Cardiovascular Research Prove Journal a
CARDIOVASCULAR RESEARCH,EDUCATION & PREVENTION FOUNDATION
CVREP BOARD
CVREP Chairman:
Prof. Mohamed Sobhy
CVREP Co-Chairmen Board Members:
Prof. Mahmoud Hassanein
Prof. Mohamed Ayman Abdel Hay
Prof. Moustafa Nawar
Prof. Salah El Tahan
Prof. Tarek El Zawawy
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Board Members:
Ahmed Abdel Aaty Eman El Sharkawy Sahar El Azab
Amr Kamal Kawkab Khedr Sameh Arab
Aly Zidan Mohamed Sadaka Sanaa Ashour
Amr Zaki Mohamed Loutfi Sherif El Biltagui
Ebtihag Hamdy Samir Rafla Sherif Wagdy Ayad
Cardiovascular Research Prove Journal b
CARDIOVASCULAR RESEARCH PROVE JOURNAL
(CVREP)
CARDIOVASCULAR RESEARCH PROVE Journal
“CVREP” Journal
About the Journal:
“CVREP” Journal is the official Journal of CardioAlex Research, Education & Prevention
foundation. It is a peer-reviewed journal, engaged in publishing high quality material on all aspects of
Cardiovascular Medicine. It includes updates on cardiology, information to junior doctors, review
articles, abstracts, articles related to research findings and technical evaluations. It also provides a forum
for the exchange of information in all fields of cardiology.
Editor in Chief: Co-Editor:
Prof. Tarek El Zawawy Prof. Mohamed Sadaka
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CardioAlex.18 Abstracts Committee:
Head of The Committee:
Prof. Mahmoud Hassanein
Abstracts Committee Members:
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Ahmed Abdel Aaty Hassan Khaled Mostafa Nawar
Ahmed El Guindy Hanaa Fereg Nabil Farag
Ahmed Hassouna Hossam Kandil Nasser Taha
Ahmed El Messiry Hany Ragy Osama Diab
Ashraf Reda Ihab Attia Sameh Arab
Adel Allam Magdy Abdel Hamid Samir Rafla
Amal El Sisi Mohamed Ayman Abdel Hay Salah el Tahan
Bassem Sobhy Mohamed Hamouda Sahar El Azab
Eman El Sharkawy Mohamed Hassan Sanaa Ashour
Gamal Shaaban Mohamed Loutfi Sonya El Seidy Hesham Aboul Enein Mohamed Sadaka
CVREP Journal Second Edition @ CardioAlex.18
Content
Section (1): Abstracts presented @ CardioAlex.18
CVREP Vol. (2) Issue (1)
Cardiovascular Research Prove Journal c
Content
Section (1): Abstracts
Abstracts Page
Cardiac Functional Changes After Bariatric Surgery at KAMC
Fatma Aboul-Enein, Aly Almuntashery, Hajar Halawani, Salman Alamri, Sumayah Fallatah, Shahad
Binafeef, Julnar Alfahmi
1.
Critical Care Nurses Practices and Attitude Toward Patient Suffering from Delirium
Mohamed A. Ghoneam
2.
Incidence of Vascular Complications Among Egyptian Population During Trans-Femoral Aortic
Valve Implantation
Nasr M. Elsoudi, Yousef A Elsayed, Mokarrab M. Ibrahim, Saifelyazel I. Shawky,Aref M, Mohamed
Moustafa
3.
Left Atrial Size and Stiffness as Predictor of Prevalence and Incidence of Atrial Fibrillation In
Patients With Rheumatic Mitral Stenosis
Ahmed Taha Hussein
4.
Provocation of Left Ventricular Outflow Tract Obstruction Using Nitrate Inhalation in
Hypertrophic Cardiomyopathy: Relation to Electromechanical Delay
Hala Mahfouz Badran, Waleed Abdou Ibrahim, Naglaa Faheem, Rehab Yassin, Tamer Alashkar, Magdi
Yacoub
5.
Pulmonary Vein Pulsatility Index (PVPI) In Fetuses of DiabeticMothers: Relationship to
Intermediate and Long Term Diabetic Control
Habeeb NM, Youssef OI and Hendawy S
6.
Short Term Outcome of Thoracic Endovascular Aortic Repair in Patients with Thoracic
Aortic Diseases
Hamdy Soliman, Mohammed N. El-Ganainy, Reham M. Darweesh, Sameh Bakhoum, Mohammed Abdel-
Ghany
7.
Transradial Percutaneous Coronary Intervention in Very Elderly Patients (Age 80 years
or above) with Acute Coronary Syndrome: Immediate and Short Term Outcome, Single
Centre Experience.
Ahmed Deiab, Vipin Thomachan
8.
Transradial cardiac interventions in Yemeni patients, A local Experience from
Hadhramout
T. Bafadhel, M. Alfalag, O. Ben-zihdan, A. Alzubidi, M. Ba-Moamen & A.N Munibari
9.
Validation of a newly generated CRT-score to predict the response to cardiac
resynchronization therapy
Mostafa Nawar, Gehan Magdy, Aly Abo Elhoda, Sarah Sultan
10.
Value of Global Longitudinal Peak Systolic Strain Derived by 2-D Speckle Tracking in
Detection of Obstructive Coronary Artery Disease
Mohamed F. Areed, Mahmoud M. Youssof, Moheb M. Wadie
11.
CVREP Journal Second Edition @ CardioAlex.18
Content
Section (1): Abstracts presented @ CardioAlex.18
CVREP Vol. (2) Issue (1)
Cardiovascular Research Prove Journal c
Section (2): Resumes
Resumes Page
A Retrospective Comparative Study Between Levosimendan and Adrenaline as a
Pharmacological Based Protocol in The Management of Low Ejection Fraction Coronary
Artery Bypass Grafting Patients: A Friend or Foe
Mohammed Abd Al Jawad
13.
Appropriate BP Measurement for Proper Management
Ahmed Bendary
14.
ACS/ STEMI Experience in Kenya
Harun A Otieno
15.
Bioabsorbable Scaffolds Fourth Revolution or Failed Revolution: Are We Looking at The
Wrong Targets?
Sundeep Mishra
15.
Can CAD Be Prevented? Lessons Learned from an Indigenous Hunter-Horticulturist Culture
of the Bolivian Amazon.
Gregory s. Thomas
17.
Cell Based Therapies for IHD and Heart Failure: Problems, Promises, Perspectives and
Pitfalls
Rosalinda Madonna
18.
Coronary Arterivenous Fistula. Case Presentation
Sherif Arafa
18.
Coronary Artery Disease in The Young, Increasing Laboratory Testing Menu and
Controversial Significance.
Amina Hassab
19.
Designing MTM Plan Based on PK/PD of Statins
Noha A. Hamdy
20.
Device Related Infection; Prevention and Management
Amr Nawar 21.
3D-TEE The Added Value in Paravalvular Regurgitation
Hani Mahmoud Elsayed 21.
Driving and Sports in Patients with ICDs
Mohammad Shenasa 22.
DES Slightly Edge Out DCBs in Treatment of In-Stent Restenosis: Meta-analysis
Samih lawand 23.
Early Repolarization Syndrome. How to Manage?
Samir Rafla 24.
Exercise and Cardiovascular Risk Factor in Patients with Hypertension
Toure Ali Ibrahim 25.
How to Use Hardware for CTO PCI?
Sundeep Mishra 25.
CVREP Journal Second Edition @ CardioAlex.18
Content
Section (1): Abstracts presented @ CardioAlex.18
CVREP Vol. (2) Issue (1)
Cardiovascular Research Prove Journal c
Left Atrial Function in Heart Failure
Michael Henein
26.
Masked Hypertension: Definition, Impact and Outcomes
Patricio Lopez
27.
New Knowledge from Fourier Stud
ELSayed Farag 28.
Off Pump as a Default Technique for CABG
Ihab el sharkawy 28.
Patient Preparation for Primary PCI
Mohammed Adel Ghoneam 29.
Post TAVI PCI. Is it Possible?
Hamdy Soliman 30.
Predictors of Severe Coronary Stenosis at Cath in Patients with Normal Myocardial Perfusion
Imaging
Khalid A Alnemer
30.
Recurrent Syncope: Update from the Guidelines
Peter A. Brady
31.
Right Minithoracotomy – an Alternative Approach
Mohamed El Ghanam 32.
Right Ventricular Outflow Tract Stenting; What Do We Know?
Hala Agha 32.
Role of Nuclear Medicine in Assessment of Myocardial Viability
Abo AlMagd AlNouby 33.
Statin Resistance
Atef El-Bahry
34.
Stent for Life” Portugal: How to Implement a STEMI Network.
Helder Pereira 34.
The Role of Intraoperative Transesophageal Echo (TEE) to Guide Mitral Valve Repair
Mohamed Adel Mostafa 35.
The Importance of Coronary Sinus Flow in Prediction of No-Reflow After Primary
Percutaneous Coronary Intervention for Acute Myocardial Infarction
Mohamed El Tahlawi
36.
Unprotected Left Main PCI in The Setting of Anterior STEMI and Cardiogenic Shock
Osama Hassan 37.
Would "High Intensity Cholesterol Lowering Strategy "Replace" High Intensity Statin
Strategy"?
Yasser Huzayen
38.
CVREP Journal Second Edition @ CardioAlex.18
Content
Section (1): Abstracts presented @ CardioAlex.18
CVREP Vol. (2) Issue (1)
Cardiovascular Research Prove Journal c
Section (3): Case Presentation
Case Presentation Page
Quadrifurcation LMCA CHIP Case
Khaled N. Leon
40.
Section (4): Case Reports
Case Reports Page
Have You Seen a Case Like This?
Alaa Khalil
43.
Rheumatic Mitral and Congenital Pulmonary Stenosis Mahmoud Sharaf Eldeen
44.
The Silent Creeper
Waleed Waheed Etman
45.
CVREP Journal Second Edition @ CardioAlex.18
Cardiovascular Research Prove Journal 0
SECTION (1): ABSTRACTS
PRESENTED @ CARDIOALEX.18
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 1
Cardiac Functional Changes After Bariatric Surgery at KAMCFatma Aboul-Enein, Aly Almuntashery, Hajar Halawani, Salman Alamri, Sumayah Fallatah,
Shahad Binafeef, Julnar Alfahmi
ABSTRACT
BACKGROUND
Bariatric surgery is an effective way for long-term
weight loss success. Recent studies have found that
weight loss is significantly associated with improved
metabolic parameters in addition to overall decrease
in cardiovascular morbidity and mortality.
Conversely, some studies have observed the
development of unexplained sinus bradycardia after
significant weight loss.
We conducted a retrospective study to evaluate the
electrical and functional cardiac changes on morbidly
obese patients who underwent bariatric surgery and
to demonstrate the incidence of arrhythmia.
OBJECTIVE
METHODS
A retrospective chart review of all patients who
underwent bariatric surgery at King Abdullah
Medical City (KAMC) to evaluate changes in
echocardiographs and ECG. Myocardia performance
index (MPI), automated left ventricular ejection
fraction (EF) using QLAB,left ventricular end
diastolic volume (LVEDV), global longitudinal strain
(GLS), and pericardial fat, heart rate, RP, QRS, QT,
QTc, BMI, total cholesterol, LDL, HDL,
triglycerides and glycated hemoglobin (HgA1c) were
compared before and after at least one year
postoperatively.
RESULTS 800 consecutive patients were identified, 99 had ECG
and Echo e and post operatively.
There was significant decrease in BMI, 49 vs 33, p
<0.0001 total cholesterol 198 vs185 p<0.001
Triglyceride 134 vs 92; P<0.001, HgA1c 6.5 vs 5.6 ;
P<0.001, heart rate 78 vs 70; P<0.001.
Pericardial fat improved from 0.64 to 0.42 P<0.05;
LVEDV decreased from 112.3 to 93.7; P<0.05. MPI
improved from 0.64 to 0.47 P =0.007 EF increased
from 48 % to 61% P<0..005 and GLS showed
tendency for improved from 17.2% to 21.3 P>0.05 .
CONCLUSION
Bariatric surgery offers significant improvement in
cardiac risk factors. Furthermore, our data shows
significant improvement in cardiac structure and
function. These findings underscore the role of
bariatric surgery on heart health over and above
weight loss.
KEYWORDS
Bariatric surgery; Cardiac function; Obesity;
arrhythmia; bradycardia.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 2
Critical Care Nurses Practices and Attitude
Toward Patient Suffering from Delirium
Mohamed A. Ghoneam Assistant lecturer of Critical Care & Emergency
Nursing Department, Faculty of Nursing, University of Beni-suef, Egypt.
INTRODUCTION:
Delirium is common and is often a harbinger of
death especially in ICU patients. It is a sudden
change in mental status, with fluctuating course,
marked by decreased attention. It is caused by
underlying medical problems, drug
intoxication/withdrawal. Aims: Identify Critical care
nurses’ practices and attitudes towards patients
suffering from delirium.
MATERIALS AND METHODS:
A descriptive design was followed in this study.
The study was conducted in the critical care units of
Alexandria Main University Hospital and intensive
care units of Beni-Suef Main university hospital.
Tool I: Delirium critical care nurses’ practices
observational. Tool II: Critical Care Nurses’
attitudes toward patients suffering from delirium
Structured
Interview Schedule. Results: The vast majority of
nurses had poor total practice score. Seventy four
percent of nurses had a fair total attitude
Recommendation: Assess relationship between
sleep deprivation and incidence of delirium.
Facilitating open visitation in the adult intensive
care environment to allow flexibility for patients
and family.
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CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 3
Incidence of Vascular Complications Among Egyptian
Population During Trans-Femoral Aortic Valve Implantation Nasr M. Elsoudi, Yousef A Elsayed, Mokarrab M. Ibrahim, Saifelyazel I. Shawky,
Aref M, Mohamed Moustafa
ABSTRACT .
OBJECTIVE
To describe the incidence of vascular
complications in trans femoral TAVI patients,
based on the VARC criteria, and to identify
predictors of these serious events among the
Egyptian population.
METHODS
We performed a prospective cohort study of 30
consecutive transfemoral TAVI recipients.
Vascular complications were defined by the Valve
Academic Research Consortium (VARC) criteria.
RESULTS
In our cohort of elderly patients (74.17 ± 8.828
years), the logistic Euro Score was 25.8% 11.9%.
The Edwards valve was used in 7 cases, the Core
Valve in 20, and Evolute R valve in 3 cases.
Ejection fraction assessed by ECHO was 58.27 ±
10.540. The minimal Rt femoral artery diameter
was 10.0 ± 1.9 mm. Tortuosity of Rt femoral
artery was observed in 5 cases. Vascular
complications were observed in 7 patients (23.3
%). The other 23 (76.7 %) patients had no post-
procedural complication., (VARC major: 2 (6.7
%), minor: 5 (16.7 %)). There was significant
difference between low Ejection fraction, minimal
luminal diameter, vascular tortuosity, and
incidence of vascular complications. n.
