Day 2 :
Keynote Forum
Nandkishore Kapadia
Kokilaben Dhirubhai Ambani Hospital & Medical Research Institute, India
Keynote: Biopsy free echocardiography surveillance of rejection after heart transplant
Time : 09:00-10:00
Biography:
Nandkishore Kapadia has completed his MBBS and MS from Indore University, MCh from Madras University, PhD from VGU British-I land, Post-doctoral studies from Allegheny University School of Medicine, Philadelphia, USA. He has published more than 20 papers in reputed journals. He is the Head of the Department of Adult Cardiac Surgery and Director of Heart and Lung Transplant Program at Prestigious Kokilaben Dhirubhai Ambani Hospital, Mumbai India.
Abstract:
Introduction: Surveillance for Acute Rejection (AR) and Cardiac Allograft Vasculopathy (CAV) is essential for graft and patient survival. CAV can arise and progress without symptoms and subclinical ARs can facilitate. Standard surveillance of AR and CAV is based on routine Endomyocardial Biopsies (EMBs) and Coronary Angiographies (CA) at predefined intervals, 9 to 13 times during first post-transplant year, there after 3-4 biopsy annually. These invasive screening tests are distressing, costly and not without complications, yet they cannot identify all sub-clinical ARs. We adopted biopsy free echocardiography surveillance for detection and treatment of rejection.
Method: 16 transplants were followed from 2013 November till June 2018. Besides complete blood count, renal function test, liver function test, cyclosporine, tacrolimus level, electrocardiogram and three-monthly echocardiography with color Doppler. 13 patients are long term survivors; only one patient out of these was diagnosed to have acute rejection treated with immune-suppression included methyl prednisolone, anti-thymic antibody after endomyocardial biopsy confirmed Grade- III rejection. Patient fully recovered.
Result: Doppler Tissue-Imaging (DTI) and strain-imaging for myocardial wall motion and deformation analysis, allowed quantification of minor myocardial dysfunction for early detection of subclinical AR and CAV. Two patients had mild rejection Grade-IIB were treated by increasing dose of steroid and raising level of calcineurin inhibitor.
Conclusion: DTI and strain-imaging are important tools enabling more efficient AR monitoring with fewer EMBs instead of unnecessary and distressing routine EMB-screenings. Myocardial velocity and deformation imaging is also suited for early detection of myocardial dysfunction induced by CAV, prognostic evaluation of CAV and timing of CAs aimed to reduce the number of routine CA-screenings.
Keynote Forum
Syed Raza
Awali Hospital, Bahrain
Keynote: Patient adherence to heart failure medications: Where are we going wrong?
Time : 10:00-11:00
Biography:
Dr Syed Raza graduated from Aligarh University in India in 1993. After completing his postgraduate degree in Medicine from the same university, he moved to the UK for higher specialist studies. He successfully completed MRCP and CCT and later also awarded Fellow of the Royal College of Physicians of Edinburgh. He was awarded Professor John Goodwin prize for outstanding performance in Diploma Cardiology exam at Hammersmith Hospital, University of London in 2001. Dr Raza is Fellow of American College of Cardiology, American College of Chest Physicians as well as Fellow of European Society of Cardiology. He is also on the committee of Acute Cardiovascular Care. Heart Failure and Cardiovascular Imaging (European Society of Cardiology). He is currently serving as consultant in Cardiology and Head of the department of Medicine at Awali Hospital, Bahrain. He is the educational coordinator and chairman of resuscitation committee of the hospital. He is the regional coordinator and examiner for MRCP exam for the Royal College of Physicians of Edinburgh. He is external examiner for Arabian Gulf Medical University.. He has to his credit numerous publications and he has presented his work in different parts of the world. He is peer review author for some well-respected International journals. He is Review author for abstracts for European Society of Cardiology Annual Congress 2018.
