Day 1 :
Keynote Forum
S Jamal Mustafa
West Virginia University, USA
Keynote: Coronary flow regulation and it’s signaling by adenosine
Time : 09:00-10:00
Biography:
S Jamal Mustafa is a Professor of Pharmacology at West Virginia University School of Medicine and a Senior Advisor to the Pilot Core of the West Virginia Clinical Science and Translational Institute. He has served as an Assistant Dean for Research at the Health Sciences Center from 2005-15. He has received Dean’s
Award for Excellence in Research from School of Medicine in 2008 and became a Robert C Byrd Professor in 2010. In addition, he received Chancellor’s Award for Outstanding Achievement in Research and Scholarly Activities from Health Sciences Center in 2013. He had published over 200 manuscripts. For almost 40 years, he had been studying the role of adenosine receptors in coronary flow regulation and it is signaling in coronary smooth muscle and endothelial cells from various species including human. He and his teams past work has led to the approval of a selective A2A adenosine receptor agonist (Lexican®) for myocardial perfusion imaging. Currently he and his team are using adenosine receptor and beta-adrenergic receptor knockout mice to understand the relationship between these receptors in coronary flow regulation leading to treatment of coronary artery disease.
Abstract:
Adenosine acts through its receptors (A1, A2A, A2B and A3) via G-proteins and causes an increase in Coronary Flow (CF) mostly through A2A AR. However, the role of other ARs in the modulation of CF is not well understood. Using Knock Outs (KO), we investigated the role for each AR in the regulation of CF. Using the isolated heart from A3 KO mice; we reported an increase in A2A-mediated CF. Similarly, we found an increase in CF in A1 KO mice with A2A agonist (CGS- 21680; CGS). In addition, in A2A KO mice response to CGS was abolished, thus confirming the KO. On the other hand, A2A KO mice showed a decrease in CF to NECA (non-selective agonist). BAY60-6583 (A2B selective agonist; BAY) was without an effect on CF in A2B KO mice; however, it increased CF significantly in A2A KO. CGS also caused a significant increase in CF in A2B KO mice. In addition, exogenous adenosine-induced increase in CF in wild type, A2A KO and A2B KO mice were significantly reduced with catalase. BAY-induced increase in CF in WT was significantly inhibited with Glibenclamide. Overall, our data support stimulatory roles for A2A and A2B and inhibitory roles for A1 and A3 in the regulation of CF. These observations provide new evidence for the presence of all four ARs in CF regulation. We propose that, activation of A2A/B may release H2O2 which then activates KATP channels, leading to vasodilation. These studies may lead to the better understanding of the role of ARs in coronary disease and better therapeutic approaches.
Keynote Forum
Brajesh Mittal
Garhoud Private Hospital, UAE
Keynote: Stent blockage: Different shades of grey
Time : 10:00-11:00
Biography:
Currently Brajesh Mittal is working as Consultant Interventional Cardiologist and Head of Cardiology Department at Garhoud Private Hospital, Dubai. He is the Chairman of SCALE- “Stemi Care for All in Emirates” and CME Committee and Garhoud Hospital. His main area of interest is complex coronary and primary angioplasty. He has several publications and presentations at national and international level and is a regular participant as Faculty at large forums incl. European Society of Hypertension, Euro PCR, Arab Health, Emirates Cardiac Society, National Interventional Council India and Cardiology Society of India
Abstract:
Stent blockage has and estimated incidence of 1-5%. It is multifactorial nature and may have devastating consequences viz. AC myocardial infarction/sudden cardiac death, case fatality rate can be as high as 45%. It is prudent to identify those at high risk and should have a clear aim to minimize occurrence. There are several predictors of stent thrombosis and are related to 3 groups: patient, lesion and procedure. Among the most important ones are antiplatelet non-responsiveness, noncompliance or premature cessation. Long lesions/small vessels; stent under expansion. Strongest factors are: Discontinuation OR Dual Antiplatelet Therapy (DAPT), stent under sizing, intermediate lesion proximal to stent, concomitant malignancy, and acute coronary syndrome. Overall early ST >>late ST (>70%). Drug eluting stents also carry the risk of more frequent Very Late Stent Thrombosis (VLST). Underlying pathology depends upon the timing of stent occlusion; while acute and subacute stent occlusion is predominantly thrombotic, later occlusions are more of neo-atherosclerosis. A good mix is being underlying neo-atherosclerosis, thin cap fibroatheroma and thrombus on top. DAPT compliance and procedural optimization are the two most important areas of attention for all the interventional cardiologists to minimize and avoid this potentially devastating complication.