CONCLUSION Vascular complications in trans femoral TAVI
remain a significant issue despite improving center
experience and smaller delivery systems. Vascular
complications defined by VARC can be predicted
by information from bassline
and Procedural Characteristics of the patients. so
good selection of patient may improve TAVI-
related outcomes.
KEYWORDS
Transcatheter aortic valve implantation
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 4
Left Atrial Size And Stiffness As Predictor of Prevalence
And Incidence of Atrial Fibrillation In Patients WithRheumatic Mitral Stenosis
Ahmed Taha Hussein
ABSTRACT .
BACKGROUND
Stiff left atrial (LA) is independent of LA diameter
and associated with low LA compliance. We
investigated the physiological and clinical
implications of LA compliance among patients with
Rheumatic tight Mitral stenosis either in sinus rhythm
or in atrial fibrillation (AF).
OBJECTIVE
This retrospective cohort study was aimed at
assessing the demographic & clinical characteristics,
immediate and short-term outcome of VEP
undergoing PCI.
PATIENTS AND METHODS
Among 135 consecutive patients with tight rheumatic
mitral stenosis, we included 100 patients with sinus
rhythm (81.7% female, 25.7±10.6 years) and 35
patients with AF (70.2% female, 27.3±12.4 years).
We measured LA compliance, LA diameter and
trans-valvular pressure gradient by Doppler
echocardiography and compared the values with
clinical parameters and the AF prevalence.Results:
AF patients had lower compliance compared to sinus
rhythm patients (3.1±0.5 Vs 5.6±0.7 ml/mmHg,
P=0.009) while there was no significant difference in
their LA diameter (49.6±1.6 Vs 48.3±1.3, P=0.14)
and also insignificant difference in maximum trans-
valvular pressure gradient (17.1±2.9 Vs 16.2±2.1
mmHg, P=0.21). During a mean follow- up of 32±17
months, low LA compliance was independently
associated with incidence of AF (HR:4.2;
95%CI:3.077–6.503; p = 0.031).]
CONCLUSION Low LA compliance, as estimated non- invasively by an
Doppler echocardiography was independently
associated with higher clinical prevalence of AF and
predicts early incidence in patients with Rheumatic
Mitral Stenosis.
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CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 5
Provocation of Left Ventricular Outflow Tract Obstruction
Using Nitrate Inhalation in Hypertrophic Cardiomyopathy:
Relation to Electromechanical Delay Hala Mahfouz Badran, Waleed Abdou Ibrahim, Naglaa Faheem, Rehab Yassin, Tamer
Alashkar, Magdi Yacoub
ABSTRACT
BACKGROUND
Left ventricular outflow tract obstruction (LVOT) is
an independent predictor of
adverse outcome in hypertrophic cardiomyopathy
(HCM). It is of major importance that the
provocation modalities used are validated against
each other.
OBJECTIVE To define the magnitude of LVOT gradients provocation
during both isosorbide dinitrate
( ISDN) inhalation and treadmill exercise in non-
obstructive HCMand analyze the correlation to
the electromechanical delay using speckle tracking.
METHODS
We studied 39 HCMpts (64% males,mean age 38 ^
13 years) regional LV longitudinal strain and
electromechanical delay (TTP)was analyzed at rest
using speckle tracking. LVOT gradient was measured
at rest and after ISDN then patients underwent a
treadmill exercise echocardiography (EE) and LVOT
gradient was measured at peak exercise.
RESULTS
The maximum effect of ISDN on LVOT gradient was
obtained at 5 minutes, it increased to a significant
level in 12 (31%) patients, and in 14 (36%) patients
using EE,with 85.6% sensitivity & 100% specificity.
Patients with latent obstruction had larger left atrial
volume and lower E/A ratio compared to the non-
obstructive group (p , 0.01). LVOTG using ISDN
was significantly correlated with that using EE (p ,
0.0001), resting LVOTG (p , 0.0001), SAM(p ,
0.0001), EF% (p ,0.02) and regional
electromechanicaldelay but not related to global LV
longitudinal strain.Using multivariate regression,
resting LVOTG (p ¼ 0.006)& TTP mid septum (p ¼
0.01)were found to be independent predictors of
latent LVOT obstruction using ISDN.
CONCLUSION
There is a comparable diagnostic value of nitrate
inhalation to exercise testing in provocation of LVOT
obstruction in HCM. Latent obstruction is
predominantly dependent on
regional electromechanical delay.
KEYWORDS
LVOT obstruction provocation, electromechanical
delay, hypertrophic cardiomyopathy ------------------------------------------------------------------- 1-Cardiology DepartmentMenoufiya University, Egypt
2-The BAHCMNational Program, Egypt 3-Aswan Heart Center, Egypt 4Imperial College, London, UK
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CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 6
Pulmonary Vein Pulsatility Index (PVPI) in Fetuses of
Diabetic Mothers: Relationship to Intermediate andLong Term Diabetic Control
Habeeb NM, Youssef OI and Hendawy S
ABSTRACT .
BACKGROUND
Consequences of uncontrolled diabetes during
pregnancy are severe for both mothers and fetuses
.Cardiovascular abnormalities
(CVS) abnormalities are among the most common
in infants of diabetic mothers .Fetal
echocardiography has increased
knowledge about CVS changes in prenatal period.
METHODS
This cross sectional study was conducted
on 42 pregnant mothers,30diabetics( gp1) and 12
normal gestational age matched as
control(gp2)following up at obstetric clinic Ain
Shams university hospital ,their gestational ages
ranged from 22to 28wks with a mean of
24.4+1.6wks .studied groups were subjected to
history taking ,clinical examination ,laboratory
investigations(CBC,HbA1C, serum fructosamine
level(colorimetricassay) for long and intermediate
term assessment of blood glucose control, fetal
echocardiography using standard views(four
chamber, five chamber, three vessels and tracheal
views)(vivi7,GE,Horten,Norway),fetal TDI at basal
part of interventricular septum, mitral annulus and
pulsed wave Doppler at junction of upper
pulmonary vein with left atrium for pulmonary vein
pulsatility index (PVPI)assessment.
RESULTS
no statistically sig difference was found between
gp1and gp2and between uncontrolled diabetic
(gp1b (HbA1cmore than 7)gp1d (serum
fructosamine more than 285umol/l)as regards
maternal age and number of births
(0,54,0.28,0.27and0,48 respectively).
A statistically significant increase was found in
PVPI in gp1 than gp2(p=0,026),between
uncontrolled diabetic mothers {gp1b than 1a(p less
than 0,01)and gp1d than gp1c p less than
0,001}.No significant difference was found
between patients and controls(p0.04) between gp1b
and gp1c as regards interventricular septal
thickness ( IVS) thickness(0,02 and 0.03
respectively, no sign diff was found between gp1
and gp2,gp1a and 1b and gp1cand gp1d as regards
septal Em, Am, Em/Am. Lateral Em,Am,Em/Am
(p=0.77,0,62,0.16.0,69,0,7,0.10 and 0,13)
A significant positive correlation was found
between IVS thickness and age in gp1(p less than
0,01)
CONCLUSION
fetuses of diabetic mothers showed increased PVPI
than control This increase was significantly
marked in fetuses
from intermediate and long term blood glucose
uncontrolled
diabetic mothers than controlled ones denoting
ventricular
incompliance and some degree of diastolic
dysfunction in those fetuses that could not be
simply explained by IVS hypertrophy as this was
not the case in current study and warrants further
research.
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CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 7
Short Term Outcome of Thoracic Endovascular Aortic
Repair in Patients With Thoracic Aortic Diseases Hamdy Soliman, Mohammed N. El-Ganainy, Reham M. Darweesh,
Sameh Bakhoum, Mohammed Abdel-Ghany
ABSTRACT
BACKGROUND
Open surgical repair for thoracic aortic diseases is
associated with a high perioperative mortality and
morbidity. Most of type B aortic dissections are
uncomplicated and are medically treated which
carries a high mortality rate. Thoracic endovascular
aortic repair is the first-line therapy for isolated
aneurysms of the descending aorta and complicated
type B aortic dissection.
OBJECTIVE
To test the safety of early thoracic endovascular
aortic repair in patients with uncomplicated type B
aortic dissection and patients with thoracic aortic
aneurysms.
METHODS
A total of 30 patients (24 men and 6 females; mean
age 59±8 years) with uncomplicated type B aortic
dissection and descending thoracic aortic aneurysm
who underwent endovascular aortic repair in
National Heart Institute and Cairo University
hospitals were followed up. Clinical follow-up data
was done at one, three and twelve months thereafter.
Clinical follow-up events included death,
neurological deficits, symptoms of chronic mal-
perfusion syndrome and secondary intervention.
Multi-slice computed tomography was performed at
three and six months after intervention.
RESULTS
Of the 30 patients, 24 patients had aortic dissection,
and 6 patiens had an aortic aneurysm. 7 patients
underwent
hybrid technique and the rest underwent the basic
endovascular technique in whom success rate was
100%. Two patients developed type Ia endoleak
however both improved after short term follow up.
The total mortality rate was 10% throughout the
follow-up. Both death and endoleak occurred in
subacute and chronic cases, while using TEVAR in
acute AD and aneurysm showed no side effects.Early
thoracic endovascular aortic repair showed better
results and less complications.
CONCLUSION
Along with medical treatment, early thoracic
endovascular aortic repair should be considered in
uncomplicated type B aortic dissections and thoracic
KEYWORDS TEVAR, Thoracic Aortic Diseases,
Aortic aneurysm
---------------------------------------------------------------------- 1-Prof. Dr. Hamdy Soliman, MD Chief of the Endovascular Unit ,National
Heart Institute; (NHI ) Imbaba, Cairo.
2-Prof. Dr. Mohammed Abd El Ghany, MD Prof. of Cardiovascular medicine, Cairo University.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 8
Transradial Percutaneous Coronary Intervention in Very
Elderly Patients (Age 80 years or above) with Acute
Coronary Syndrome: Immediate and Short term Outcome,
Single Centre Experience. Ahmed Deiab, Vipin Thomachan
ABSTRACT
BACKGROUND
There are very few data about Percutaneous
Coronary Intervention (PCI) in very elderly patients
(VEP), especially through the Trans Radial (TR)
approach.
OBJECTIVE
This retrospective cohort study was aimed at
assessing the demographic & clinical characteristics,
immediate and short-term outcome of VEP
undergoing PCI.
METHODS
Retrospective analysis of Electronic Medical Records
(CERNER) of patients admitted in our hospital
between 2014 and 2016, who underwent PCI. The
primary outcome was all cause mortality at 30 days
and 6 months.
RESULTS
60 VEP (mean age 85.53±4.6 year) underwent PCI at
our institute (male 46.7 %; female 53.3 %), between
2014 and 2016. Of these, 41 patients (68.3%) had
PCI for NSTE-ACS and 16 patients (26.7%) for
STEMI. 27 patients (65.9%) with NSTE-ACS and 14
patients (87.5%) with STEMI underwent PCI through
TR route. Cross over to TF (trans-femoral) required
in 2 patients (4.4%).
Total one month and 6 months mortality rates were
10% and 15% respectively. One month mortality rate
in TR and TF groups were 7.3% and 18.8%
respectively. Mortality rate at 6 months were 7.3% (3
out of 41 patients) in TR group and 37.5% (6 of 16
patients) in TF group (p=0.00496).
6 months mortality of STEMI patients in TR and TF
groups were 21.4% (3 out of 14 patients) and 100%
(2 out of 2) respectively (p=0.0251). Mortality of
NSTEMI patients in TR and TF groups were 0%
(none of 27 patients) and 28.6% (4 out 14 patients)
respectively (p=0.0035).
Co-morbidities and multi-vessel disease (MVD) were
more prevalent in TF group compared to TR group,
but these were not statically significant except past
history of revascularization (past revascularization
31.2% in TF and 14.3% in TR group, p= 0.0455; DM
62.5% and 58.5% p= 0.078716; CVD 68.7% and
51.2% p=0.23014; CKD 37.5% and 36.5%
p=0.95216; AKI 43.7% and 21.9% p= 0.09894;
MVD 56.3% and 39% p=0.238).
6 patients presented in cardiogenic shock; of these 4
had PCI through TF route. Hospital mortality in
shock patients were 50% (1 out of 2 patients) in TR
and 50% (2 out 4) in TF groups respectively.
The present study has several limitations. This study
was based on a single centre experience and the
number of study patients were small, especially
STEMI patients who had trans-femoral PCI. More
unstable patients had trans-femoral PCI and study
follow up was for short duration.
CONCLUSION
This study shows that common presentation of ACS
in very elderly patient is NSTE-ACS and majority of
patients are women.
Mortality is very high in VEP compared with
younger patients. In both STEMI and NSTE-ACS,
advanced age is independently associated with high
mortality.
PCI is a safe treatment option for ACS in VEP and
Trans Radial PCI appears to be a safer treatment
option compared with trans-femoral PCI.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 9
Transradial cardiac interventions in Yemeni patients ,
A local Experience from Hadhramout T. Bafadhel, M. Alfalag, O. Ben-zihdan, A. Alzubidi, M. Ba-Moamen & A.N Munibari
ABSTRACT
INTRODUCTION
Accessing the coronary arteries from the upper limbs
is not a recent concept. The first cardiac angiography
was performed utilizing the brachial vein in 1929.
Although the first transradial coronary stenting was
1993. Nowadays this route is gaining popularity in
the field of interventional cardiology.
Coronary Catheterization in Yemen is performed
mostly via transfemoral approach. Nabdh Al-hayat
cardiac centre located in Hadhramout , Yemen was
the first cardiac charity centre in the country and
mostly using the transradial approach (TR) for
percutaneous coronary intervention (PCI)
METHODS
Evaluate the cases done during period between
April 2018 till end of November 2017 referred for
cardiac catheterization to the coronary angiography
laboratory in Nabdh Al-hayat Charitable Cardiac
centre. All the patients were subjected to through
clinical evaluation, laboratory investigations, resting
ECG and Echocardiography examination. All the
data of the patients were fed to PC and statistical
analysis were performed using SPSS ver. 21 .
The different correlations were analyzed accordingly
RESULTS:
A total of 1270 cardiac catheterization cases were
done, 932 of them was diagnostic procedure and 338
was PCI . A some of 1149 done via TR (90.5%) and
121 cases done via femoral approach (9.5%). 851
cases done via radial approach were diagnostic
cardiac catheterization and 289 cases was coronary
intervention as shown in tables below. Mean age
were 57.9 Years (SD ±11.1086) , Males were
predominant (78.4% ) while patient aged 50 years
and younger represents 27.2% of all the cases while
patients aged 70 years and older were 12.6% .
Hematomas were recorded only in two cases done
using TR route. No single death reported.