Abstract:
Background & Aim: Poor adherence to medications is a common problem among Heart Failure (HF) patients. Inadequate adherence leads to increased HF exacerbations, reduced physical function and higher risk for hospital admission and death. Many interventions have been tested to improve adherence to HF medications, but the overall impact of such interventions on readmissions and mortality is unknown. We conducted a study to explore patients’ understanding and adherence to Heart Failure (HF) medications at a general hospital setting.
Method: We prospectively studied 196 patients (outpatients plus inpatients) of HF at our hospital. The information was gathered by oral interview as well as using questionnaire. There is currently no Heart Failure nurse working in our hospital.
Result: There were 110 male and 86 female patients with average age of 54 years. Most patients (78%) in NYHA class II and III. 15% of patients stopped or reduced the dose of diuretics on their own as they thought they didn’t need them anymore or they were thought to interfere in their life style. 36% patients believed that ACE inhibitors or ARBs were for blood pressure and therefore they had either stopped or were intending to stop. 43% patients were not keen on taking beta-blocker because of fear of various side effects and 12% of them already stopped the beta-blocker on their own. 56% of patients did not like the idea of increasing the dose of ACE Inhibitor, ARBs or beta-blocker to the maximum. Patients were ignorant of the role of different HF medications Aldosterone antagonists (86%), ACE Inhibitor or ARBs (76%), Beta blocker (70%). None of the patients who were on Ivabradine knew the role of the drug in HF but at the same time were not informed of any known side effects.
Conclusion: Heart Failure (HF) medications are evidence based with stringent research and scientific back up. They have proven benefit in terms of reducing morbidity and mortality significantly. However, compliance amongst patients to adhere to prescribed medications is poor. This is largely because of their lack of knowledge and poor understanding about themedications. It is therefore worth spending time and resources in educating patients with the help of multi-disciplinary heart failure team to achieve better outcome.
- Clinical Cardiology| Neonatal Cardiology | Cardiac Nursing | Hypertension | Heart failure | Echocardiography | Clinical Case Reports on Cardiology
Location: Conference Hall 1
Chair
Ahmed Mohammed Samman
Ministry of Health, Saudi Arabia
Session Introduction
Ahmed Mohammed Samman
Ministry of Health, Saudi Arabia
Title: The role of advanced cardiac imaging is diagnosis of complex adult’s congenital heart disease
Time : 11:30-12:05
Biography:
He worked in Arab Board Internal medicine in – (KFSH) King Faisal Specialist hospital –Riyadh-Saudi Arabia from 1996 to 2001 and he has Canadian Fellowship in Cardiology- (UBC) - university of British Columbia (2001-2004), Canadian Fellowship in Adult Congenital cardiology- (UOT) University Of Toronto (2004-2005), Canadian Fellowship in Adult Echocardiography – (UOT) University Of Toronto (2005-2006), Canadian Fellowship in Cardiac Magnetic Resonance - (UOC) University Of Calgary (2006-2007) and American College of Cardiology (ACC) - Cardiac CT angiography Training –(Riyadh May-2010). He is currently working as
supervisor of cardiac services in Jeddah, dedicated for the establishment of cardiac services pathways including Cardiac Imaging and ACHD.
Abstract:
Background: The recent improvements in non-invasive, cross-sectional cardiovascular imaging modalities (MR and CT) have
resulted in a change in our approach to the assessment and follow up of patients with Congenital Heart Disease (CHD).
Currently, clinical practice is to use echocardiography in all cases of CHD. However, echocardiography can be technically
difficult to perform, providing sub-optimal imaging. In these situations, we use cardiovascular MR to further define CHD
anatomy and physiology. This is particularly important prior to and following corrective surgical and interventional procedures.
Method: Sequential segmental analysis is illustrated using different cases from adults with CHD. Cardiovascular MR is critical to the non-invasive assessment of ventricular/valvular function and blood flow through haemodynamically significant lesions and shunts. We specifically use MDCT in the initial diagnostic assessment of great vessel anatomy in young patients, especially in circumstances where functional information is not required. Finally, the use of cardiac catheterization/angiography if haemo-dynamic information is required (pulmonary vascular resistance studies) or if there is a high degree of suspicion of coronary artery abnormalities.
