PhD, consultant in cardiology, exercise physiologist. He completed his PhD in echocardiography from Medical University of Wrocław. He covered internship in Department of Cardiology, Free University of Amsterdam, the Netherlands, lecturer in Postgraduate School of Cardiology, University of Perugia, academic teacher and researcher in Department of Physiology, former consultant in cardiology in Department of Cardiac Surgery and Cardiology, Medical University of Wrocław, former Head of Department of Cardiac Rehabilitation, Wrocław , private practice in cardiology, Wrocław, research projects evaluator for EU. He has published 103 papers on cardiology and human physiology.
Abstract:
Physical capacity is a complex process and may be subject to significant modulation due to intensity of aerobic and anaerobic processes, efficacy of thermoregulation, psychomotor performance and psychological factors irrespective of normal functioning of the cardiovascular and musculoskeletal systems. Hence, the dynamics and magnitude of changes in core body temperature in response to acute physical exercise in cardiopulmonary exercise test (CPX) and their relationship to exercise capacity have not been elucidated yet. The role of the cortical centers in modulation of fatigue perception in physically active people is also controversial. The cerebral cortex is a significant determinant of psychomotor performance. The results of the study confirmed a significant relationship between core body temperature at maximal physical effort (Tc ) in CPX and psychomotor performance in healthy amateur athletes. The psychomotor performance was also related to carbon dioxide output at maximal physical exercise, ventilatory equivalent for carbon dioxide at the anaerobic threshold. Thermometabolic (VO2AT divided by Tc) and neurothermometabolic (VO2AT divided by the sum of Tc and psychomotor performance score) index are strongly related to parameters of exercise capacity as measured at maximal physical effort during CPX (VE, VCO2). The Rate of Perceived Exertion (Borg scale) immediately after CPX is not related to Tc, exercise capacity parameters and psychomotor skills. The magnitude of changes in core body temperature during CPX may affect the parameters of physical fitness through modulation of psychomotor skills. Psychomotor performance influences ventilatory parameters. Subjective perception of physical effort does not correlate with exercise capacity parameters in CPX.
Zaid Altheeb
New York Medical College, USA
Title: Value of neutrophil to lymphocyte ratio as a predictor of mortality in patients with heart failure with preserved ejection fraction
Time : 13:05 - 13:25
Biography:
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. Member in American college of physicians ACP. Member in American College of Cardiology ACC. Publications in the field of cardiovascular medicine
Abstract:
Background Inflammation plays an important role in left ventricular remodeling and myocytes hypertrophy and remodeling. Higher levels of inflammatory markers, like IL-6, TNF-a, and CRP, were found in patients with heart failure with preserved ejection fraction (HFpEF). Neutrophil to lymphocyte ratio (NLR) represents a widely available, nonspecific marker of systemic inflammation. It was validated as a significant predictor of adverse outcomes in multiple cardiovascular diseases, such as acute coronary syndrome and valvular heart disease. In this study we aimed to explore the utility of NLR as a predictor of long-term mortality in patients with HFpEF. Methods 376 patients admitted to our hospital between 2010 and 2012 for acute HFpEF exacerbations were evaluated for study inclusion. 296 patients met the study inclusion criteria. Depending on the initial NLR level, patients were divided into two groups; NLR >= 4.5 and NLR < 4. Three-year vital status was obtained via electronic medical records and Social Security Death Index. Survival analysis was used to evaluate the predictive value of NLR level between these two groups. Results There was a higher all-cause 3-year mortality (6.8% vs 15.3%, Chi-squared 4.6, p 0.033) in patients with NLR >= 4.5 when compared to those with NLR =4.5 (84.7% vs 93.2%, Chi-squared 5.423, P 0.02, HR 2.3456, CI 1.19-4.64). Using univariate Cox proportional-hazards regression analysis, patients with NLR >=4.5 had 2.35 fold increase in 3-year mortality when compared to those with NLR < 4.5 (HR 2.35, CI 1.12-4.79, P 0.0244). In a multivariate cox regression analysis, with the adjustment for age, sex, race, history of coronary artery disease, stroke, hypertension, diabetes, end-stage renal disease and tobacco use, NLR remained a significant independent predictor of 3-year mortality and patients had a 2.53 fold increased risk of mortality (HR 2.53, CI 1.14-5.62, P 0.0229). Conclusions NLR, using a cutoff value of 4.5, represents an independent predictor of long-term mortality in patients with HFpEF.