KEYWORDS
Transradial, hadramout, nabdhal hayat
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Month Total cases Diagnostic Coronary
interventional
4/2017 72 68 4
5/2017 141 118 23
6/2017 92 55 37
7/2017 230 180 50
8/2017 162 120 42
9/2017 166 110 56
10/2017 207 149 58
11/2017 200 132 68
TOTAL 1270 932 338
Month Total cases Radial approach
Femoral approach
4/2017 72 68 (94.4%) 4 (5.6%)
5/2017 141 134 (95%) 7 (5%)
6/2017 92 83 (90.2%) 9 (9.8%)
7/2017 230 220 (95.6%) 10 (4.4%)
8/2017 162 151 (93.2%) 11 (6.8%)
9/2017 166 141(84.9%) 25 (15.1%)
10/2017 207 179 (86.5%) 28 (13.5%)
11/2017 200 173 (86.5%) 27 (13.5%)
TOTAL 1270 )90.5%(1149 ) 9.5%(121
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 10
Validation of A Newly Generated CRT-Score to Predictthe Response to Cardiac Resynchronization Therapy
Mostafa Nawar, Gehan Magdy, Aly Abo Elhoda, Sarah Sultan
ABSTRACT
BACKGROUND
Cardiac resynchronization therapy (CRT) is an
indispensable mode of treatment for the increasing
number of patients with severe systolic heart failure
.(1) A new CRT-score was recently generated in
Alexandria University to predict responders to
CRT.(2) The CRT score includes QRS duration ≥150
ms, LBBB morphology ,non-ischemic
cardiomyopathy (ICM), sinus rhythm ,preserved RV
function with TAPSE ≥15 mm, female gender, the
absence of history of renal disease and significant
chronic obstructive pulmonary disease (COPD). Each
parameter was assigned to a single point except QRS
duration ≥150 ms was assigned to 2 points of
maximum 9 points.
METHODS
The study included 50 consecutive heart failure (HF)
patients eligible for CRT implantation with New
York Heart Association (NYHA) functional class II
or III and LVEF ≤35%. Routine device and clinical
follow-up were performed at baseline and at 6 month
intervals. Response was defined as combined
improvement of NYHA class and reduction in left
ventricular end-systolic diameter >15%.
RESULTS
Fifty patients were included [76% men ,mean age
60.66±11.56years ; 96% NYHA class III, 25 patients
had ICM, 98% of patients had LBBB, 43 patients had
QRS duration ≥150msec. Baseline left ventricular
ejection fraction (LVEF) was 27.36±5.01%; left
ventricular end systolic diameter was 68.82±12.39
mm. CRT was successfully implanted in all patients ;
CRT response was achieved in 43 patients (86%), the
mean LVEF improved from 27.3 ±5.01 to 38.71
±10.91 (P <0.001), the. The CRT response rate has
been markedly significant according to the CRT-
score. Patients with score ≥ 6 had response rate of
95.3 % vs 4.7 % if the score < 6 (P = 0.002,
sensitivity = 95.35 and specificity =71.43).
CONCLUSION
The newly generated CRT score is a good predictor
to improve the appropriate use of CRT and to
increase the CRT response rate. PCI is a safe
treatment option for ACS in VEP and Trans Radial
PCI appears to be a safer treatment option compared
with trans-femoral PCI.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 11
Value of Global Longitudinal Peak Systolic Strain Derived
by 2-D Speckle Tracking in Detection of Obstructive
Coronary Artery Disease Mohamed F. Areed, Mahmoud M. Youssof, Moheb M. Wadie
ABSTRACT .
BACKGROUND
Non-invasive identification of patients with coronary
artery disease (CAD) remains a clinical challenge
despite the widespread use of imaging and
provocative tests and Speckle tracking
echocardiography has been validated for assessment
of global and regional left ventricular myocardial
function which is affected in patients with obstructive
CAD
OBJECTIVE
Early detection of obstructive coronary artery disease
using average global longitudinal Peak Systolic strain
(GLPS-Avg) derived by 2-D Speckle Tracking.
PATIENTS AND METHODS
75 patients with chronic stable angina were enrolled
in this prospective case control study, (Mean age was
56.69 ± 6.96 y, 35 were males), 42.7 % were diabetic
and all patients were assessed by thorough history
taking, clinical examination,12 lead surface ECG,
conventional, speckle Echocardiography and
coronary angiography in Mansoura specialized
medical hospital over a period of 7 months from
march 2017 to October 2017
RESULTS
Statistically significant decrease was found in GLPS-
Avg values in patients with obstructive CAD when
compared to patients with normal coronary
angiography (p<0001) and in patients with 3 or more
risk factors when compared to patients with one or
two risk factors (p=0.014), And when syntax score
was increasing among patients with obstructive CAD
a significant decrease in median GLPS-Avg values
was noted (p<0.001), but when regional systolic
strain values were compared to affected coronary
arteries no significant difference was found
(p=0.844) i.e almost identical correlation between
affected segments by speckle tracking and obstructed
arteries by coronary angiography.
Multivariate logistic regression analysis showed that
GLPS-Avg was found as a predictor for obstructive
coronary artery disease in patients with chronic stable
angina (p=0.028 with odds ratio 31.4 and 95% CI
(1.85-535))
ROC curves were established and cutoff value was
determined for GLPS-Avg as -16 with 89.8%
sensitivity and 100% specificity
CONCLUSION
longitudinal strain derived by speckle tracking can be
used as non-invasive simple test for evaluation of
patients with chronic stable angina and as a predictor
for presence or absence of obstructive CAD
KEYWORDS
Speckle Tracking – Coronary artery disease –
Coronary Angiography.
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CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 12
SECTION 2: RESUMES, ARTICLES AND
TOPICS PRESENTED @ CARDIOALEX.18
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 13
A Retrospective Comparative Study Between Levosimendan
and Adrenaline as a Pharmacological Based Protocol in the
Management of Low Ejection Fraction Coronary Artery
Bypass Grafting Patients: A Friend or FoeMohammed Abd Al Jawad, MD,Lecturer of Cardiothoracic Surgery, Faculty of medicine,
Ain Shams University
Coronary artery bypass grafting is the
most common cardiac surgery in
adults till today. Various factors
contribute to the outcome of this
procedure mainly the perioperative
left ventricular ejection fraction,
degree of ischemia and coronary
lesion anatomy. Among other factors are the insertion
of Intra-Aortic Balloon Pump (IABP) and associated
perioperative low cardiac output status.
Following cardiac surgery, the myocardial
contractility tends to decrease owing to the fact of
myocardial edema and decreased myocardial
compliance. This process continues to occur in the
early post-operative period which requires careful
and delicate pharmacologic management in patients
already suffering from depressed left ventricular
functions.
A standard pharmacological protocol in the early
post-operative period is composed of inotropic
adrenaline infusion with coronary dilator glyceryl
trinitrate (GTN) infusion.
More recently, a new drug “Levosimendan” was
proposed as an effective inotropic support with a
different mechanism of action rather than that of
catecholamines. Levosimendan is a calcium
sensitizer that has a relatively more favorable
metabolic profile. Increasing myocardial contractility
without increasing oxygen demand and the
"unfavorable" tachycardia thorough sensitization of
Troponin C to Calcium, enhancing their binding and
increasing.myocardial.contractility.
To assess the “potential benefit” of preoperative
levosimendan administration, a number of RCTs
were initiated in multicenter approach; namely:
LEVO-CTS Trial, The CHEETAH Trial and
levosimendan in Coronary Artery revascularization
(LICORN) trial. All these trials concluded that
Levosimendan showed no statistically significant
outcome in terms of mortality in patients with low
ejection fraction.
In our retrospective study, we aimed to compare the
two pharmacological protocols in terms of mortality
(as a primary outcome) and incidence of low cardiac
output syndrome in the early post-operative period.
The study included 63 patients,35 of them belonged
to the Adrenaline protocol. The preoperative ejection
fraction was comparable in both Adrenaline and
Levosimendan groups, being 29.45±3.75 and
30.67±4.28 respectively.
The current study concluded that levosimendan use
may be associated with lower incidence of
postoperative arrhythmia, less need for mechanical
support, less mechanical ventilation hours, less ICU
stay periods. However, the primary outcome for this
study showed no statistically significant difference
between the two pharmacological protocols.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 14
Appropriate BP Measurement for Proper Management Ahmed Bendary, MD, Cardiology Department, Benha faculty of Medicine
Blood pressure (BP) can be measured
using one of the following three
acceptable strategies: Ambulatory
blood pressure monitoring (ABPM),
home BP monitoring or office-based
BP measurements, which may be
automated or manual.
Screening for hypertension is typically performed in
the clinician's office. Although these office
measurements are recommended to identify patients
who might have hypertension, many such individuals
will not have hypertension upon further testing (ie,
they have white coat hypertension). Our approach to
measuring BP for the purposes of diagnosing and
confirming hypertension depends in part upon the
feasibility of performing ABPM, home BP
monitoring, and, if neither ABPM nor home BP
monitoring are feasible, whether an automated
oscillometric BP (AOBP) device is used in the
clinician's office
We perform ABPM if it is feasible to establish the
diagnosis.
Sometimes, ABPM is not feasible (ie, due to lack of
access or expense) in such cases, we perform home
BP monitoring if it is feasible.
If home BP monitoring is not feasible (patient cannot
afford a cuff or find a suitably sized cuff), then BP
must be measured in the office. However, if office
BP is used to confirm the diagnosis of hypertension,
multiple measurements on different days are required
-If the office has an AOBP device that can
automatically take and average multiple
measurements with the patient alone in a room, then
we use this technique to measure BP.
-Conversely, if no such AOBP device is available, we
use routine office BP measurements.
Patients being managed for previously diagnosed
hypertension should monitor their BP at home, if
possible. If home BP cannot be monitored,
management of the patient can be informed by office
measurements (performed using an AOBP device if
available).
All home monitors should be checked for accuracy,
initially and then at least annually, in the clinician's
office, and patients or caregivers should be able to
demonstrate the correct technique of BP
measurement. When using home monitoring in obese
patients, appropriately sized arm cuffs may be
unavailable; in these situations, wrist cuffs may be
used.
In gneral, measurements obtained by ABPM and
home BP monitoring are lower than those obtained
by routine office measurement by approximately 5 to
10 mmHg. In addition, office readings obtained using
an AOBP device
more losely approximate ABPM and home BP
readings than standard office measurement.
If manual office readings are used to diagnose and
monitor BP, proper measurement requires
attention to all the following: Time of
measurement, type of measurement device, cuff
size, patient position, cuff placement, technique of
measurement, number of measurements.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 15
ACS/ STEMI Experience in Kenya Harun A Otieno, Africa Heart Associates, Nairobi Kenya
Kenya is experiencing an increase of
acute myocardial infarction cases. Many
patients present lat over 13 hours after
the onset of symptoms and few primary
PCI centers exist in the country. For a
population of 48 million, there are only
8 catheterization laboratories most
being located in the capital city. Compounding the
problem further is the widespread lack of simple
diagnostic tools to detect the condition early. A recent
online survey demonstrated that only 21% of lower level
public health facilities had an EKG machine available.
Thrombolytics and Primary PCI are being routinely
performed but the costs are prohibitive to most Kenyans.
When available guideline based reperfusion goals are
achieved less than 50% of the time.
Stent - Save a Life, Kenya is working together in
partnership with Heart Attack Concern Kenya, the
Kenya Cardiac Society to improve the overall care and
systems for heart attacks in the country. During the
annual Africa STEMI Live meeting, held in April
2018, we hosted a pre conference STEMI Workshop
together with the Emergency Medical Foundation
Kenya, where regional Heart Attack champions and
teams attended a whole day meeting learning about
early recognition, ECG recognition and guideline
based strategies for reperfusion, Over 26 counties were
represented out of a total of 47 total counties in Kenya.
SSL Kenya is working on data collection using the
Teamscope® mobile smartphone based application to
collect information right at the point of care by
physicians treating heart attack victims. Finally, we are
promoting early detection by supporting simple,
affordable EKG technologies in all emergency
departments nationwide and creating a link to
emergency ambulance services that will improve a
systems based approach to heart attack care in Kenya.
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Bioabsorbable Scaffolds Fourth Revolution or Failed
Revolution: Are We Looking at the Wrong Targets? Sundeep Mishra
The prospect of leaving a metallic
prosthesis in the body, especially
when it is no longer required has
always been a matter of concern to
both physicians and patients alike.
In case of metallic stents for coronary or peripheral
interventions this is of particular worry because they
don’t remain innocuous, rather interfere with
vascular remodeling and flow and serve as a nidus
for accumulation of platelets (stent thrombosis) as
also interfere with future interventions in the area.
Bioresorbable scaffolds (BRS) were developed with
a view to address some of these philosophical and
practical issues particularly that of late stent
thrombosis with metallic drug eluting stents (DES)
and were purported to represent ‘‘Fourth
Revolution’’ in stent technology.
The trick was to match physical performance of the
metallic stent but at the same time making the
scaffold disappear at a variable period of 6 months
to 3 years after implantation. The initial results with
this technology, in simple lesions with a careful
application of technique, seemed equivalent to any
metallic stent with the advantage of melting away in
due course of time and possible favorable
remodeling of artery and a better flow. However,
soon problems of late scaffold thrombosis and post-
procedural myocardial infarctions started cropping
up, the very reasons BRS was developed in the first
instance. Thus suddenly medical opinion moved
from ‘‘Fourth Revolution’’ to possible ‘‘Failed
Revolution.’’ This whole fiasco demands
explanation and possible learning for future.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 16
Bioresorbable scaffold (BRS) technology has
currently fallen into disrepute because of inordinately
high risk of scaffold thrombosis and post-procedure
myocardial infarction. Low tensile and radial
strengths of polymeric BRS contributing to improper
strut embedment have been identified as major
correlates of poor outcomes following BRS
implantation. Magnesium has a better tensile/radial
strength compared with polymeric BRS but it is still
far lower than cobalt-chromium. Newer innovations
utilizing alteration in polymer composition and
orientation or even newer polymers have focused on
attempts to reduce strut thickness but may have little
effect on tensile/radial strength of finished product
and therefore may not impact the BRS outcome on
long run. Currently, newer generation BRS usage
may be restricted to suitable low risk younger
patients with proper vessel preparation and
application of technique.
If home BP cannot be monitored, management of the
patient can be informed by office measurements
(performed using an AOBP device if available).
All home monitors should be checked for accuracy,
initially and then at least annually, in the clinician's
office, and patients or caregivers should be able to
demonstrate the correct technique of BP
measurement. When using home monitoring in obese
patients, appropriately sized arm cuffs may be
unavailable; in these situations, wrist cuffs may be
used.
In general, measurements obtained by ABPM and
home BP monitoring are lower than those obtained
by routine office measurement by approximately 5 to
10 mmHg. In addition, office readings obtained using
an AOBP device
more closely approximate ABPM and home BP
readings than standard office measurement.