Conclusion: This approach can improve non-invasive diagnosis and reveal detailed anatomy that is important for both clinical
decision-making and surgical planning of adults with CHD.
Samah Salah Alasrawi
AlJalila Children`s Hospital,UAE
Title: Cardiovascular hemodynamics assessment in children
Time : 12:05-12:40
Biography:
Samah Salah Alasrawi is a Pediatric Cardiologist at Al Jalila Children’s Specialty Hospital. She has completed her Bachelor’s degree and Master’s degree in Pediatric Cardiology from Damascus University, Syria. She has clinical and research interests in congenital heart diseases, pulmonary hypertension, cardiomyopathies and arrhythmias in children.
Abstract:
Objective: To know how we can assist the cardiac hemodynamics, what we measure: Intra cardiac pressures. What we calculate: Cardiac output, Qp (pulmonary blood flow), Qs (systemic blood flow), PVR (Pulmonary vascular resistance), SVR (systemic vascular resistance), Ejection Fraction, RVSP (Right ventricle systolic pressure), PAP (Pulmonary Artery Pressure). Obtaining accurate hemodynamics requires careful attention to detail, Calculation of cardiac output has many potential sources of error, limit assumptions as much as possible. Valuable information about disease states can be obtained with basic diagnostic catheterization and good Echo.
Kashif Bin Naeem
Al Baraha Hospital, UAE
Title: Role of R-R interval variation study in the diagnosis of Cardiac Autonomic Neuropathy (CAN) in patients with Diabetes Mellitus (DM) in the Middle East population
Time : 12:40-13:15
Biography:
Kashif Bin Naeem is currently working as a Specialist (Non-invasive) Cardiologist at Al Baraha Hospital, Dubai, Ministry of Health and Prevention, UAE. He has completed his Residency in Internal Medicine from London in 2007 and was awarded MRCP, UK. He has recently been awarded CESR (CCT equivalent) Certification in Cardiology, UK. He also holds Diplomate Certification in Comprehensive Echocardiography, NBE, USA. He is an active researcher and has several publications as well as abstracts in international meetings. He is the current Member of Dubai Research and Ethics Committee.
Abstract:
Introduction & Aim: Cardiac Autonomic Neuropathy (CAN) is a serious and common complication of diabetes. Meta-analyses of published data demonstrate that reduced cardiovascular autonomic function as measured by Heart Rate Variability (HRV) is strongly (i.e. relative risk is doubled) associated with an increased risk of silent myocardial ischemia and mortality. Despite its relationship to an increased risk of cardiovascular mortality and its association with multiple symptoms and impairments, the significance of CAN has not been fully appreciated and not studied in the Middle East population. Hence, we conducted a study to measure the HRV by R-R interval variability in diabetic patients to determine the incidence of autonomic neuropathy.
Method: A prospective analysis of 37 patients fulfilling the criteria for diagnosis of diabetes mellitus with/without neuropathic/ autonomic symptoms was performed between Jan 2017 and Oct 2017. We followed a protocol where R-R interval variation and Sympathetic Skin Response (SSR) were studied in all patients. R-R interval variation was studied during (1) deep breathing (at rate of 6/min), (2) breath holding for 15 seconds and (3) standing. The coefficient of variation of RR interval during the procedure were studied for all the 3 above mentioned manoeuvers while the ratio of R-R interval maximum to R-R interval minimum was studied for procedures of deep breathing and breath holding only. Additionally, the ratio of the 30th:15th R-R interval was analyzed during standing only.