- Clinical Cardiology| Cardiac Surgery | Rehabilitation of Cardiovascular Diseases and Healthcare | Interventional cardiology | Cardiac Diseases
Location: Conference Hall 1
Chair
Yassmin Hanfi
King Fahad Armed Forces Hospital, Saudi Arabia
Session Introduction
Yassmin Hanfi
King Fahad Armed Forces Hospital, Saudi Arabia
Title: Double-chambered left ventricle and abnormal papillary muscle formation
Time : 11:30-12:05
Biography:
Yassmin Hanfi is a Consultant Cardiologist specialized in Advanced Cardiac Imaging (TTE, TEE, CCTA, CMR). Her cardiac training was in Paris with advanced international cardiac teams followed by subspecialty in London at the Royal Brompton Hospital. Her specialty of cardiac imaging is an everyday practice for cardiologist and health care practitioner.
Abstract:
Papillary muscles develop separately from mitral valve leaflet and chordae. Where papillary muscles origin from myocardial
ridge of the anterior wall and to the posterior wall of the left ventricle, chordae and mitral valve leaflets origin from a cushion tissue. The myocardial ridge gradually loosens from the ventricular wall and meanwhile the cushion tissue transforms into leaflet and chordae. Abnormality in the development of papillary muscle could be responsible of a rare form of double chamber LV. The double chamber LV can be mis-diagnosed as aneurysm or rupture LV. Identification of such form of double chamber LV would have an impact for the patient management care. Here is a case report of double chamber LV with variable presentation as previously published. Case report 17 years old male patient with a recent history of palpitation not related to exertion. Normal ECG findings. A trans-thoracic echocardiogram revealed mildly dilated left ventricle with abnormal trabeculated appearance and papillary muscle apparatus forming double chamber LV with mild obstruction. Cardiovascular Magnetic Resonance (CMR) cine images showed a well formed compacted myocardial layer with normal systolic thickening excluding the LV non-compaction pathology. Although confirmed an anomalous muscular bridge opposite to the normally formed Anterolateral (AL) papillary muscle causing partial division of the LV in two chambers without significant obstruction at rest (Panels A, B, D). Peak recorded velocity <1 m/s by velocity mapping at rest (Panel E). While the posteromedial papillary
muscle is abnormally hypoplastic and heavily fragmented (Panels G, H). The mitral valve found to be with mild bellowing of its anterior leaflet with no significant regurgitation. Late gadolinium enhancement phase at the abnormally hypoplastic posteromedian papillary muscle.
Mohammed Takroni
King Faisal Specialist Hospital and Research Center, Saudi Arabia
Title: The effectiveness of a home-based cardiac rehabilitation program using individualized exercise (physiotools-R) compared to hospital-based cardiac rehabilitation programs and standard care on the exercise capacity, psychological well-being and quality of life of CHD patients post-CABG surgery
Time : 12:05-12:40
Biography:
Mohammed Abdullah Takroni a cardiac rehabilitation specialist graduated from king Saud University at 1992 with a bachelor degree in physical therapy, in Fellowship program in cardiopulmonary rehabilitation at Duke University and Medical (DUMC), North Carolina, USA, 1996. Master degree in physical therapy from King Saud University 2008, and also Master degree in sport medicine and rehabilitation, Manchester Metropolitan University (MMU), United Kingdom, 2009. PhD, in Cardiovascular and pulmonary Rehabilitation, Glasgow Caledonian University, Glasgow, UK, 2011. Member of the American Association of Cardiovascular and pulmonary Rehabilitation (AACVPR), member of the Irish Association of cardiopulmonary rehabilitation (IACR), member of the British Association for Cardiovascular Prevention and Rehabilitation (BACPR), member of Saudi Heart Association (SHA). Develop the Cardiac Rehabilitation programs at King Faisal specialist hospital and research center (KFSH&RC), Riyadh, Saudi Arabia. Innovated the Vascular, Pulmonary, and post open-heart surgery and heart transplantation protocols which
are applied now in most of the Cardiac centers in Riyadh and around the kingdom. Participate in several symposiums, local and international. Presented several lectures and study days inside an outside the kingdom as cardiac rehabilitation specialist, Currently, head section of cardiac rehab team king Faisal Heart Institute, king Faisal specialist hospital and research center, and the inpatient supervisor, physical therapy department.