If manual office readings are used to diagnose and
monitor BP, proper measurement requires attention
to all the following: Time of measurement, type of
measurement device, cuff size, patient position, cuff
placement, technique of measurement, number of
measurements.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 17
Can CAD be Prevented?
Lessons Learned from an Indigenous Hunter-Horticulturist Culture of the Bolivian Amazon.
Gregory S. Thomas, MD, MPH; Fiona R. Sylvies, BS; Adel H. Allam, MD
In 2009, an interdisciplinary research
team led by Adel Allam MD,
Abdelhalim Nureldin, PhD and
Gregory Thomas, MD, MPH
performed whole body noncontrast
CT scanning on 22 Egyptian
mummies (1981 BCE and 334 CE) housed at the
Museum of Egyptian Antiquities in Cairo.
Cardiovascular tissue was present in 16. Using the
presence of vascular calcification observed on CT
scanning as definitive evidence of atherosclerosis,
9 of the 16 mummies were diagnosed with
atherosclerosis (Allam AH, et al, JAMA
2009;302(19):2091-2094). The team, ultimately
called the Horus research team, subsequently
imaged another 115 mummies from 4 distinct
ancient cultures around the world (Thompson et al,
Lancet 2013;381):1211-1222). Despite a mean age
of only 37 years, atherosclerosis could be
documented in one-third of 137 mummies studied.
Horus team concluded that atherosclerosis was
inherent to the process of aging.
Soon thereafter, the Horus team joined forces with
the Tsimane Health and Life History Project
(THLHP) team led by anthropologists Hillard
Kaplan, PhD and Michael Gurven, PhD. The
THLHP team had been studying the 14,000-person
indigenous Tsimane tribe, who live in the Amazon
basin in Bolivia. The Tsimane are subsistence
farmers, each family hunts, fishes and farms for
their own food. As such, they serve as a model of
how humans lived prior to urbanization and the
specialization of labor inherent in this transition.
Their diet is high in unprocessed carbohydrates
that they have grown. Protein is from fish and lean
meat. The THLHP team had reported that
myocardial infarctions and cardiac death were rare
among the Tsimane. However, this was difficult to
substantiate as the Tsimane live in remote rain
forest with only intermittent medical care.
The teams joined forces to perform noncontrast
coronary CT scanning on 706 living Tsimane aged
40-91 years of age (mean age 58) (Kaplan H et al.
2017;389:1730-1739). To the Horus team’s
surprise, the average Tsimane did live a life
without developing coronary artery calcification
(CAC) – 85% of the 706 adults had no CAC. The
Figure shows that the rate of progression of CAC is
much slower in the Tsimane than in the United
States cohort (MESA). Moderate CAD, defined by
a CAC >100 AU, occurred in 3% of the Tsimane,
about 1/10th of the prevalence in the US.
The best explanation for this finding is the
dramatic dearth of risk factors for CAD among the
Tsimane. Mean blood pressure of the 706 Tsimane
studied was 116/73 mm Hg, mean fasting blood
sugar 79 mg/dL, none had a FBS of >126 mg/dL,
BMI was 24, and lifetime LDL was 71 mg/dL.
Smoking was extraordinarily rare. Physical activity
patterns were not assessed in this cohort, however,
averaged the equivalent of 16,000-17,000 steps per
day in a separate study of representative Tsimane
adults.
Data from ancient mummies and the contemporary
Tsimane demonstrate that while humans are
inherently prone to atherosclerosis, a lifetime of
remarkably low risk factor burden can delay or
defer coronary atherosclerosis over the course of a
human.lifetime
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 18
Cell based therapies for IHD and heart failure: problems,
promises, perspectives and pitfalls Rosalinda Madonna
Despite improvements in modern
cardiovascular therapy, the morbidity
and mortality of ischemic heart disease
(IHD) and heart failure (HF) remain
significant in Europe and worldwide.
Patients with IHD may benefit from
therapies that would accelerate natural processes of
postnatal collateral vessel formation and/or muscle
regeneration. In this seminar, we discuss the use of
cells in the context of heart repair, and the most
relevant results and current limitations from clinical
trials using cell-based therapies to treat IHD and HF.
The lecture will undertake a critical appraisal of
where the stem cell field stands and where it appears
to be headed, by critically reviewing the current
approaches using stem cell or cell-based therapies to
treat IHD and HF.
We identify and discuss promising potential new
therapeutic strategies that include the use of
biomaterials and cell-free therapies aimed at
increasing the success rates of therapy for IHD and
HF.
The lecture will also discuss promising new
strategies for stem cell therapy enhancement that
include ex vivo cell-mediated gene therapy, with the
aim of increasing the success rates of therapy for
IHD and HF.
The lecture will also discuss promising new
strategies for stem cell therapy enhancement that
include ex vivo cell-mediated gene therapy, with the
aim of increasing the efficacy and outcome of stem
cell therapies in the future.
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Coronary Artery Disease in the Young, Increasing
Laboratory Testing Menu and Controversial SignificanceAmina Hassab, Clinical Pathology Department - Alexandria University of Medicine
Coronary artery disease (CAD) is a
devastating disease not only affecting the
patient physically and emotionally, but it
also constitutes a huge burden on the
society and economy. It has long been correlated
with advanced age, nevertheless it is seen in young
adults but in a much less frequent rate. Several
factors contribute to the development of the disease,
besides the well known culprits (hyperlipidemia,
diabetes, smoking and hypertension) genetics play a
profound role in the development of CAD in the
young.
Multiple biochemical processes take role in the
formation of coronary artery disease including and
not limited to inflammatory response, endothelial
function, platelet function, thrombosis, lipid
metabolism and homocysteine metabolism. These
biochemical events are driven by the genetic makeup
of individuals.
Knowing the derivative genetic variation behind
these disorders shall provide deep insight of the
pathogenesis of the disease and opens a new avenue
for future therapy. Nowadays these genetic tests are
quite available and widely used, however, proper
selection of patients that would benefit from such
testing is still controversial.
Moreover, mimicking traditional models adopted by
guidelines to predict risk of CAD including the
aforementioned risk factors and family history,
genetic risk for developing CAD is recently
introduced.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 19
Genetic risk scoring tests has been emerging recently
with promising results that could be of help
particularly in assessing young patients for the risk of
developing CAD. Added to the complexity of
coronary artery disease is the epigenetic role for
disease pathogenesis which was recently addressed in
a large study. Proper laboratory test utilization is
mandatory for optimum patients' care and is the most
cost effective way of their management. Genetic
testing role awaits future incorporation in routine
testing on a wider scale.
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Coronary Arterivenous Fistula. Case presentation
Sherif Arafa
A 30 years old man complaining of
exertional dyspnea (NYHA II) and
chest pain with no relevant medical
history. Previous Echocardiography
was diagnosed as posterior pericardial
effusion and mild mitral regurgitation
for medical treatment with no
improvement. On examination there was continuous
murmur audible on parasternal area. Repeating
Echocardiography revealed large Coronary AV
fistula communicating between left coronary artery
and coronary sinus. MSCT was done and confirmed
the presence of large fistula communicating between
aneurysmally dilated circumflex and dilated coronary
sinus. Patient was referred for surgery with repair of
the fistula, coronary arteries and coronary sinus.
Patient was discharged with marked improvement of
symptoms on follow up.
Coronary artery abnormalities may involve
abnormalities in origin, termination, structure or
course. Coronary artery fistulae are abnormalities of
the termination of coronary artery which bypass the
capillary bed and enter in a cardiac chamber
(coronary-cameral fistula) or pulmonary or systemic
circulation (coronary AV fistula).1st described by
Krause in 1865. They are present in about 0.002% of
the general population. Most are congenital but may
be acquired. Usually single but may be multiple.
Small fistulas usually do not cause any hemodynamic
compromise while larger fistulae can cause coronary
artery steal phenomenon, which leads to ischemia of
the segment of the myocardium perfused by the
coronary artery and may lead to heart failure. The
mechanism is related to the runoff from the high-
pressure coronary vasculature to a low-resistance
receiving cavity due to a diastolic pressure gradient.
Diagnosis is usually done by echocardiography,
coronary multslice CT, cardiac MRI or coronary
angiography. Treatment includes Medical treatment
for heart failure, Antiplatelet therapy and
prophylactic precautions against bacterial
endocarditis. Transcatheter closure by embolization
using coils or other devices and the surgical
obliteration of the fistula by epicardial and
endocardial ligations which is the cornerstone of l
treatment and remains until now the most effective
treatment.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 20
Designing MTM plan based on PK/PD of StatinsNoha A. Hamdy, Department of Clinical Pharmacy & Pharmacy Practice, Faculty of
Pharmacy, Pharos University in Alexandria, Alexandria, Egypt
Cardiovascular Disease (CVD)
remains the leading cause of
morbidity & mortality. In addition,
the prevalence of some risk factors,
notably diabetes & obesity, is
increasing. CVD prevention should
be delivered for the general population by
promoting healthy lifestyle behavior and for
moderate to extremely high-risk CVD or patients
with established CVD. The importance of CVD
prevention proved to be cost effective in several
studies.
Statins reduce CV morbidity and mortality in both
primary & secondary prevention of coronary heart
disease, in addition to reduction of the risk of stroke.
The degree of LDL reduction is dose dependent and
varies among statins depending on their differences
in lipophilicity/hydrophilicity, pharmacokinetic and
pharmacodynamics properties. Patients are
classified based on their risk factors, extreme risk of
CVD has a new LDL goal to below 55mg/dl, with
this strong decline in LDL target, statins will find
extended use.
Medication Therapy Management (MTM) services
provide pharmacists with new opportunities for direct
patient care. The goals of MTM services are
improved medication understanding, adherence and
detection of medication-related problems, including
adverse drug reactions in addition to monitoring drug
response. The integration of pharmacokinetic (PK),
pharmacodynamics (PD) and clinical
pharmacokinetic sciences should be translated into
MTM counselling sessions in order to provide better
patient care and improve therapeutic outcomes.
Some pharmacokinetic properties like elimination
half-life correlates to the optimal time for statin
administration which differ from statin to the other.
Food might influence some statin bioavailability.
The concomitant administration of P-glycoprotein
inhibitors, bile acid sequestrants, and drugs altering
gastric pH were discussed regarding their effects on
statins hypocholesterolemic action.
Another PK property is binding to plasma proteins,
and whether displacement from protein binding
sites alter statin effects or not was also elaborated,
as statins are highly extraction ratio drugs. The
diversity in hepatic enzymes metabolism, by
cytochrome P450 (CYP-450) isoforms, among
statins highlighted the concomitant administration of
drugs that might increase statin intolerance. In
addition, statins exhibit different elimination
pathway which should be considered on individual
basis.
Pharmacodynamics properties, including therapeutic
and adverse responses, raise the importance of
polypharmacy consideration and tools for minimizing
statins intolerance.
MTM sessions should be carefully designed by
experienced clinical pharmacists, using
pharmacokinetic/ pharmacodynamics knowledge and
integrating pharmacists’ communication skills to
improve patient adherence, clinical outcomes and
promote health.
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CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 21
Device Related Infection Prevention and ManagementAmr Nawar, MD. Lecturer critical care department, faculty of medicine Cairo University
Roughly 40 years have passed since
permanent pacemakers (PMs) became
available in clinical medicine. More
recently, implantable cardioverter-
defibrillators (ICDs) and cardiac
resynchronization therapy (CRT)
have been introduced. The rate of
device implantation is increasing with the aging of
the general population and the indications are
expanding.
Similar to other prosthetic materials, infections
complicate a small proportion of patients with these
devices. With the increase in device implantation, the
incidence of device infections has also been growing
at a faster rate Infection is one of the most feared
complications of cardiac implantable electronic
devices (CIEDs). While relatively uncommon,
cardiac device infection (CDI) has been reported to
be increasing in frequency.
A CDI can present with a pulse-generator pocket
infection or bloodstream infection with or without
device-related endocarditis. A CDI is associated with
increased morbidity, mortality, and financial cost.
Recent guidelines advocate complete system removal
in the event of CDI in both systemic and pocket
infections. Transvenous lead extraction (TLE) is the
preferred approach if feasible.
In this lecture the risk factors, preventive measures
and well as therapeutic options will be discussed
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3D-TEE The Added Value in Paravalvular Regurgitation Hani Mahmoud-Elsayed, Associate Consultant, Director of Echocardiography Lab
..
Paravalvular regurgitation (PVR) is not
uncommon post-procedural complication
that can occur after both surgically and
percutaneously implanted valves.
Significant PVR has an unfavorable impact
on both morbidity and mortality.
Heart failure as well as clinically
significant hemolysis are the main indications for
intervention in such cases. Surgery was the standard
of care for years till the advent of the percutaneous
approach that was shown in many series to be
effective and safer than surgery in certain group of
patients with particular feasibility criteria.
Multimodality imaging has a crucial role in
assessment of the severity as well as defining the
suitable therapeutic approach.
Although two-dimensional trans-thoracic (TTE) &
trans-esophageal echocardiography (TEE) can readily
detect the regurgitation, however, delineation of the
exact shape & location of the defect is far more
accurately done using three-dimensional
echocardiography, particularly 3D-TEE.
Through providing wide-sector, en-face,
anatomically oriented views (volumes), 3D-TEE can
exactly delineate the location as well as the size and
shape of the defect, and can quantify the severity of
the regurgitation and hence guide decision making
regarding the suitable therapeutic approach.
An equally important point is the added value of 3D-
TEE during guiding the percutaneous closure of PVR
leaks. Many important steps such as the trans-septal
puncture, positioning of the catheter, deployment of
the plugs (Figure) and assessment of the result are
much easier and more accurately done using 3D-TEE
guidance.
3D-TEE has become an important component in the
assessment and treatment of PVR
.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 22
Driving and Sports in Patients with ICDs Mohammad Shenasa, MD, PhD- Heart & Rhythm Medical Group
San Jose, CA
As the number of patients with
implanted pacemakers and implantable
cardioverter-defibrillators (ICDs)
increases significantly, the number of
individuals with an ICD who drive and
play sports also increases.
This lecture is divided in two parts, as
the topic reads.
I. Driving in Patients with ICD
a. Should patients with ICDs be driving?
b. Do ICDs increase the risk of accidents while
driving?
I. Driving in Patients with ICD
a. Should patients with ICDs be driving?
b. Do ICDs increase the risk of accidents while
driving?
The risks may be related to:
1. Atrial and ventricular arrhythmias
2. ICD shocks (appropriate or inappropriate)
3. Failure of device to detect and/or terminate the
arrhythmias
4. Syncope
5. Sudden death
Both physicians and the public have concerns
regarding the fact that driving with an ICD may
increase the risk of accidents and harm. The earlier
guidelines and consensus are relatively old and were
done in patients with less sophisticated devices.