Govindan Vijayaraghavan
Kerala Institute of Medical Sciences, India
Title: Septic myocarditis is mainly due to cardiac failure without significant myocardial necrosis
Time : 13:05 - 13:25
Biography:
Govindan Vijayaraghavan is a cardiologist from India, credited with establishing the first 2D Echocardiography laboratory in India. He is the vice-chairman & Founder Director of the Kerala Institute of Medical Sciences and the President of the Society for Continuing Medical Education and Research, Trivandrum, Kerala. He was honoured by Government of India in 2009 for his services in the field of medical sciences by awarding him Padmashri
Abstract:
Background: Sepsis patients with myocardial injury has very high mortality(30-60%).Only a few studies incorporating electrocardiography, high sensitive troponin T(hsTnT), N-terminal pro-BNP(pro-BNP) and echocardiography has been conducted in these patients . Methods and Results: Out of 204 patients with sepsis enrolled, 111 patients satisfied the inclusion criteria and 103 completed the study. Myocardial injury was defined by elevation of hsTnT > 25 pg/ml. Initial hsTnT, pro-BNP and 2D echocardiography were repeated if sepsis progresses. Primary and secondary end point were in hospital mortality and left ventricular dysfunction(LVD).Simple sepsis was diagnosed in 45%; 19% had septic shock and 36% developed severe sepsis. male predominance(63%) with majority being diabetic (66%) and above 50 years of age (54%).Sinus tachycardia was present in 65% and T inversion in inferior leads in 32%.Systolic dysfunction(SD) was present in 42%, diastolic dysfunction (DD) in 21% and 21% had both SD and DD. HsTnT was elevated in 84% of the patients. Both HsTnT and pro-BNP were significantly correlated with LVD (p<0.001).Though pro BNP and HsTnT vary in different levels of LVD (table1), variation was more marked with pro-BNP. Both levels were lesser in DD than SD. Grade III DD was always associated with severe SD .Pro-BNP had significant correlation with pro-calcitonin level (p<0.001) and APACHE II score (p<0.001); HsTnT had significant correlation only with APACHE II score (p<0.001). CRP level did not have correlation with cardiac markers. In hospital mortality was 8%.In survivors hsTnT was 158pg/ml and pro-BNP was 6400 pg/ml.In non-survivors hsTnT was 256 pg/ml (p<0.047) and pro-BNP was 21805pg/ml(p<0.001).Pro BNP has better correlation with the survival. ROC curve showed that a pro-BNP level >8530 pg/ml signified with mortality (sensitivity-100% and specificity-80%) and HsTnT level >178pg/ml correlated with mortality with 88% sensitivity and 71% specificity. Base line creatinine was normal in all patients; 55% had elevated creatinine during the sepsis and had linear correlation with hsTnT level (p<0.01). Conclusion: Pro-BNP is a powerful tool for prognostication in sepsis with myocardial dysfunction and a value>8530 pg/ml signified decreased survival with 100% sensitivity. The significant elevation of pro-BNP with minimal elevation of hsTnT indicated that the pathophysiology is mainly myocardial stretch and not myocardial necrosis in sepsis; with full recovery in survivors. Table 1: distribution of pro-BNP and HsTnT in LVD (*21% had combined LVD) ECHOCARDIOGRAPHY % Mean pro-BNP(pg/ml) Mean HsTnT(pg/ml) Normal 16 2433 (700-4100) 76 (<25-160) Mild LV SD 11 5481 (3200-9200) 210 (80-360) Moderate LV SD 13 9608 (5400-16100) 254 (150-480) Severe LV SD 18 16844 (7200-25000) 268 (148-450) Grade I DD 8 3132 (1024-5250) 117 (60-220) Grade II DD 13 6596 (3500-9000) 125 (26-240)
Rohit Sane
Madhavbaug Cardiac Rehabilitation Centre, India
Title: Functional capacity is an independent predictor of mortality in heart failure patients with low ejection fraction
Time : 13:25 - 13:45
Biography:
Rohit M Sane, MBBS, is a pioneer of non-invasive cardiac care management. Dr. Rohit Sane is the Founder of Madhavbaug Cardiac Rehabilitation Center which includes 138 OPDs & 2 IPDs in Maharashtra, India. For more details log on to www.madhavbaug.org
Abstract:
Abnormal six-minute walk test (6MWT) findings which indicates decreased functional capacity is considered as predictor of increased cardiovascular risk and mortality. However, the importance of this variable as predictor of mortality in heart failure (HF) patients with low ejection fraction (EF) is not well established. Therefore, we aimed to determine the influence of 6MWT findings on prediction of cardiac-related mortality in patients with low EF. Analyses were based on 108 heart failure patients with low EF undergoing treatment at Madhavbaug Cardiac Rehabilitation Centre between January 2012 and January 2014. Estimated functional capacity measured through 6MWT findings (expressed as the distance walked in meters) to determine its prognostic importance during 3 years of follow-up. Of 128 patients, 50 (39%) died during follow-up; all reported deaths were found to be as cardiac related. In survived patients group, the distance walked was greater than 409.72(±93) meter while in died patients group, it was less than 300.17(±124) meter. The 2D echo data suggested that in both the groups, the left ventricular mass was 290 g and ejection fraction was 28.7 % and 26.62 % in survived and died patients, respectively. On univariable analysis, estimated functional capacity measured through 6MWT findings was a strong predictor of death, with 50 (39%) deaths occurring in patients achieving p< 0.05. On multivariable analysis, the strongest independent predictors of cardiac related mortality were poor functional capacity. The distance walked by patients in 6MWT had strong relation to the number of reported deaths, functional capacity was a predictor of death. For reported cardiac mortality, functional capacity remained as independent predictor of mortality.
Makoto Suzuki
Sakakibara Heart Institute, Japan
Title: An inspection of therapeutic hypothermia preceding coronary reperfusion in patients with a cardiogenic shock complicating anterior ST-segment elevation myocardial infarction
Time : 13:45 - 14:05
Biography:
Makoto Suzuki is a cardiologist Cardiovascular Medicine, Sakakibara Heart Institute, Tokyo, Japan. His main research interests are myocardial infarction, coronary inflammation, myocardial mal-reperfusion, cardiology.
Abstract:
We retrospectively investigated our hypothesis that pre-percutaneous coronary intervention (PCI) procedural therapeutic hypothermia may have clinical advantages in patients with a profound cardiogenic shock complicating anterior ST-segment elevation myocardial infarction (STEMI). Methods: Of 483 consecutive patients treated with PCI for a first anterior STEMI including 31 patients with aborted sudden cardiac arrest between 2009 and 2013, a total of 37 consecutive patients with an anterior STEMI complicated with profound cardiogenic shock defined as the presence of hyperlactic acidemia (serum levels of lactate N4 mmol/L) with mechanical circulatory support were identified. An impaired myocardial tissue-level reperfusion (angiographic myocardial blush grade 0 or 1) and in-hospital mortality were evaluated in accordance with the presence or absence of pre-PCI procedural therapeutic hypothermia. Results: Thirteen patients were treated with pre-PCI procedural therapeutic hypothermia and 24 were not inducted with therapeutic hypothermia. Five patients with and 18 without pre-PCI procedural therapeutic hypothermia impaired myocardial tissue-level reperfusion (38% vs. 75%, p = 0.037). A total of 26 patients with in-hospital death (overall in-hospital mortality 70%) were composed of 6 with and 20 without therapeutic hypothermia (in-hospital mortality 46% vs. 83%, p = 0.028). A multivariate analysis demonstrated a significant association of pre-PCI procedural therapeutic hypothermia (p=0.021)with in-hospital survival benefit. Adverse events associated with therapeutic hypothermia were not found in 12 patients who completed this treatment. Conclusions: The present study may imply a crucial possibility of clinical benefits of pre-PCI procedural therapeutic hypothermia in patients with a cardiogenic shock complicating anterior STEMI
- Symposium
Location: Berlin, Germany
Session Introduction
Paul Peter Lunkenheimer
University of Muenster, Germany
Title: The ventricular mass is structured to function as an antagonistic system
Biography:
Paul Peter Lunkenheimer is a Professor of Cardiac Surgery at University Hospital Münster, Germany. He completed many projects like Harmonic partial left ventriculectomy using a Saugglockentechnik: Simplified Terminal technology, protecting the coronary arteries, preoperative diagnostic, structural and functional responses to the radius reduction.