Result: Autonomic studies were performed in 37 diabetic patients. 70.2% (26/37) had abnormal study. HRV abnormality was found in 69.7% (23/33) of the patients. SSR abnormality was found in 35% of the patients (8/23). In diabetic patients without clinical features of sensory, motor or autonomic involvement, autonomic study abnormality was found in 80% (8/10). HRV abnormality was detected in 70% (7/10) and SSR abnormality in 12.5% (1/8). Among diabetic patients with features of autonomic neuropathy, 70% (7/10) had abnormal study. HRV abnormality was detected in 66.7% (6/9) and SSR abnormality in 33.3% (3/9). Among symptomatic (motor/ sensory) diabetic patients without autonomic symptoms, 72% (13/18) had abnormal study. HRV abnormality was found in 70.6% (12/17) and SSR study abnormality in 41.2% (07/17). Among patients with HRV abnormalities, the abnormalities were detected in 11.5% (3/26) on deep breathing, 46.2% (12/26) on Valsalva maneuver and 69.2% (18/26) on standing (30th:15th R-R interval).
Conclusion: Cardiac autonomic involvement in DM is common (70.2%) as detected by our study, even in patients without clinical evidence of sensory/motor neuropathy (80% detected in our study) or autonomic neuropathy (72%). However, patients with clinical autonomic manifestations are associated with more incidence of electrophysiological abnormality (70%). R-R interval variation study is more sensitive (70%) than the sympathetic skin response study (35%). Among the maneuvers for measurements for R-R interval variation, abnormalities are detected more in standing compared to deep breathing and Valsalva.
Mujeeb A M
Kerala Institute of Medical Sciences, India
Title: Renal failure: The worse scenario in heart failure
Time : 14:15-14:50
Biography:
Mujeeb A M has obtained his MD degree from Irkutsk State Medical University, Russia. He has worked as a Medical Officer for 4 years in various hospitals. He has completed his Post Graduate Diploma in Clinical Cardiology. He has worked as Clinical Cardiologist in Kerala, India. He is currently working as Clinical Cardiologist in National Cardiac Centre, IGMH Male, Maldives. He is also a PhD Fellow in Cardiology from Irkutsk State Medical University.
Abstract:
Introduction & Aim: Renal impairment is a common and independent risk factor for morbidity and mortality in patients with heart failure. In this study we have analyzed the outcome of patients with a combination of heart failure with renal failure. Here we have analyzed the co morbid factors, readmissions and mortality of patients with heart failure with normal and abnormal renal function.
Method: This prospective observational study was conducted in the Kerala Institute of Medical Sciences, over a period of 2 years from 1st June 2012. All patients who have admitted in the cardiac care unit with signs and symptoms of heart failure (NYHA class 3 or 4) irrespective of etiology were selected. These patients belonged to coronary artery disease, valvular heart diseases, cardiomyopathies, congenital heart diseases and cor pulmonale. From the 287 heart failure patients 124 patients had renal failure. Renal parameters were assessed by renal function tests and by calculating GFR. Cardiac functions were assessed clinically and echocardiographically.
Result: These 287 patients were sub-divided into two groups, 124 patients had a combination of Heart Failure and Renal Failure (HFRF) and 163 Heart Failure Patients with Normal Renal Function (HFNRF). Renal failure patients were elder than the other group. The mean age of patients with normal and abnormal renal function were 62(11) years and 66 (9) years respectively. Co-morbid factors were more with HFRF patients. Diabetes mellitus in HFRF patients were 76.6% (n=95) compared to 58.3% (n=95) in HFNRF patients (p- .001). Hypertension was found in 66.1 % (n=82) in HFRF patients and 51.5% (n=84) in the other group (p-0.013). Anemia was found in 64.5% (n=80) and 36.8% (n=60) of patients with HFRF and with HFNRF respectively (p<0.0001). We followed the patients for two years. Recurrent admissions and mortality were more in HFRF patients. There were 87.9% (n=108) of patients readmitted in the HFRF group, but only 44.1% (n=72) required readmission in HFNRF patients (p- .001). There were 53.2% (n=66) of patients were expired in HFRF patients compared to 25.7% (n=42) in HFNRF patients (p<0.000).
Conclusion: Heart failure itself is a morbid condition with bad prognosis and the mortality is very high. This condition became worse when these patients develop renal failure. In our study we found that the co morbidities, recurrent admission and mortality were more in renal failure patients. Heart failure with renal failure is a bad combination; these patients should be
monitored.