Abstract:
Background: Saudi Arabia is facing significantly increased mortality rate from Cardio Vascular Diseases (CVDs). Studies
have reported that participation in Phase III cardiac rehabilitation (CR) program is associated with a reduction in morbidity and mortality for patients following CABG. Currently, there is no phase III provision of CR for coronary heart disease (CHD) patients in the KSA (King Saudi Arabia).
Aim: To evaluate the effectiveness of home CR program using individualized exercise (physiotools-R) compared to a phase III
hospital CR program and standard care with home instructions on the exercise capacity, psychological well-being, physiology,
body composition and quality of life of CHD patients after CABG surgery.
Method: A total of 73 eligible participants were recruited from the King Faisal Heart Institute (KFHI), in Riyadh. All the
participants had CHD and were 6-8 weeks post-CABG surgery. Participants were randomly assigned to one of three groups: A
hospital CR group (n=25), a home CR group (n=24) and a control group (n=24). Measurements were at baseline post 8 weeks of CR intervention and then again after 4 weeks of observation. Hospital CR program of group based aerobic circuit training and a similar structured individualized exercise program using physiotools-R were used as intervention groups for 8 weeks, three times a week for two hours per session, then four weeks of observation as follow up. The control group followed standard care which comprised home instructions about self-walking and post-operation precautions.
Result: The ISWT (incremental shuttle walking test) distance is clinically improved after in both intervention groups compared
to baseline p<0.001. However, after four weeks of observation follow up, the ISWT distance of the hospital group decreased, but unpredictably, it continued to improve in the home group p<0.001. No significant change was reported in the control group p>0.05. Similarly, all outcome measures: METs (measurement of exercise tolerance), HADS-A (hospital anxiety and depression scale-A), HADS-D (hospital anxiety and depression scale-D), PCS (population cohort study) and MCS (mechanical circulatory support) showed statistically significant improvement post-CR intervention p<0.001.
Conclusion: The findings confirm that home CR using an individualized exercise has similar or possibly even better, effects in comparison to hospital-based Phase III CR in improving the exercise capacity, psychology, quality of life and body composition of CHD patients post-CABG surgery. Therefore, applying a home CR program for patients in remote areas will reduce the rehospitalization rate and will contribute to improving the quality of life of those patients. Continuous improvement of the home group post follow up was the challenge.
Olivier Jegaden
Mediclinic Airport Road Hospital, UAE
Title: Minimally invasive cardiac surgery-Where do we stand?
Time : 12:40-13:15
Biography:
Olivier Jegaden is a Professor of Cardiac Surgery & the Head of the department at CHU of Lyon in France. He joined the Cleveland Clinic Abu Dhabi and is the Professor of Surgery in the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University in Ohio, USA. he is currently working at Mediclinic Airport Road Hospital, UAE. He is an expert in total arterial revascularization for coronary disease, minimally invasive valve repair and transcatheter valve replacement.
Abstract:
Recognition of the significant advantages of minimizing surgical approach has resulted in a substantial increase in the
number of minimally invasive cardiac surgical procedures being performed. Synchronously, technological advances in
optics, instrumentation and perfusion technology have facilitated its adoption rate. This technology has been applied to many cardiac surgical procedures mitral valve repair, aortic valve replacement and coronary artery bypass grafting in 1 or 2-vessel disease patients. Meta-analyses and propensity matched comparisons have demonstrated the non-inferiority of minimally invasive cardiac surgery in low or intermediate risk patients. However, in advanced cardiac disease, these new surgical standards are not less invasive enough to reduce the cardiac risk of the procedure or the negative impact of the comorbidity factors, and it has opened the way of transcatheter techniques. The place of each option is presented and discussed.
Shyam K Ashok
Aster Ramesh Group of Hospitals, India
Title: CABG in diffuse coronary artery disease
Time : 14:15-14:50
Biography:
Shyam Krishnan Ashok has completed his MBBS and then MS in General Surgery, he did his MCH in CVTS from Seth GS Medical College, Mumbai, India. He later joined Narayana Hrudayalaya, Bangalore, India. He has worked as a Fellow in Adult Cardiothoracic Department in Royal Melbourne Hospital, Australia. His area of interest is coronary artery bypass, especially total arterial revascularization. He is currently working at Aster CMI Hospital as Consultant Cardiothoracic Surgeon.