The largest observational study (TOVA) from Albert
et al in 2007 was an observational, prospective,
multicenter data collection and showed that the risk
of ICD shock due to VT/VF was transiently increased
in the first 30 minutes after driving (Albert, C. et al. J
Am Coll Cardiol 2007; 50:2233-40). A more recent
consensus statement from EHRA in 2009 suggested
that patients who receive ICDs for primary
prevention have a restriction for only 4 weeks post-
implant. Those with an ICD implantation for
secondary prevention as well as appropriate ICD
therapy have a 3-month restriction from driving.
Those who participate in public driving have
permanent restrictions from driving.
II. Safety of Sports in Patients with ICDs
Should patients with ICDs engage in sports?
Until recently, there have been no prospective studies
with patients whom have an ICD and only
observational cases were reported.
Risks include:
1. Exercise induced arrhythmias resulting
appropriate and inappropriate therapies and in some
cases syncope
2. Trauma to the ICD system (generator and
lead)
3. Inability of the ICD to defibrillate and
terminate the arrhythmia due to vigorous exercise
Earlier guidelines suggested that athletes with ICDs
should be disqualified from most competitive sports
except those with low intensity activities (class 1A).
However, these guidelines are based on less
sophisticated devices, and also no prospective
studies. ICD effectiveness has not been tested
prospectively during athletic activities.
In a recent perspective multi-national registry, 328
participants in organized sports and 44 in high-risk
sports were recruited (33% female, aged 10-60
years). Sports-related phone interview, medical
records, interrogation of the ICD events, as well as
clinical data were obtained. Pre-ICD history of
ventricular arrhythmias was present in 42% of
participants. Running, basketball, and soccer were
the most common sports. Primary endpoints were
death, resuscitation from cardiac arrest, arrhythmias,
or shock-related injury during sport.
Results included 49 shocks in 37 participants (10%
of study population) during competition/practice, 39
shocks in 29 participants (8%) during other physical
activity, and 33 shocks in 24 participants (6%) at
rest. The ICDs terminated all episodes, and freedom
from lead malfunction was 95% at 5-year follow up
(Circulation 2013; 127:2021-30).
Conclusion:
1. Individuals who are driving their own personal
cars may return to driving after following the
appropriate guidelines. This should be followed
on an individualized basis to rule out risk of ICD
shocks.
2. ICDs have not been shown to increase the risk of
accidents while driving.
3. Many athletes with ICDs can engage in vigorous
and competitive sports without physical injury or
failure to terminate the arrhythmia despite both
appropriate and inappropriate shocks.
4. Aggressive sports, such as American football, are
not advised.
5. Sports participation for athletes with implantable
cardioverter-defibrillators should be an
individualized risk-benefit decision.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 23
DES Slightly Edge Out DCBs in Treatment of In-Stent
Restenosis: Meta-analysis Samih Lawand
There were signs that DCBs might be
superior in some subgroups, with one
expert suggesting their advantage
would grow over time.
PARIS, France—Drug-eluting stents
appear to be better than drug-coated balloons (DCBs)
at treating in-stent restenosis, at least when it comes
to preventing TLR, but the difference isn’t
particularly large and results may vary among
clinical subgroups, according to a recent meta-
analysis.
“In treating patients with restenosis, the
interventional cardiologist must carefully weigh
whether the extent of this advantage outweighs the
potential longer-term risks of implanting a permanent
additional stent layer,” lead investigator Daniele
Giacoppo, MD (Deutsches Herzzentrum München,
Germany), said in his presentation last week at
EuroPCR 2018.
Even with modern DES and medical therapy, the rate
of coronary in-stent restenosis reaches as high as
10% to 15%, Giacoppo noted. “Although generally
less dramatic compared with stent thrombosis, it can
be associated with worse outcomes, too.”
In 2015, Giacoppo and colleagues published a
hierarchical Bayesian network meta-analysis of 24
trials and 4,880 patients showing that, among the
available options for treating in-stent restenosis,
DCBs and DES each held the lead over BMS,
brachytherapy, rotational atherectomy, and cutting
balloons when compared to plain balloon
angioplasty. “Importantly, all of the existing trials
have no power for clinical endpoints and over time
provided mixed results,” he said.
For the newer study, the researchers wanted to
directly compare the two top contenders: DCBs and
DES.
DES Slightly Ahead, but Not Always
The meta-analysis, known as DAEDALUS,
compared paclitaxel-coated balloons and drug-eluting
stents for the treatment of coronary in-stent
restenosis, with individual patient-level data from 10
randomized trials whose primary investigators had
agreed to participate in the study. Among them were
PEPCAD II, ISAR-DESIRE 3, PEPCAD China ISR,
RIBS V, SEDUCE, RIBS IV, TIS, DARE,
RESTORE, and BIOLUX-RCT, which involved a
total of 1,084 patients treated with DCBs and 996
who received DES.
One-third of the restenosis was seen in BMS, while
two-thirds occurred in patients being treated with
DES. Baseline characteristics between the DCB and
DES groups were well balanced, apart from a higher
percentage of prior MI in the balloon-treated patients
(50.1% vs 45.5%; P = 0.041). Minimum lumen
diameter was significantly longer with DCB than
with DES, while target lesion length was shorter and
percent diameter stenosis was lower. “But in each
case, the imbalance was not clinically relevant,”
Giacoppo noted.
At 3-year follow-up, the overall risk of TLR was
higher with DCBs compared with DES (16.0% vs
12.1%; HR 1.32; 95% CI 1.02-1.70), as was
ischemia-driven TLR (14.4% vs 10.4%; HR 1.37;
95% CI 1.04-1.81). Landmark analysis showed that
outcomes were consistent before and after the cutoff
of 1 year.
Yet due to a “moderate degree of heterogeneity”
among the trials, further analyses suggested there is
either borderline or no significant difference in TLR
between the two treatments, Giacoppo reported.
Looking at clinically relevant subgroups, the
researchers found that DES were superior to DCBs in
men, patients without diabetes, those receiving
second-generation DES, and those with lesion
lengths of at least 20 mm. However, the P-values for
interaction did not reach significance. There was one
exception, Giacoppo pointed out in his presentation:
“Interestingly, we found that in bare-metal stent
restenosis, the two treatments were comparable,
while in drug-eluting stent restenosis, [use of a] drug-
eluting stent was associated a better outcome
compared with drug-coated balloon.”
For the safety composite endpoint of all-cause death,
MI, or target-lesion thrombosis, the DCB and DES
groups had similar results.
‘Leaving Nothing Behind’
Bruno Scheller, MD (Universität des Saarlandes,
Homburg, Germany), commenting on the findings for
TCTMD, said what’s interesting about the new study
is its exploration of what might drive differences in
TLR among patients treated for in-stent restenosis.
Also, he added, “they looked at hard clinical
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 24
endpoints: death, myocardial infarction, vessel
thrombosis.”
Scheller drew parallels between drug-coated balloons
and bioresorbable scaffolds (BRS). With both, the
underlying principle is “leaving nothing behind” over
the long term. With BRS, there may be a short-term
penalty of more myocardial infarction and device
thrombosis, he said, but with DCB, “we do not have
to pay this price.”
Citing the safety endpoint, which occurred at a rate of
10.9% with DES and 9.3% with DCB (P= 0.101),
Scheller said the gap may eventually begin to favor
drug-coated balloons. “You can expect the absence of
a second layer of metal may over time be beneficial
in hard clinical endpoints,” he suggested, adding,
“The real benefit . . . will be seen after 3, 5, or even
10 years.”
Still, much like with BRS, lesion preparation is key
with DCBs, said Scheller, who served as a panelist
during the late-breaking session where others also
emphasized this point. Operators familiar with the
PSP protocol used with BRS—preparing the vessel,
adequate sizing, and postdilatation—should be able
to easily apply it to DCBs, he observed.
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Early Repolarization Syndrome:
How To Manage? Samir Rafla, Prof. of Cardiology, Alexandria University
●Early repolarization = A package
of deal: E.R. = J point + Raised ST
Early repolarization (ER), also
recognized as “J-waves” or “J-point
elevation”’ is an
electrocardiographic abnormality consistent with
elevation of the junction between the end of the QRS
complex and the beginning of the ST segment in 2
contiguous leads.
Early repolarization syndrome (ERS), demonstrated
as J-point elevation on an electrocardiograph, was
formerly thought to be a benign entity. Recent studies
have demonstrated that it can be linked to a higher
risk of ventricular arrhythmias and sudden cardiac
death (1-5).
The prevalence of ERS varies between 3% and 24%,
depending on age, sex and J-point elevation (0.05
mV vs 0.1 mV) being the main determinants. ERS
patients are sporadic and they are at a higher risk of
having recurrent cardiac events. Isoproterenol are the
suggested therapies in this set of patients.
On the other hand, asymptomatic patients with ERS
are common and have a better prognosis (4).
The clinical presentation of patients with ERS can be
subdivided into two main groups.
The first includes those that manifest recognized
symptoms of ERS, i.e., high risk patients with
syncope and survivors of cardiac arrest. A study by
Abe et al[6] demonstrated that the ER was noticed in
18.5% in patients with syncope compared to 2% in
healthy controls, this equates to almost 10 - fold
increase risk of syncope in patients with ERS.
CONCLUSIONS:
It is also not possible to identify asymptomatic
individuals with a primary arrhythmogenic disorder
attributable to ER. All patients with ER should
continue to have follow up and risk assessment.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 25
Exercise and Cardiovascular Risk Factor in Patients
with Hypertension Toure Ali Ibrahim Niamey- Consultant Cardiologist Teaching Hospital of
Lamorde Niger. -Niger
It is well known that practice of
exercise can reduce the prevalence
of some cardiovascular risk
But in hypertensive patients some
precautions must be taken to avoid
cardiovascular risk as rhythm
disturbances, conduction disturbances, sometime
even sudden death particularly in some particular
hypertensive group. So a clinical and paraclinical as
clinical examination,
•EKG, cardiac echocardiogramme and ionogram can
help to prevent sudden and paroxystic events
particularly in moderate to high level and the
screening should take in count the age the level of
HBP, comorbidities the types of treatments including
none cardiovascular drugs as antibiotics etc….. For
people at risk for hypertension, there are a number of
lifestyle options that may avert the condition —
maintaining a healthy body weight, moderating
consumption of alcohol, exercising, reducing
sodium intake, altering intake of calcium,
magnesium and potassium, and reducing stress.
•Following these options will maintain or reduce
the risk of hypertension. For people who already
have hypertension, the options for controlling the
condition are lifestyle modification,
antihypertensive medications or a combination of
these options; with no treatment, these people
remain at risk for the complications of
hypertension.
To decrease CV risk among hypertensive people
who exercise or wish to begin. It is recommended
that hypertensive individuals should aim to
perform moderate intensity. Professionals with
expertise in exercise prescription may provide
additional benefit to patients with high CV risk
or in whom more intense exercise training is
planned.
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How to Use Hardware for CTO PCI Sundeep Mishra
Interventions in chronic total
occlusion (CTO) represent a niche
area of percutaneous coronary
interventions (PCI).
The essential difference lies in the
character of the lumen which is occluded in
CTO PCI (versus patent in a garden variety of
PCI).
This difference culminates into not only
increased complexity and difficulty of the
procedure but also makes it more prone to
complications. Clearly the niche area requires
an optimal utilization of a broader range of
hardware. Thus for a regular PCI only few
hardware and their use need to be known. On
the other hand if CTO PCI is to be undertaken,
Knowledge of a whole gamut of accouterment
need to be acquired (both their characteristics
and utilization) and their use mastered.
However, the multiplicity of CTO hardware and
their physical character and the terminology
used by experts create confusion in the mind of
an average interventional cardiologist,
particularly a beginner in this field. This
knowledge is available but is scattered. In
general guidewires are the key to success of any
CTO procedure but additionally knowledge and
handling of several other devices needs to be
perfected.
The essential difference lies in the fact that
in CTO PCI.
the disease lumen is occluded (versus patent
in a garden variety of PCI). This difference
culminates into not only increased
complexity and difficulty but also makes it
more prone to complications.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 26
“septal surfing,” “externalization,” etc, a
complete new language associated with CTO
intervention which has on one hand added to the
mystique of the procedure but on the other hand
created confusion in the mind of regular
interventionists and taken procedure out of their
realm.
This presentation is an attempt to clarify and
simplify some of the concepts and techniques so
that it is easily understandable by regular
interventional cardiologists with the overall aim
of increasing the popularity and acceptability of
these procedures.
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Left Atrial Function in Heart Failure Michael Henein
The left atrium (LA), wrongly called
the left heart collecting chamber,
plays an important role in maintaining
overall cardiac function in health and
disease. The LA myocardium is a
complex structure although its
thickness is only 3 mm, so significantly less than
that of the left ventricle (LV). Myocardial fibre
bundles take different shapes, number and position,
subepicardial versus subendocardial. Add to the
complexity of the chamber is its 4 inflows
(pulmonary veins) and its outflow (the mitral valve)
with its relationship to the annulus, chordae,
papillary muscles and longitudinal and
circumferential LV muscle fibres. Of note, despite
the basal LA muscle fibres are predominantly
circumferential, they differ from their LV
counterpart in being incomplete, particularly at the
medial part.
In contrast to the LV, the LA has more than one
function. During early diastole as LA pressure rises
above that of LV, the mitral valve opens and early
diastolic filling phase starts with significant
acceleration determined by the released LA
restoring forces from the previous systolic phase,
and is completed with the pressure equalization
between the two chambers. This phase is followed
by a brief period of diastasis with no significant
circulation between the two chambers, except in
patients with severe LV disease and raised diastolic
pressures, in whom a flow reversal might be
detected with pulsed Doppler across the opened
mitral valve. Finally, after the P wave and complete
atrial depolarization, LA myocardium contracts in
order to fill LV with the second filling component,
which correlates directly in its peak velocity with
age. Thus, LA could be seen as having three
function components, reservoir, conduit and pump,
respectively.
Having such delicate structure, LA is known for
being very sensitive to intra and extra cavitary
pressures. Mild increases in LA pressure are
accommodated by slight increase in cavity size but
more significant pressure increases, particularly if
rapid, could result in atrial arrhythmias e.g.
fibrillation. Likewise, although less common,
increases in exterior wall tension by aortic root
dilatation may have similar effect. With such close
relationship changes in LA size and myocardial
function, intra-cavitary could accurately be
predicted. LA volume index >34 ml/m2 or
reduction of peak atrial longitudinal strain <19 %
have been shown to predict raised LA pressure
>15mmHg. Furthermore, same cut off values have
been shown to predict failure catheter ablation and
recurrence of atrial fibrillation.