Yagoub Musa
Alshaab Teaching Hospital, Sudan
Title: Frequency and cause of acute decompensation and hospital re-admission in patients with chronic heart failure (ADHF- Sudan)
Time : 09:00-09:35
Biography:
Yagoub Musa is the Fellow of the Royal College of Physicians of London and Fellow of the Heart Failure Association of the ESC. He is a Consultant Cardiologist trained in Interventional Cardiology at the NHCS, Singapore. He has completed CAS in Heart Failure at Zurich University, Switzerland. He is the Founder Head of the only Heart Failure Unit in Sudan and Chairman of Sudan working group on heart failure.
Abstract:
Background & Aim: Heart Failure (HF) re-admission identifies patients at high risk for adverse events. This study aimed to establish the frequency and factors associated with decompensation and readmission of patients with chronic HF at one of biggest cardiac centers in Sudan.
Method: In this prospective, observational, cross-sectional study, subjects≥18 years who re-admitted as Acute Decompensation (ADHF) at Alshaab Hospital (Khartoum-Sudan) in period from February-May 2016 were included; patients with first acute heart failure admission (Acute De-novo HF) and those who refused to participate were excluded. Descriptive statistics were used to determine the baseline characteristics of the study population and to compare them with those from other studies and registries.
Result: 220 consecutive patients are included, mean age of 63.7±14.5 years, 125 (56.8%) males. 141 (64.1%) are originally from rural areas, 151 (68.6%) are illiterates and only 4.0 (1.8%) are formally employed. 195 (88.64%) have HFrEF (EF<40%, 13 (5.91%) HFmrEF (EF 40-49%) and only 12 (5.45%) HFpEF (EF≥50%) Dilated Cardiomyopathy (DCM) was the commonest cause of heart failure in these studied patients, ischemia is the second, hypertension is the third (63.6%, 21.7%, 8.2%, respectively) while valvular heart disease is the fourth (6.5%). 51 (23.2%) re-admitted within the first 30 days, 59 (26.8%) within one to three months while half within a period of three to six months following the last discharge. During the last six months, 4.0 (1.8%) of patients re-admitted once, 38 (17.3%) twice, 66 (30%) thrice and 112 (50.9%) re-admitted ≥4 times. The cause of acute decompensation identified in 196 (89.1%) with non-adherence as the first cause of decompensation and re-admission, worsening renal function is the second, acute coronary syndrome is the third and tachyarrhythmias is the fourth (31.8% ,14.1%, 11.4% and 10.0% respectively).
Conclusion: In this study, acute decompensation and re-admission is very frequent but mostly preventable.
Yassmin Hanfi
King Fahad Armed Forces Hospital, Saudi Arabia
Title: Workshop in cardiac imaging What to except from transthoracic echocardiography TTE
Time : 14:50-16:20
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:
What to except from transthoracic echocardiography TTE
For non-specialized cardiologist, cardiac fellow, GP, Technician on how to answer the clinical question using TTE. Explanation of each method used in TTE for LV EF assessment (Fractional shortening, fractional area changes, ejection fraction and stroke volume), regional wall motion assessment, ischemic complication, ischemic rupture of LV septum and LV free wall, ischemic MR, LV apical thrombus and pericardial effusion.
RV assessment by TTE
The right ventricle plays an important role in the morbidity and mortality of patients presenting with signs and symptoms of cardiopulmonary disease. However, the systematic assessment of right heart function is not uniformly carried out. This is due partly to the enormous attention given to the evaluation of the left heart and a lack of familiarity with ultrasound techniques that can be used. Parameters will be explained such as fractional area change [FAC], S’, tricuspid annular plane systolic excursion [TAPSE]; RV index of myocardial performance [RIMP] new updated and normal values, systolic pulmonary artery (PA) pressure (SPAP).
CMR in RV assessment and beyond
CMR is the gold standard for right ventricular assessment, has a superior acoustic window over other modalities and free of ionizing radiation.