Abstract:
Statement of the Problem: In India 2.78 million deaths are due to cardiovascular diseases of which 50% are due to CAD.
Peculiarities of CAD patterns in Indian patients-Younger age at presentation, high incidence of DVD and TVD, diffuse
involvement, distal disease and significant LV dysfunction at presentation. Diffuse CAD has the length of significant stenosis >20 mm, multiple significant stenosis (>70% narrowing) in the same artery separated by segment of apparently normal vessel and significant narrowing involving the whole length of coronary artery.
Method: We perform OP CAB and use LIMA and veins as conduits to perform the surgery. Once the conduits are harvested, we heparinize with IV Heparin 3 mg/Kg given to achieve an ACT>300. Using the octopus as stabilizer, we perform an endarterectomy of the LAD first and then use a vein patch to cover the defect. LIMA is then used to anastomose the LAD on the vein patch. Veins are used to bypass the LCX and RCA, as deemed appropriate. The proximal ends of the vein grafts are anastomosed to ascending aorta with side clamp and heart beating. Intra OP we start Lomodex infusion 20 ml/hr which is continued for 24 hours and the inotropes used are Adrenaline and Dobutamine as and when necessary. Post-operatively Aspirin 75 mg is given and Heparin infusion started after 6 hours to maintain ACT of around 150 for 24 hours. Patients are usually extubated after 4 hours provided they are hemodynamically stable. Anticoagulation by Acitrom is commenced orally from day 1 to maintain an INR of 2 for 3 months.
Result: Out of the 20 patients in last 18 months outcomes have been excellent with no in-hospital mortality or cerebrovascular
incidents.
Conclusion: Off pump CABG with coronary endarterectomy offers a good solution to the problem of diffuse coronary artery disease.
Elena Leonova
Federal Central Tuberculosis Research Institute, Russia
Title: Factors associated with right ventricular dysfunction among patients with pulmonary sarcoidosis
Time : 14:50-15:25
Biography:
Elena Leonova is a PhD researcher from the Department of Differential Diagnosis of Interstitial Lung Diseases and Extracorporeal Therapeutic Methods, Federal Central Tuberculosis Research Institute. She had her researches on cardiovascular problems among patients with interstitial lung diseases. Along with the research work and teaching activities, she is actively engaged in medical practice.
Abstract:
Background & Aim: Arterial Stiffness (AS) is one of the most potent prognostic factors of cardiovascular morbidity and
mortality. Obesity has many effects on cardiovascular structure, function and hemodynamics. Effects of AS and Body Mass
Index (BMI) on the Right Ventricle (RV) function among patients with Pulmonary Sarcoidosis (PS) are unknown. The aim is to investigate the RV systolic dysfunction by several echocardiographic parameters among patients with PS and determine how it is associated with AS and BMI.
Method: We identified 82 patients with biopsy-proven pulmonary sarcoidosis, who underwent echocardiography, spirometry, Diffusing Capacity of Carbon Monoxide (DLCO), plethysmography. Pulmonary High Resolution Computed Tomography (HRCT) was assessed by Kazerooni scale (ground-glass and fibrosis). Aortic Pulse Wave Velocity (PWV), BMI were evaluated. RV systolic function was assessed among all subjects using different methods (Tricuspid Annular Plane Systolic Excursion (TAPSE), RV myocardial Performance Index (MPI) and RV systolic excursion velocity by tissue Doppler (S’)).
Result: RV systolic dysfunction was found in 17% of subjects by TAPSE, 19.5% by RV MPI and S’. All parameters of RV systolic
function correlated with DLCO (p<0.01), total lung capacity (p<0.001), HRCT, PWV (p<0.01). In multivariate regression
analysis the factors associated with RV systolic dysfunction were the PWV (p=0.006), HRCT (p=0.001).
Conclusion: The systolic function of the RV is associated with lungs involving and arterial stiffness. BMI has not shown any
correlation with RV systolic dysfunction.
Nahid El Faquir
Erasmus University Medical Center, Netherlands
Title: The role of contact pressure in the development of conduction abnormalities after TAVI: A patient specific computer simulation analysis
Time : 15:25-16:00
Biography:
Nahid El Faquir is a Research Fellow in Interventional Cardiology at the Erasmus University Medical Center, Rotterdam, Netherlands. She has received her MD degree from the Erasmus University. Her main research interest is interventions in structural heart disease.