Abstract:
Introduction: Throughout the 20th century, it has generally been accepted that the cardiomyocytes making up the ventricular mass contract exclusively in centripetal direction. The validity of the law of Laplace depends on that prerequisite, as does the diagnostic reliability of hemodynamic measures such like intra-cavitary pressures, cardiac output and the velocity of aortic blood flow. The background to this notion was the postulate of Otto Frank that all cardiomyocytes are aggregated together in strictly tangential fashion relative to the epicardial surface plane. There is now increasing structural and functional evidence, however, that the cardiomyocytes are capable simultaneously of producing constrictive and dilating forces. Myocardial structure: Using macroscopic peeling, histology, diffusion tensor magnetic resonance imaging, and pneumatic distension followed by computed tomography, we have identified a wide range of angular deviations of the aggregated cardiomyocytes from the strictly tangential arrangement, with the measured angles ranging between 0 and 45 degrees relative to the epicardial surface plane, with some exceeding 45 degrees during systole and in the setting of hypertrophy. Contractile function: Measurements of developed forces throughout the left ventricular walls by means of needle force probes have confirmed the presence of two types of signal in human, as well as in animal, hearts. Auxotonic forces are generated in the two-fifths of the myocardial aggregates that deviate from the tangential alignment, are functioning partially to counteract systolic mural thickening. The anticipated unloading forces are generated by the remaining aggregates, which are aligned tangentially to produce cavity constriction and mural thickening. Intrinsic antagonism: The two forces simultaneously act in opposite direction, thus providing an antagonistic system to facilitate rapid ventricular dilation during early diastole, to stabilize ventricular shape and to optimize the timing of the sequence of local mural inward motion. The intrinsic antagonism, nonetheless, is prone to dysfunction, especially in the settings of hypertrophy and fibrosis. This is because, with progressive mural thickening, there is a dramatic increase in the deviation of the aggregates from their predominant tangential alignment. Asymmetrical sensitivity to inotropic stimulation: We have also shown that the aggregates that generate auxotonic forces are significantly more sensitive to positive and negative inotropic stimulation than those generating the unloading forces. The intrinsic antagonism, therefore, is susceptible to appropriate selective therapy. This is particularly the case in the setting of hypertrophy, since during cardiac surgery we have shown the antagonistic forces to be critically augmented.
Peter F Niederer
ETH Zurich, Switzerland
Title: The architecture of the mammalian left ventricle: Similarity with a bird's nest?
Biography:
Peter F Niederer is an Emeritus Professor at the Institute of Biomedical Engineering, ETH Zurich, Switzerland. He is also the President of the IT'IS Foundation.
Abstract:
In order to demonstrate the hierarchically ordered connectivity of the left myocardium, gentle inflation by compressed air and subsequent CT-based analysis was performed on excised pig hearts. Perimysial spaces become thereby visible and allow demarcating lamellar segments. In addition to the well-known global helical pattern of the spatial direction field, a quite inhomogeneous arrangement with respect to lamellar segment orientation manifests itself. In particular, up to 30% of the lamellar segments deviate significantly, by more than 10° (up to 45 and more degrees) from a surface-parallel direction. Visual impression might in fact suggest some similarity with a bird’s nest. These findings along with force measurements made in the ventricular wall can be interpreted as follows. First, constrictive units with a primarily transmural orientation counteract to some extent systolic constriction and act in an antagonistic fashion. This feature may on the one hand be protective (excessive deformations are avoided), on the other, modulation of wall thickening according to local conditions is enabled. Second, architectural variations are expected to be such as to prohibit local stress concentrations and equalize overall loading conditions. Geometrically regular fiber architectures were examined in the form of mathematical models that showed, among other, that even slight disturbances of a regular pattern lead to a significant loss of cardiac performance. In contrast, in case of architecture involving appreciable stochastic local aberrations, even large changes seem to have a minor effect on the ejection fraction thereby stabilizing ventricular function over a wide range of physiological conditions.
Morten Smerup
Copenhagen University Hospital, Denmark
Title: Structure-function relationship in myocardial sub-structures
Biography:
Morten Smerup is from the Department of Cardiothoracic Surgery, Copenhagen University Hospital, Denmark. He has surgical experience of +50 general surgical cases, incl. appendectomies, herniotomies and gall-bladder surgery, +50 CABG cases, Thirteen aortic valve replacements and one tricuspid valvuloplasty, fifteen ASD cases, three partial AVSD cases, four VSD cases, two pulmonary valve replacements (both re-dos), two BT-shunts, three coarctation repairs, two RVOTO, one pulmonary artery banding, one subaortic membrane and more than 50 standard pediatric cannulation procedures.