In heart failure and progressive increase in LV
diastolic pressure, LA pressures increase as does its
cavity size and its function reduce, hence the
increased incidence of atrial arrhythmias. These
changes correlate with the progressive broadening of
the P wave overtime. Finally, with the increase in
LA cavity size its mechanical function compromise
as does its emptying. This is compensated for by
further rise of cavity pressure, worsening symptoms,
and increased risk of arrhythmia.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 27
Masked Hypertension: Definition, Impact and Outcomes Patricio Lopez-Jaramillo MD PhD, Endocrinology, Hypertension
The diagnosis of hypertension is based
on clinic blood pressure (BP), but the
use of ambulatory blood pressure
monitoring (ABPM) along with clinic
BP has made the classification of
hypertension more complex.
The correlation between BP taken during routine
clinic visits and ambulatory BP is only moderate.
Thus, many individuals exhibit a large discrepancy
between these two measures. Masked hypertension is
defined as having non-elevated clinic blood pressure
(BP) with elevated out-of-clinic average BP,
typically determined by ambulatory BP monitoring.
Approximately 15–30% of adults with non-elevated
clinic BP have masked hypertension. Masked
hypertension is associated with increased risks of
cardiovascular morbidity and mortality compared to
sustained normotension (non-elevated clinic and
ambulatory BP), which is similar to or approaching
the risk associated with sustained hypertension
(elevated clinic and ambulatory BP). For the
diagnosis of masked hypertension, non-elevated
clinic BP is typically defined as <140/90 mmHg.
Studies differ on whether mean awake ambulatory
BP or mean 24-hour ambulatory BP is used to define
masked hypertension. The most widely used
definition for elevated ambulatory BP has been a
mean awake ambulatory BP ≥135/85 mmHg.
However, other definitions such as mean 24-hour
ambulatory BP ≥125/79 mmHg or ≥130/80 mmHg
have been used [1].
The European Society of Hypertension position paper
incorporates elevated nighttime BP (≥120/70 mmHg)
as part of the definition of masked hypertension: non-
elevated clinic BP with elevated mean awake
ambulatory BP and/or elevated mean 24-hour
ambulatory BP, and/or elevated mean night time
ambulatory.BP.
Individuals with non-elevated clinic BP and
elevated mean nighttime ambulatory BP have
masked nocturnal hypertension.
Individuals with non-elevated clinic BP and
elevated mean nighttime ambulatory BP with
normal mean awake ambulatory BP
have isolated (masked) nocturnal hypertension
[2]. Recently the American College of Cardiology
(ACC)/American Heart Association (AHA)
hypertension guidelines [3] proposed new values
for defining hypertension: office blood pressure
(BP) ≥130 systolic or ≥80 mmHg diastolic.
Furthermore, BP goals for hypertensive patients
under pharmacological treatment have been
recommended <130/80 mmHg. New BP limits for
office BP have been extended to define
corresponding normal values for ambulatory BP
monitoring (ABPM). Values of 125/75 mmHg for
24-hour, 130/80 mm Hg daytime, and 110/65
mmHg nighttime periods have been proposed, and
corresponding to the office cut-off of 130/80 mm
Hg. Recently [4] it was demonstrated that with the
use of these new criteria the prevalence estimates
ranged from 14% to 66%, being 2-fold higher
under ACC/AHA criteria than under ESH criteria.
Using mean daytime BP, prevalence was 14% to
15% with the ESH criteria,2 and 28% to 30%
with those proposed by the ACC/AHA guidelines.
Corresponding figures by using mean 24-hour BP
were 20% and 39%, respectively. When compared
with patients with both normal office and
ambulatory BP, masked hypertension was
associated with a worse cardiovascular risk
profile, being older, more frequently males and
smokers, with higher office systolic BP, and more
frequently had prevalent cardiovascular disease.
The LASH have proposed to mantein the criteria
of the ESH [5].
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 28
New Knowledge from Fourier Study
ELSayed Farag MD, Zagazig University Secretary General of EAVA
PCSK9 inhibition with evolocumab
● LDL-C by 59%
-Consistent throughout duration of trial
-Median achieved LDL-C of 30 mg/dl
(IQR 19-46 mg/dl)
● CV outcomes in patients already on statin
therapy
-15% broad primary endpoint; 20% CV death,
MI, or stroke
-Consistent benefit, incl. in those on high-intensity
statin, low LDL-C
-25% reduction in CV death, MI, or stroke after 1st
year
-Long-term benefits consistent w/ statins per mmol/L
LDL-C.
●Safe and well-tolerated
-Similar rates of AEs, incl DM & neurocog events w/
EvoMab & placebo.
-Rates of EvoMab discontinuation low and no
greater than placebo
-No neutralizing antibodies developed. (1)
In patients with known cardiovascular disease:
PCSK9 inhibition with evolocumab significantly &
safely major cardiovascular events when added to
statin therapy.
Benefit was achieved with lowering LDL cholesterol
well below current targets. (1)
LDL-C reduction with evolocumab reduces
cardiovascular events across hsCRP strata with
greater absolute risk reductions in patients with
higher-baseline hsCRP. Event rates were lowest in
patients with the lowest hsCRP and LDL-C. (2)
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Off pump as a default technique for CABG Ihab el Sharkawy, Lecturer of cardiothoracic surgery, Cairo University
The debate between off pump and
conventional CABG has always been
there. Both techniques are safe with
each one have its own pros & cons.
OFCABG can be used as the default technique.
Proper preoperative preparation as well as
professional coordination between the surgical team
and anaesthesiologist is the cornerstone to do this
technique safely. Also important surgical tips and
tricks are needed for proper exposure during doing
the anastomosis to ensure good quality anastomosis.
Stabilizers, shunts , pericardial suspension stitches
and OR table positioning all provides an excellent
exposure for proper anastomosis.
Although OPCABG can be used as a default
technique however still some patients will benifit
more from conventional CABG.
Shifting from OPCABG to conventional CABG
should be concidered whenever needed, proper
timing for this shift is important for patient safety.
Several studies have showed no significant
differences between both techniques as reguard the
anastomosis quality.
OPCABG is technicaly more demanding than
conventional CABG & needs more supervised
training, in expert hands all targets could be done
safely & easily.
Two techniques are used for OPCABG, either
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 29
clamp technique or shunt technique.
The use of intercoronary shunts allows the surgeon
to operate in a bloodless field and secure both heel
and toe of the anastomosis. Also this prevents
ischemia induced by clamping the coronary artery.
OPCABG using total arterial conduits allow to do
CABG without touching the aorta which prevent all
possible complications related to aorta clamping
and cannulation as aortic dissection and CNS
complications related to atheroma showering.
OPCABG provides a chance to avoid the
sternotomy incision and instead a mini anterior
thoracotomy is used “MIDCAB” which is not only
for cosmetic reasons but also for diabetic obese
female patients who are at high risk of sternotomy
wound infection which is a serious life threatening
complication.
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Patient Preparation for Primary PCI
Mohammed Adel Ghoneam, Assistant lecturer of medical surgical & Critical care
nursing department.Faculty of Nursing Beni-Suef University
At 1967 CABG has been refined and has
been the treatment of choice for many
patients with CAD. Since the late 1970s,
techniques to treat CAD have expanded
beyond PTCA. Today, the term
percutaneous coronary intervention (PCI) is used to
describe invasive procedures to treat CAD.
Primary PCI consists of urgent balloon angioplasty
(with or without stenting), without the previous
administration of fibrinolytic therapy or platelet
glycoprotein IIb/IIIa inhibitors, to open the infarct-
related artery during an acute myocardial infarction
with ST-segment elevation. Prepare patient for
Primary PCI.
Monitors all preliminary laboratory tests, including
cardiac enzymes; coagulation studies (PT and partial
thromboplastin time [PTT]), serum electrolytes,
creatinine, and BUN levels. Potassium levels must be
within normal limits because low levels result in
increased sensitivity and excitability of the
myocardium. Aspirin should be given to all patients
with STEMI (if no contraindication is present) as
soon as possible after the diagnosis is established.
Clopidogrel is increasingly used, preferably with
a loading dose of 600 mg. Unfractionated
heparin is still the "golden standard" therapy in
patients with STEMI undergoing primary PCI.
Informed cocent for primary PCI procedure is
obtained from the patient or patient’s family
before the procedure after a detailed discussion
of the potential complications, anticipated
benefit and alternative therapies. The nurse plays
an important role in answering any questions
that the patient and his or her family may have
regarding the procedure and follow-up care
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CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 30
Post TAVI PCI- Is it Possible? Hamdy Soliman MD, FSCAI, Consultant of cardiology and head of endovascular unit in
the National heart institute
Patients who have been subjected to
TAVI procedure may develop coronary
artery disease and the approach to fix
those lesions my be difficult especially
for those who have CoreValve( self
expandable valve) but my be feasible for patients
with balloon expendable valve Sapien XT or Sapien
3 valve.
There are some recommendations for operators who
didnt face this approach before especially in centers
not dealing with TAVI procedure before First ,the
choice of the guiding catheter used to cannulate the
Left main artery through the struts above the
functioning covered part of the valve in self
expandable valves but for the ballon mounted valves
it my be easier for cannulation since coronary ostia
are above the valve. Some difficulty my face the
operator if the valve was highly deployed and friction
during manipulation with the guiding cath eter . The
left Judkin catheter is the best but in some cases like
our case i used the XB guiding catheter to get more
support to cross with a long stent in a long LCX
lesion. Successful PCI was performed for LAD and
LCX in the first patient we did with Corevalve
through left radial approach.
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Predictors Of Severe Coronary Stenosis At Cath In
Patients With Normal Myocardial Perfusion Imaging Khalid A Alnemer MD,FRCPC,FACC Department of Internal Medicine, Cardiology Division
Myocardial perfusion imaging (MPI)
using single photon emission computed
tomography (SPECT) is a frequently
used non-invasive modality in patients
with suspected angina. A normal MPI is
associated with an excellent prognosis.it is well
validated and has proven value in identifying patients
at high risk of a serious cardiac event, whereas a
normal MPI study confers a benign prognosis with a
low annual serious cardiac event rate of 0.6% per
year.However, there has always been concern that
MPI can miss high-risk coronary artery disease
(CAD) as in patients with balanced ischemia due to
flow-limiting three-vessel CAD or left main
stenosis, while this group is particularly prone to
adverse cardiac events and may have benefit of
revascularization.
Nakanishi et al studied the prevalence and predictors
of high-risk CAD in patients with normal
MPI.Subsequent invasive coronary angiography was
performed within 60 days after normal MPI in 580
patients in two centers. High-risk CAD was defined
as 3 vessels with ≥70% stenosis, 2 vessels with
≥70% stenosis including proximal left anterior
descending, or left main with ≥50% stenosis.
Overall, 36% in this highly selected group ofpatients
had evidence of anatomically obstructive CAD, with
high-risk CAD in 7.2% of all patients.
Predictors for high-risk CAD were the presence of
mild/equivocal perfusion defects, transient ischemic
left ventricle dilatation or abnormal ejection fraction,
and a pre-test probability of ≥66%. Although their
number of false-negative MPI with 7.2% of patients
high-risk CAD is impressive, it should be realized
that these 42 patients are selected from a total of
25,698 patients with normal MPI. Another study by
s.yokota etal on 229 patients ,found their Mean age
was 62 ± 11 years, 48% were women. Severe
stenosis was observed in 34%, and of these patients
60% had single-vessel disease (not left main
coronary artery disease). After adjusting for several
variables, including diabetes,smoking status,
hypertension and hypercholesterolaemia, predictors
of severe stenosis were male gender, odds ratio (OR)
2.7 (95% confidence interval (CI) 1.5–4.9), older age,
OR 1.9 (95% CI 1.02–3.54) previous PCI, OR 2.0
(95% CI 1.0–4.3) and typical angina, OR 2.5 (95%
CI 1.4–4.6. The majority of these patients have
single-vessel disease.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 31
Recurrent Syncope: Update from the Guidelines Peter A. Brady MD. FRCP FACC- Professor of Medicine and Cardiology
Electrophysiology- USA
Recurrent syncope is a common problem yet precise diagnosis can be difficult due to the many causes of this condition. Extensive evaluation is both time-
consuming and expensive. A good history and examination are
essential and can often make the diagnosis without further testing. Knowledge of cardiac conditions in the past such as myocardial infarction, significant valvular disease or conduction system disease increase the likelihood of a cardiovascular cause for syncope and should be further evaluated. Neurological cause of syncope are rare and always associated with residual neurological deficit or slow recovery. Updated syncope guidelines will be reviewed and discussed.Historical features that are worrisome for cardiogenic syncope include: sudden onset with rapid recovery, lack of prodrome and cardiac awareness of palpitations. Examination findings include evidence of heart failure or congestion, cardiomegaly or significant valvular stenosis or evidence of dynamic outflow tract obstruction suggestive of hypertrophic cardiomyopathy. In patients in whom a cardiac etiology is suspected pertinent investigations include: 12 lead ECG looking for myocardial infarction or hypertrophy or arrhythmia – heart block or ventricular tachycardia, transthoracic echocardiogram to exclude significant left ventricular dysfunction or valvular abnormality and evidence of other cardiomyopathy.
Minimal invasive Mitral valve surgery programme
was initiated at cardiothoracic surgery department -
AIN SHAMS UNIVERSITY 2 years ago. In this
presentation, we present how we started this
programme and our experience in right
minithoracotomy approach for performing Mitral
valve surgeries. We also expanded the use of such
approach to perform surgery for ASD closure and
resection of left atrial Myxoma. Join our presentation
for more details and all the bits and tricks about this
approach.
In such cases where a specific cardiac abnormality is
found, such as high- grade AV block, therapy (in this
case a permanent pacemaker) is recommended. In
other cases, more investigations is required. In some
cases, electrophysiological testing is recommended.
However, this test is not useful in most patients with
no evidence of conduction system problems, or
significant myocardial scar due to prior myocardial
infarction. In such cases, the electrophysiological
study can be useful to determine the extent and site of
heart block and inducibility of a ventricular
arrhythmia. Overall, though in all patients the
electrophysiological study in only useful in
unselected patients in around 10% of cases.
One of the most common causes of syncope is
vasovagal or neuro-cardiogenic syncope. In most
cases vasovagal syncope is benign and most often
observed in younger patients without structural heart
disease and in situational circumstances such as
dehydration while standing, needle stick and other
stimuli. However, vasovagal syncope can also occur
without prodrome often times in elderly patients. The
approach to vasovagal syncope is recognition and
identification of triggers and avoidance. In most
cases no further action or work-up is needed. In some
patients, with recurrence, adequate hydration and in
some cases medical therapy with salt retaining agents
(fludrocortisone) and midodrine may be needed. It is
important not to underestimate the benefit of physical
maneuvers to help avoid syncope. Permanent
pacemaker therapy has been evaluated as a therapy
for recurrent syncope but has not been found to be of
benefit except in highly selected patients (older than
40 years, with evidence of sinus node dysfunction
and positive tilt table testing as found in the ISSUE-3
study). In summary, exclusion of a cardiogenic
mechanism for syncope is paramount. In at risk
patients implantation of defibrillator (ICD) is
warranted.
Approach to Syncope 2018
History suggestive of Cardiogenic mechanism?