Abstract:
Statement of the Problem: Conduction abnormalities after Transcatheter Aortic Valve Implantation (TAVI) still occur while indications for TAVI expand to younger and lower risk patients. The role of contact pressure generated by the valve frame in the development of conduction abnormalities post TAVI remains unknown.
Method: A European multi-center study was conducted including 112 patients with severe aortic valve stenosis who had undergone a pre-procedural CT and was treated
by a self-expanding valve. A patient specific region of the aortic root containing the atrioventricular conduction pathway was selected on CT based on the inferior border of the membranous septum. Computer simulation analysis was performed in all cases to quantify contact pressure and contact pressure index (percentage of area subjected to pressure) in the region of interest.
Findings: 62 patients (55%) developed new conduction abnormalities. Maximum contact pressure and contact pressure index (median [IQR]) were significantly higher in patients with new conduction abnormalities (0.51 MPa [0.43-0.70] and (33% [22-44]) compared to patients without (0.29 MPa [0.06-0.50] and 12% [1-28]) (Fig. 1A). Multivariable analysis showed that maximum contact pressure and contact pressure index were independently associated with the occurrence of new conduction abnormalities (p=0.01). By ROC analysis a cut-off
value was determined for maximum contact pressure and contact pressure index consisting of respectively 0.39 MPa and 14% (Fig. 1B).
Conclusion: Patient-specific computer simulation showed that maximum contact pressure and contact pressure index was
associated with new conduction abnormalities after TAVI. Patient-specific computer simulation may have an added value in TAVI planning.
Essam Hamed Amin Ali
Total Quality Management Consultant, UAE
Title: Quality management in the heart catheterization laboratory
Time : 16:00-16:35
Biography:
Essam Hamed Amin Ali is a Professional with Quality Management and Hospital Management, planning and interpersonal skills. He has completed his Doctorate degree in Business Administration in Quality Management, USA; MS in Quality Management System from the University of Wollongong, Australia and Bachelor of Medicine from Cairo University, Cairo, Egypt in 1991. He is a Member of Medical Education Committee, Ministry of Health, Abu Dhabi, UAE. His areas of expertise includes total quality management; ISO standards, EFQM model, JCI standard, strategic planning, operations management, medical staff relations, quality assurance, change management, cross cultural management, continuous quality improvement, trainer and consultancy for joint commission international on accreditation of healthcare organizations.
Abstract:
The role of the cardiac catheterization laboratory has progressed from study of cardiac function and anatomy for purposes of diagnosis to evaluation of candidates for surgery and finally to providing catheter-based, non-surgical interventional treatment. Quality management within the catheterization laboratory includes the quality control, the heart catheterization technique and the policy. Quality management is critical in the heart catheterization laboratory. The purpose of the best practices statement is to ensure patient safety, cath lab efficiency, the referring physician and patient’s satisfaction. A continued quality improvement program is patient-orientated and requires good planning. One of the main emphases in the catheterization lab is the standardization which includes the patient preparation, the procedure itself and the management. The hospital should provide the necessary resources to implement best practices through adequate staffing, equipment and information technology, in order to assure the performance of these practices and encourage ongoing review. A continuous circle of treatment planes, performance and check is regarded as the Deming cycle and leads to continuous improvement of quality. Important are both the avoidance and detection of complications. It is recommended to follow the zero mistake hypothesis of Crosby, which means quality control by the lab supervisor, a quality consciousness, a quality measurement and quality improvement, as well as using a day to day quality improvement and to teach quality control. In order to provide the safest, highest quality patient care in the cath lab, it is essential to have a comprehensive quality control program in place. Quality Control (QC) verifies that equipment and products are meeting the recommended manufacturers’ standards and they are performing at the necessary level to provide safe and effective delivery of care. It also ensures that the necessary supplies are available to provide patient care. Regular QC and maintenance extends equipment life and allows its use to be at peak efficiency. In order to develop and
maintain a high-caliber QC program, there needs to be collaborative effort between: (1) Product vendors and manufacturers, (2) regulatory agencies such as the joint commission, point-of-care testing, (3) biomedical maintenance, (4) staff development, (5) the cardiac cath lab staff and (6) other vested parties. By utilizing all available resources, a comprehensive QC program can be designed, maintained and upgraded as necessary.