Abstract:
From an anatomical point of view the individual myocytes making up left ventricular walls are organized as an anisotropic three-dimensional mesh. This can be characterized in terms of the myocyte angulation relative to the overall geometry of the heart, i.e. helical angles, transmural angles and transverse angles, but also in terms of the organization of the myocytes and the connective tissue of the heart into superstructures, the myocyte aggregates (also called myocardial sheets or –lamellae), which can be further characterized according to their relation to the overall geometry. From a functional point of view, the deformation of the cardiac walls has been extensively described using strain theory on local cuboids of myocardium, characterizing the so-called principal and shear strains. However only lately there has been a satisfactory synthesis of the anatomical and the functional aspects of the myocardium. In this talk I will attempt to describe the fundamentals with an emphasis on the clinical impact for practicing cardiologists, based upon experimental data on the diastolic and systolic architecture in normal, hypertrophic and dilated porcine hearts. Furthermore, novel theories on potential mechanisms in heart development that govern the final arrangement of the myocardium are presented.
Boris Schmitt
Deutsches Herzzentrum Berlin, Germany
Title: MRI-3D-tagging insight into beta-blocker pharmaco-dynamics on the left ventricle supports theory of inner antagonism
Biography:
Boris Schmitt completed his medical studies in Freiburg, Innsbruck and Berlin. In 2001 he started his career as a Pediatrician at the DHZB in the department of congenital heart disease. He completed his Doctoral thesis in 2005 and his medical specialization in Pediatrics in 2007. He returned to DHZB and became a member of the cardiovascular MRI team. He has been the team leader of KidCathLab since the very beginning in 2009. When the group came to life he shifted his focus from clinical work to research activities. His main interests and abilities are pediatric cardiology, catheterization and imaging. And most importantly, he has an open (h) ear (t) for new ideas. He is also a co-founder of a company for planning, implementation and marketing of telemedicine networks and he is certified in mountain and expedition medicine.
Abstract:
Beta-blockers contribute to treatment of heart failure. Their mechanism of action, however, is incompletely understood. Gradients in beta-blocker sensitivity of helically aligned cardiomyocytes compared with counteracting transversely intruding cardiomyocytes seem crucial. We hypothesize that selective blockade of transversely intruding cardiomyocytes by low-dose beta-blockade unloads ventricular performance. Cardiac magnetic resonance imaging (MRI) 3D tagging delivers parameters of myocardial performance. We studied 13 healthy volunteers by MRI 3D tagging during escalated intravenous administration of esmolol. The circumferential, longitudinal and radial myocardial shortening was determined for each dose. The curves were analyzed for peak value, time-to-peak, upslope and area-under-the-curve. At low doses, from 5 to 25μg/kg/ min, peak contraction increased while time-to-peak decreased yielding a steeper upslope. Combining the values revealed a left shift of the curves at low doses compared with baseline without esmolol. At doses of 50 to 150μg/kg/min, a right shift with flattening occurred. In healthy volunteers we found more pronounced myocardial shortening at low compared with clinical dosage of beta-blockers. In patients with ventricular hypertrophy and higher prevalence of transversely intruding cardiomyocytes selective low-dose beta-blockade could be even more effective. MRI 3D tagging could help to determine optimal individual beta-blocker dosing avoiding undesirable side effects.
Christoph Brune
University of Twente, The Netherlands
Title: The automatic framework for quantitative 3D myocardial structure analysis
Biography:
Christoph Brune is a tenure track Assistant Professor for computational mathematics (NWO, NDNS+) in the Department of Applied Mathematics at the University of Twente. In 2011-2012, he was a CAM Assistant Adjunct Professor in the Department of Mathematics at University of California Los Angeles (UCLA) working together with Prof. Andrea Bertozzi and Prof. Stanley Osher on projects in inverse problems, 4D imaging/image processing, optimal transport and machine learning. He taught classes and supervised Bachelor, Master and PhD students.