Sinus node dysfunctionConduction system disease?
Consider Permanent Pacemaker or prolonged ambulatory monitoring(LINQ)
Structural Cardiac disease
ICD indicated?
Electrophysiological study
Implant ICD
No SHD
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 32
Right Minithoracotomy: An Alternative Approach Mohamed El Ghanam, MD, FRCS C-TH, Assistant Prof of Cardiothoracic surgery,
Ain Shams University
Minimal invasive heart surgery has
been widely applied worldwide over
the last two decades for their
proposed benefits, offering patients a
faster recovery, less pain, better
cosmoses and more patient satisfaction. However, for
surgeons, it represents a challenge, trying to achieve
the same quality of surgery, which was classically
performed through a midline 12 to 15 cm sternotomy,
through smaller incisions sparing the split of the
breast bone and preserving the integrity of the
thoracic cage.
Minimal invasive Mitral valve surgery programme
was initiated at cardiothoracic surgery department -
AIN SHAMS UNIVERSITY 2 years ago. In this
presentation, we present how we started this
programme and our
experience in right
minithoracotomy
approach for
performing Mitral
valve surgeries. We
also expanded the use
of such approach to
perform surgery for
ASD closure and
resection of left atrial
Myxoma. Join our
presentation for more
details and all the bits
and tricks about this
approach.
-------------------------------------------------------------------------------------------------------------------------------------------
Right Ventricular Outflow Tract Stenting: What Do We
Know? Hala Agha, MD, Professor of Pediatrics& Pediatric Cardiology
Traditionally, the management of
infants with Fallot’s tetralogy (TOF)
with excessively reduced pulmonary
flow (Nakata index <100 mm2/m2,
pulmonary valve z score <−5), and
cyanosis has been palliation until
complete repair is feasible. Palliation
involves a procedure that augments pulmonary flow,
either by surgery: MBT shunt or limited RVOT
patch, or by catheter: PDA stent, balloon RVOT,
RVOT stent. The problems of PDA stent are the
stenosis of pulmonary arteries and the technical
approach in tortuous PDA. While, RVOT stenting
has a physiological haemodynamic result with equal
growth of PA. So RVOT stent is indicated in
symptomatic cyanotic neonate/infant with small
pulmonary arteries, complex anatomical variants of
TOF specially with congenital anomalies. The policy
is to spare of pulmonary valve annulus in RVOT
stenting to avoid transannular patching at the time of
complete repair. Angiographic measurements
underestimate RVOT length, so most often reliance
on ultrasound measurements to select the stent length
is preferable. The stent chosen for implantation
should be one size up from the measured length and
covering the proximal portion of the RVOT is
crucial.
Use of long sheaths or guide catheters is mandatory
to perform repeat side arm test injections prior to
stent positioning, to reduce the risk of stent slippage
and to avoid damage to the tricuspid
valve/conduction system by covering the stiff
coronary wire.
In AVC/TOF, long sheath is important to find a clean
passage from RV-PA and to avoid the chordal
attachments of the superior bridging leaflet.
In DORV/TOF, RVOT is classically positioned more
horizontally and care has to be employed to cover the
entire RVOT length. RVOT stenting promotes better
pulmonary arterial growth and oxygen saturations
compared with MBT in the initial palliation of Fallot-
type lesions. Take home points; stent implantation
provides an effective alternative to palliative surgical
enlargement of the right ventricular infundibulum.
RVOT stenting in patients with severe Fallot
physiology may be a good means to reduce
perioperative morbidity and mortality by gradually
increasing pulmonary blood flow. It should be
considered the first line palliation in patients who are
not suitable or considered high risk for one stage
complete repair with hypoplastic pulmonary art
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 33
Role of Nuclear Medicine in Assessment of Myocardial
Viability Abo AlMagd AlNouby,MD,Consultant of Nuclear Medicine,Lecturer of Nuclear Medicine
Military Medical Academy
Coronary heart disease (CHD), is the
leading cause of mortality and morbidity
worldwide.
For patients with chronic heart failure,
optimal medical therapy has improved
including diuretics, digoxin, angiotensin converting
enzyme inhibitors, B blockers, …etc.
Device therapy such as automatic implantable
cardioverter defibrillator and biventricular
pacemakers (cardiac resynchronisation therapy) has
been also improved.
Evaluation of myocardial perfusion defects on
myocardial perfusion scintigraphy depends on
differential blood flow through the coronary arteries.
At near maximum exercise or under the influence of
coronary artery vasodilators (e.g. - adenosine), a
coronary artery that is stenosed because of
atheromatous disease will not be able to dilate as well
as a non-diseased coronary artery and will, therefore,
not be able to deliver as much blood flow to that
portion of the myocardium.
The myocardium perfused by the diseased artery will,
therefore, demonstrated relatively less deposition of
the radiotracer than the portion of the myocardium
receiving greater flow.
Balanced 3-vessel coronary artery disease creates a
diagnostic dilemma for the nuclear medicine
physician. If all three main coronary arteries have an
equivalent degree of disease, the radiotracer will
demonstrate equal uptake in all portions of the
myocardium. Because of the reliance on
differentiation of relative perfusion to make the
diagnosis of ischemia, balanced 3-vessel disease can
produce a false-negative myocardial perfusion
scintigram. With an exercise study, hopefully the
ECG findings will be positive for ischemia. In an
adenosine study, this may be problematic as
adenosine is a strict vasodilator and rarely causes
ischemia. The ischemic changes seen in this patient's
ECG may be due to a coronary artery "steal" during
an episode of maximal coronary artery
vasodilatation. The dilated cardiomyopathy and
hypokinesis on gated images also alerted the nuclear
medicine physician that the SPECT study may be
underestimating the amount of coronary artery
disease.
A number of different tests rely on different
characteristics of dysfunctional but viable
myocardium such as :
SPECT myocardial perfusion imaging:
The tracer most commonly used for SPECT
myocardial viability are those which are also used for
perfusion mapping that are:
Thalium 201 (Th 201)
Technithium labelled agensts as Tc99m sestimibi and
Tc99m tetrafosmin using conventional gamma
camera.
Th 201 is a pottasium analouge which used to assess
both perfusion and cell membrane integrity, the 2
protocols used most frequently are :
Stress –redistribution –reinjection imaging.
Rest – redistribution imaging.
Positron emission tomography (PET), is a minimally
invasive nuclear medicine technique that uses short
lived radiopharmaceuticals to allow perfusion and
metabolic activity in various organ systems to be
detected and assessed. Although several tracers have
been used for evaluating myocardial perfusion with
PET, the most widely used in clinical practice are
Rb82 and N13-ammonia.
The main potential impact of the FDG PET/CT
testing for myocardial viability in patient with
coronary artery disease (CAD), and moderate to
severe left ventricular systolic dysfunction is in
selecting the patients most likely to benefit from
revascularization.
FDG PET/CT is then expected to improve patient
outcomes by more accurately identifying patients with
viable myocardium.
PET/CT is also expected to improve patient outcomes
through the avoidance of surgery and its associated
morbidity and mortality, in those patients who are
unlikely to benefit from revascularization.
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CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 34
Statin ResistanceAtef El-Bahry, Senior Consultant of Cardiovascular Medicine- Port-Said- Egypt; Vice President of Egyptian Association of Vascular Biology and Atherosclerosis "EAVA"
Statin resistance is different from
statin intolerance and is present in
patients who adhere to but do not
achieve expected or adequate lipid
lowering with tolerated and maximum doses of
statins, thus failure to attain goals and targets of
international lipid guidelines, putting patients at very
high risk for having cardiovascular events. There is a
paradoxical relationship between statin-mediated
pcsk9 increase and ldl-c. Low intracellular
cholesterol activates sterol regulatory element-
binding protein-2 (srebp-2) which is a transcription
factor that activates both ldl-receptors and pcsk9
genes. This results in increased expression and
secretion of pcsk9 protein, which binds the ldl-
receptors and targets it for lysosomal degradation. It
is known that statins increase ldl- receptors
expression and density on cell surface in addition to
lowering cholesterol.
Upregulation of pcsk9 protein by statin therapy may
attenuate the ldl-c reduction by statins. Pcsk9 levels
increase as a feedback response to statin treatment
rising by 10%-50% in many clinical studies. Given
these interrelationships open the way towards
understanding the question of why high intensity
statins given to subjects to the maximal tolerated
doses fail to achieve goals and targets, and explain
statin resistance. In the Jupiter study using
rousovastatin at 20mg dosage increases plasma
concentrations of pcsk9 by 28% and 34% in men and
women, respectively. A strategy based on the
measurement of ldl-c response and pcsk9
concentrations may help identify those statin
resistance subjects with increased pcsk9
concentration whom may benefit from pcsk9
modulation and adding pcsk9-inhibitors to their
therapy.
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“Stent for Life” Portugal: How to Implement A STEMI Network
Helder Pereira
The Stent for Life Initiative (SFL)
began in 2009 and was designed to
reduce ST-segment elevation
(STEMI) mortality in Europe. In
May 2017, the initiative became
global, also comprising the regions
of South America, Africa and Asia and was renamed
Stent Save a Life (SSL). Globalization has shown the
success of the SFL, but it represents a major
challenge, since it brings together very different
reality, from countries where most patients are not
reperfused, others where only streptokinase is used,
to countries where the rate of revascularization by
Primary Angioplasty (P-PCI) is greater than 90%.
We have no doubt that the experience of countries
such as Portugal, which are already at a more
advanced stage of this process, will be of great use to
those who aspire to improve the treatment of STEMI.
Portugal joined the Stent for Life Initiative (SFL) in
2011 with the aim of improving performance in P-
ICP. Now that one cycle of the process is closed and
another one opens, it is important to look to the
advances verified in this period.
In the middle of the last decade, little more than a
hundred P-PCIs per year and per million inhabitants
were carried out in Portugal and only 23% of the
patients asked for help through 112.
The following abstract summarizes the evolution of
this initiative over the last five years:
A National surveys were carried out annually, for
one-month periods, designated by Moments between
2011 (Moment Zero) and 2016 (Moment Five). A
total of 1340 consecutive patients with suspected
acute myocardial infarction with ST elevation
(STEMI) undergoing catheterization admitted at 18
national interventional cardiology centres where P-
PCI is carried out 24/7 were enrolled in this study.
There was a significant reduction in patients who
used primary healthcare as a first request for
assistance (20.3% vs 4.8%, p <0.001) and in patients
who attended a centre without P-PCI capability
(54.5% vs 42.5%, p = 0.013). On the other hand, the
number of patients who called 112-emergency
medical services (EMS) increased (35.2% vs 46.6%,
p=0.022) and patients’ transportation through the
national emergency medical system (EMS) to a
centre with P-PCI (13.1% vs 30.5%, p<0.001). The
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 35
main improvement observed at time intervals for
revascularization was a trend towards reduction of
“patient delay” (114 minutes in 2011 vs 100 minutes
in 2016, p=0.050). “System-delay” and “door-to-
balloon” (D2B) times remained constant, registering
a median of 134 and 57 minutes in 2016,
respectively.
During the lifetime of the SFL initiative in Portugal,
there was a positive evolution of "patient delay"
indicators, namely the reduction of the percentage of
patients who attended to primary healthcare centres
and local hospitals without intervention cardiology,
along with an increase of those that called EMS.
“System delay" did not significantly change over this
period. These results should be taken into account in
the future strategy of the Stent Save a Life (SSL)
initiative, namely in the reinforcement of current
educational programs towards the improvement of
system delay.
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The Role of Intraoperative Transesophageal Echo (TEE)
To Guide Mitral Valve RepairMohamed Adel Mostafa, Consultant cardiology, Saudi Arabia
In suitable patients mitral valve repair
is an excellent treatment option with
low mortality (1, 4% for valve repair
compared to 3.8% for valve
replacement) and also it has high
durability. TEE is an excellent tool to
guide the surgical technique and predicts which valve
is likely to be repaired and which valve should be
replaced.
Why some cases repaired successfully and why other
surgeries could not be repaired successfully and
ended up with replacing the mitral valve.
Knowing the anatomy of the mitral valve apparatus
and key differences between degenerative and
functional mitral regurgitation is of paramount
importance
Also it is the role of TEE to elucidate what is the
mechanism of mitral valve regurgitation and hence to
suggest which repair technique should be offered.
Intraoperative TEE provides very important measures
that the surgeon depends on to choose the size of the
ring.
The Differences in the surgical approaches offered
degenerative mitral regurgitation compared to the
functional mitral regurgitations, Also the assessment
of the regurgitation severity and the long term
outcome is completely different, the assessment of the
degree of tenting and tethering and whether it is
symmetrical or asymmetrical is of paramount
importance to understand the mechanism of MR.
Intraoperative TEE measurements before bypass the
mitral regurgitation severity, vena contracta (VC) and
flow convergence, Effective regurgitate orifice,
Tenting and the tethering of the mitral valve
It is well known that the dependence on the color jet
area is deceiving especially intraoperative as the
change the blood pressure during the cardiac surgery
affects the estimation of the mitral valve severity, So
the recommended intra-operative diameters are the
vena contracta, the regurgitant orifice area.
Measurement of VCA with quantitative 3D imaging.
The 3D data set is displayed in three simultaneous,
adjustable, orthogonal planes
TEE has an essential role in predicting and detecting
the possible complications like systolic anterior
motion (SAM) and mitral
stenosis, left ventricular
outflow obstruction that
can lead to residual mitral
regurgitation. Should the
patient send back to
bypass or not? This
should be answered by the
TEE.
To conclude intraoperative TEE is your safety net that facilitates
the surgical approach and improves the patient’s
Outcomes.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 36
The Importance of Coronary Sinus Flow in Prediction of
No-Reflow After Primary Percutaneous Coronary
Intervention for Acute Myocardial Infarction Mohamed El-Tahlawi- Assistant Prof. of Cardiology, Zagazig University
Introduction:
Failure to achieve TIMI 3 flow
(suboptimal TIMI flow) after PPCI still
occurs in up to 5-23% of patients,
which has strong effect on mortality.
No-reflow is defined as inadequate
myocardial perfusion, despite mechanical reopening
of the responsible lesion with percutaneous coronary
intervention.
Speculated mechanisms for this suboptimal epicardial
coronary blood flow include not only mechanical
epicardial vessel obstruction, dissection or thrombus,
but also coronary microcirculation disturbances.
Coronary sinus flow time was defined as the time
taken in seconds for the contrast agent in the
epicardial coronary artery to traverse the coronary
microvasculature and reach the coronary sinus origin.
Aim of the work:
The study aims to evaluate the ability of coronary
sinus flow time to predict no-reflow in acute
myocardial infarction (MI) patients undergoing stent-
based primary PCI in the infarct related artery.
Patients & Methods:
We included all patients with acute MI underwent
primary coronary intervention within maximum
duration of 60 minutes from time of admission to the
hospital.