Abstract:
Obtaining a quantitative micro-structure analysis of the myocardium is essential to its understanding as a structured continuum. To address the interplay of structure and intrinsic antagonistic function of the myocardium while comparing normal and diseased hearts there is a strong need for an automatic, robust and precise framework to measure in a rapid procedure the 3D arrangement of bundles of cardiomyocytes. In this work we focus on pneumographic micro-CT measurements of porcine hearts. The main contribution is an automatic framework for quantitative 3D structure analysis of the whole myocardium with the same impressive resolution like the measured data. Prior to and during micro-CT- imaging the myocardial interstitial space was slightly pneumatically distended for better discrimination of the heart muscle´s lamellar basic structure. Compressed air was perfused through the coronary arteries, resulting in an isolated distension of the perimysial inter-lamellar space, while the dense endomysial compartment was not reached by gas. CT-imaging was performed in a Scanco Medical micro-CT device. Via novel mathematical imaging techniques and efficient computer algorithms, adequate for very high-resolution data sets, we can obtain precise quantitative values of helical and intruding angles at each voxel of the myocardium. The mathematical framework is based on three main steps: (1) a preprocessing component, where fine fibre structures are enriched by nonlinear anisotropic noise filters and simultaneous contrast enhancement, (2) an orientation estimation component, which uses novel structure tensor methods to compute the local orientation at each voxel and (3) an advanced automatic segmentation method which extracts a 3D surface of the myocardium and simultaneously computes normal vectors, serving as precise reference directions for computing helical and intruding angles given by (2). With this imaging tool we can quantify global alignment of heterogeneously interconnected networks of lamellar units. Due to the full coverage of the cardiac mesh and simultaneous segmentation we can also analyze and compare angular distributions between different myocardial compartments. We measure a particularly high prevalence of intruding and extruding structures which deviate from the tangential alignment and which are inclined towards endocardium and epicardium with angles exceeding 40 degrees. Computed helical and intruding angles in the whole myocardium are pivotal data to explain form-stabilizing structures as well as those which drive ventricular wall motion. In the future this might allow further analysis of the relative prevalence of constrictive as compared to dilative forces. According to histological findings and underlined by data from direct measurements of contractile forces in normal and diseased hearts, the relationship of those two opposing forces is disturbed, resulting in a derailment of the intrinsic antagonism of the myocardium, particularly in cases of ventricular hypertrophy which in most cases is complicated by fibrosis.
Robert Stephenson
University of Central Lancashire, UK
Title: The structural heterogeneity of the cardiac mesh revealed by high-resolution micro-CT
Biography:
Robert Stephenson is Lecturer in Medical Sciences-Anatomy, School of Dentistry; University of Central Lancashire, United Kingdom.
Abstract:
The intricate micro-structure of the heart and its relationship with cardiac function has been debated for decades, without current consensus. Therefore scientists and clinicians strive to improve our understanding of cardiac anatomy in 3D and provide 4D explanations of its role in contractile function in health and disease. Ex-vivo contrast enhanced micro-CT utilizes the same principles as clinical CT, producing 3D tomographic images non-destructively. Micro-CT, however, permits spatial resolutions approaching the scale of individual cells (5-20 μm). Our iodine based contrast agent allows differentiation of multiple soft tissue types; fat, myocardium, conduction system and extracellular matrix show decreasing X-ray absorption and thus grayscale values respectively. Using micro-CT to image human and rabbit hearts ex-vivo, we reveal the true structural heterogeneity of the heart in 3D and provide new insight into the structural basis for antagonistic forces generated within healthy and failing hearts. We show how the myocyte chains aggregate to form a heterogeneous interconnected network of lamellar units, bound internally by dense endomysium and externally by sparse perimysium. The units are seen to be complex and variable 3D structures, which exhibit sheet, cord and branched elements. They maintain the helical myocyte arrangement, but can twist and intrude radially, occasionally forming orthogonal abutments with adjacent units. We have obtained 3D myocyte orientation at near cellular resolution. Using computer algorithms we extract the helical and intrusion angle of the myocytes on a voxel by voxel basis; the longitudinal chains they form are then tracked and visualized in 3D. Thus we reveal the heterogeneity of myocyte arrangement, showing the classic helical depictions to be over-simplified. Many myocytes have intruding angles greater than 20°, with an increased population observed in the sub-endocardium. This number is reduced in regions of dilatation in failing hearts, potentially hampering diastolic filling and reducing intrinsic stability thus perpetuating dilatation. This data gives new insight into the structural heterogeneity of the cardiac mesh, revealing the complex 3D morphology and interactions between the lamellar units and myocyte chains housed within them. We show how the intrusion of chains of myocytes offers a structural basis for intrinsic antagonism, and show how myocyte intrusion is reduced in regions of dilatation, providing new information on contractile dysfunction in the setting of intrinsic antagonism.