We excluded patients with one or more of the
following criteria:
●hypothyroidism or hyperthyroidism.
●acute or chronic hepatic or renal failure.
●acute or chronic pulmonary diseases.
●malignancies.
●autoimmune diseases.
●acute or chronic infectious diseases.
●congenital heart disease.
●passed time AMI.
All patient’s angiographic films were analyzed for:
I- Estimation of coronary sinus filling time before
and after primary PCI. CSFT in seconds = (last frame
count – first frame count)/15
The frame count in which dye is first seen at the
origin of coronary sinus is counted as the last frame
count.
Frame count at the maximum opacification of LAD at
D1 or S1, whichever was earlier is the first frame
count.
II- Estimation of TIMI flow grade after primary PCI.
Patients were classified into 2 groups; optimal flow
group & no-reflow group.
Results:
The study included 90 patients. Optimal group
included 62 patients (68.9%) while no reflow group
included 28 patients (31.1%).
There was high significant difference between both
groups regarding CSFT before primary PCI with
longer time in no-reflow group.
There was a highly significant negative correlation
between TIMI flow and CSFT before PCI.
Conclusion:
CSFT before prirmary PCI can be used as a predictor
of non-optimal coronary flow in patients with acute
MI.
This simple rapidly calculated parameter could be
done after the angiography and during the
preparation of PCI to get ready for dealing with no-
reflow.predicted.by.CSFT
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 37
Unprotected Left Main PCI in the Setting of Anterior STEMI and Cardiogenic Shock
Osama Hassan, Prof. of Cardiology, Ain Shams University
Acute occlusion involving the
unprotected left main coronary artery
(ULMCA) is a clinically catastrophic
event, often leading to abrupt and
severe circulatory failure, lethal
arrhythmias, and sudden cardiac death. Although
coronary artery bypass grafting (CABG) is the
standard of care for ULMCA disease in patients with
stable ischemic heart disease, uncertainty surrounds
the optimal revascularization strategy for patients with
ST-elevation myocardial infarction (Ml) and ULMCA
occlusion who survive to hospitalization, and
treatment guidelines in this setting are vague.
Percutaneous coronary intervention (PCI) is
technically feasible in most patients, has the
advantage of providing more rapid reperfusion
compared with CABG with acceptable short- and
long-term outcomes, and is associated with a lower
risk of stroke.
PCI of the ULMCA should be considered as a viable
alternative to CABG for selected patients with Ml,
including those with ULMCA occlusion and less than
Thrombolysis In Myocardial Infarction flow grade 3,
cardiogenic shock, persistent ventricular arrhythmias,
and significant comorbidities. The higher risk of target
vessel revascularization associated with ULMCA PCI
compared with CABG is acceptable given the primary
need for rapid reperfusion to enhance survival
ULMCA stenting may be considered in patients
with anatomic conditions that are associated with
a low risk of procedural complications and
clinical conditions that predict an increased risk
of adverse surgical outcomes
Patients with ULMCA disease with ST-segment
elevation myocardial infarction (STEMI) who
survive to hospitalization are typically critically
ill, may suffer from cardiogenic shock, and have
high mortality rates, and both the acuity of the
event and critical condition of the patient may
pre-clued the opportunity for emergency CABG.
Although data on long- term follow-up are
limited in this indication, patients who survive to
discharge following ULMCA· PCI have a
favorable prognosis
Nonrandomized and randomized data examining
ULMCA PCI in nonemergency cases compared
with CABG have not demonstrated significant
differences in the outcomes of death or MI. This
has led to increasing interest surrounding the role
of PCI in more acute situations involving
ULMCA disease, in which patients are often too
critically ill and hemodynamically unstable to
undergo.CABG
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 38
Would "High Intensity Cholesterol Lowering Strategy"
Replace" High Intensity Statin Strategy"? Yasser Huzayen, MD, FESC Ain shams Medical School
Regression of LDL-c levels is
considered the cornerstone in
Dyslipidemia management current
guidelines & general consensus
recommend high intensity statin
treatment as the preferred strategy for
LDL-c management.
The application of the ACC/AHA guidelines may be
associated with under-treatment of high risk patients
due to suboptimal LDL-C response to high-intensity
statins in clinical practice.
Achieving a precise goal with this strategy is not
reached in some clinical scenarios thus mandates
other treatment strategies to be put in mind.
A new risk category was added recently and is
addressed by the American Association of Clinical
Endocrinologists "AACE" & American College of
Endocrinology "ACE"
This category has been endorsed recently in 2018
which is the "Extreme Risk" category These two
clinical societies put a cutoff point of 55 mg/dl for
LDL-c for this category which made it too hard for
statins alone to reach Other recent modalities: "high
intensity cholesterol lowering strategies" paved the
road for more control of cholesterol levels and more
cardiovascular protection in some clinical situations
e.g. DM, ACS
Using PCSK9 Inhibitors or combined therapy
"statin/ezetimibe" are supported by land mark clinical
trials "FOURIER and IMPROVE-IT" that showed a
tremendous numeric control with proven protection
in cardiovascular outcome.
For PCSK9 Inhibitors; FOURIER Study showed a
decrease of LDL-C by 59%and an improvement of
CV outcomes in patients already on statin therapy
with Safe and well-tolerated course
For Statin/Ezetimibe; IMPROVE-IT Study In terms
of efficacy showed an up to 60% reduction in LDL-c.
In terms of C.V. outcomes, this strategy showed
proven CV benefit in post ACS patients and in
diabetics with astonishing NNT results
I do have the honor and pleasure to give a lecture in
CardioAlex.18 trying to clarify these new strategies
of management and to figure out if they would
replace the established current strategy of using "high
intensity statin" in Cholesterol management.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 39
Section (3): CASE PRESENTATIONS
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 40
Quadrifurcation LMCA CHIP Case Khaled N. Leon MD, FSCAI, Consultant Cardiologist
National Heart Institute
Recently, a newly introduced
term in the field of Percutaneous
Coronary Interventions was
introduced, namely CHIP
“Complex Higher-Risk Indicated
Patient” emerging as a
subspecialties in PCI, and it seems that we really
need to shed more light on it.
The tctMD, published last month the good news
of appointing Prof. Dr. Mohamed Sobhy, as a
key player in the international CHIP team, his
presentation about decision-making algorithms
have made it easier to identify those at highest
risk for selected periprocedural complications
(e.g. bleeding, contrast induced nephropathy
etc..).
Due to the fact that we are facing much more
complex cases these days, so revascularization
strategies have to be discussed in a heart team,
and the percutaneous approach is nowadays
being a patient preferred choice, hence,
necessitated the rise of more sophisticated and
detailed treatment plans.
In this conference CardioAlex18, I would like to
invite you to join us in a Live in a Box session,
showing an example of a complex higher-risk
indicated patient.
A 52 years old heavy smoker, diabetic,
dysplipidemic male patient who presented with
SOB on mild effort and for that he did several
investigations, proving that he has good LV
systolic function by echo, normal kidney
functions, and finally an angiogram, that
showed totally occluded mid RCA showing a
short CTO segment, and the distal coronary bed
opacifies from faint inter-coronary collaterals
showing the PDA & PLA with a smaller pre-
bifurcation segment.
The LMCA is diseased but without significant
angiographic lesion, and actually trifurcates into
a totally occluded LAD at its ostium, and a 50%
occluded Ramus intermedius that bifurcates into
two medium sized branches, that run to supply
the lateral wall of the LV, and a healthy LCx,
which gives the impression of a quadri-furcating
LMCA in the spider view.
After calculating the Syntax II score and The
Euroscore, the patient laid in the middle zone
which qualifies him to receive a MV PCI, 2
CTO lesions, quadrifurcating diseased LMCA,
defines this case as a CHIP.
As you shall see, the strategy of treatment
needed a heart team consultation first, then a
detailed explanation to the family members
about the hazards, and costs as well.
They preferred to do a PCI strategy, and so the
plan was set to start with the RCA first to open
it up and then go to the left system later.
Crossing the RCA was not really easy, as it
appeared angiographically, however, we could
cross with the assistance of balloon support, and
then we crossed using a 1.2 x 15 mm and then
1.5x20 successively.
We were able to deploy a 2.75x28 mm DES
with good angiographic outcome, and MBG III,
in the RCA territory.
The Left system was cannulated by a 7F JL 4
Guiding catheter, and the same wire was used to
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 41
try to cross the LAD, however after several
trials we failed to cross, so I replaced it with
Pilot 150 and again with the help of the 1.2x15
mm balloon, we could cross, the real challenge
was that the LAD was emerging at a right angle
from the LMCA, and the second obstacle was
the S shaped proximal totally occluded segment
that made the wiring of the LAD almost
impossible with the current equipment that we
had.
Finally, we wired the RI branch and predilate it
with 2.5x20 mm balloon after several pre
dilatations of the LAD we could deploy a
Xience expedition 2.75 x 38 mm stent exactly at
Its ostium with a back stop balloon placed in the
Then we noticed a dissection in the LMCA
body, so we used a 3rd Xience expedition 4.0x18
mm to stent it at 22 atmosphere pressure and the
dissection flap sealed and a nice angiographic
reconstruction of LMCA & LAD was done with
a PTCA of the side branch RI, PS bifurcation
technique.
So this is a case of 2 CTO’s Bifurcation lesion,
complicated by LMCA that was well sealed
with a DES.
A true CHIP case.
RI branch PS bifurcation technique.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 42
Section (4): CASE REPORTS
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 43
Have You Seen A Case Like This ? Alaa Khalil
A tall statured 17 Y old previously
healthy boy was transferred to our
hospital from another facility on
ventilator with diagnosis of Septic
shock , ARDS and presumed infective
endocarditis. bed side echo there,
revealed a mass attached to TV and MVP with
severe MR.
His family denied history of any high-risk behavior
for sexually transmitted diseases, alcohol abuse,
intravenous drug abuse, recent dental procedures,
persisting skin infections, congenital heart disease,
or rheumatic fever.
At our institution, the physical exam was
remarkable for pan-systolic murmur over the apex,
bilateral basal to mid-zone lung crackles. His
physique was remarkable for disproportionate
ration of the lower extremities to torso and very
large upper extremities span, he has a high arched
palate and the thumb wrist test was positive all
suggested marfanoid habitus. His initial laboratory
data showed significant leukocytosis and elevated
inflammatory markers and microscopic hematuria.
Blood, respiratory and urine cultures were negative.
Chest imaging showed pulmonary edema like
picture/ARDS. TTE and TEE revealed large sessile
cauliflower like mass attached to ventricular side of
TV annulus and septal leaflet with highly mobile
sphere like mass attached to its tip without
hemodynamic compromise, Flail anterior MV
leaflets with ruptured chordi at A2,A3 scallops and
severe MR, Aortic valve showed retraction of RCC
with triangular gape causing severe AR
The consensus was for surgery to remove the mass
and send for C/S and histopathology
repair/replacement of valvular lesions.
Vegetations were removed and sent for culture and
histopathology. All culture specimens were
negative, Aortic valve specimen revealed No
evidence of IE ,only myxoid changes ( C/W
connective tissue diseases).Both aortic and mitral
valves were replaced by mechanical valves.
We did a literature review about native TV
Endocarditis with atypical vegetation at ventricular
side and if there any relation to connective tissue
disorder like Marfan syndrome,
We found that, Isolated tricuspid (TV) endocarditis
accounts for 5%-10% of cases of infective
endocarditis (IE)and is uncommon in an
immunocompetent adult in absence of risk factors
or CHD. Persistent fever associated with pulmonary
events, anemia, and microscopic hematuria is
known as ‘tricuspid syndrome’, and should alert for
TVE, Early Echo is recommended in such patients.
Sometimes atypical presentation of vegetations at
ventricular side of TV may occur in some Patient
with VSD and L-> R shunt which Encroach on the
Papillary Muscle and Right Ventricular Cavity.
Echocardiography is the mainstay of assessment of
Marfan's syndrome which may include aortic valve
with Annuloaortic ectasia, especially with dilatation
of aortic root, is found in 60% to 80% of adult
cases which can cause severe AR or may progress
to aortic root dissection. Also Mitral valve may
suffer from MVP which is less benign than the
common type of MVP identified in the general
population. Flail leaflet is an independent predictor
of progression of MR and MV-related clinical
events.
Back to our case, we found no single case report in
the literature with combination of those rare
findings.
CVREP Journal Vol. (2) Issue (1)
Cardiovascular Research Prove Journal 44
Rheumatic Mitral and Congenital Pulmonary Stenosis Mahmoud Sharaf Eldeen Mahfouz Reda, Sohag University Hospital
Introduction:
Percutaneous balloon valvotomy
(PBV) using a single or double
balloon technique has been used for
nonsurgical treatment of pulmonary,
aortic, mitral, tricuspid, and bio- prosthesis stenosis.
Recently, the application of this technique has been
extended for treatment of double valve stenosis and
successful combined dilatation of mitral and aortic,
tricuspid and pulmonary, and mitral and tricuspid
stenosis have been reported.
Until now no documented case of combined
dilatation of both rheumatic mitral and congenital
pulmonary valve stenosis. We performed successful
simultaneous dilatation of mitral and pulmonary
valves as the first case in March 2018, and the report
is the current publication.
Case Report:
A 36-year old female presented with dyspnea on
minimal exertion [NYHA] class III) 0f 6 months’
duration, she complained of occasional paroxysmal
nocturnal dyspnea. She gave a history of rheumatic
heart disease 20 years ago. She was of normal built
and her height was 166 cm and auscultatory findings
of both mitral and pulmonary stenosis.
Echocardiography revealed domed-shape pulmonary
valve with post stenotic dilatation and pressure
gradient of 70 mmHg across the valve which was
correlated with the peak to peak catheterization
gradient. RT ventricular hypertrophy and rheumatic
mitral valve disease were associated.
The mitral valve showed dooming of anterior mitral
valve leaflet and MVA of 1.4 cm2. Mitral
valvuloplasty score of 8 and mildly dilated LA
(diameter of 4.1 cm).
Procedure and Result:
Balloon mitral valvuplasty using a 28 mm Inoue
balloon catheter was carried out first for two reasons:
1-Avoiding increase in the pulmonary blood flow
(pulmonary congestion) if we dilate the pulmonary
valve first.2- Hazard of heparin use before
septostomy. After successful balloon mitral
valvuloplasty with re-insertion of the 8 Fr sheath over
the retained guide wire a JR 6 f catheter and changed
superstiff wire 0.35 mm were used to cross the
pulmonary valve. Tyshak 2.5X 4 cm balloon was
used successfully used
to dilate the pulmonary
valve with 20 mmHg
Peak to peak residual
gradient. Patient was
hemodynamically
stable and only noticed
that her oxygen
saturation dropped to
85 % after procedure.
After one weak at
follow up the patient
was symptom free and
her oxygen saturation
raised to 95%.
Conclusion:
May be as the first case of combined balloon
valvuloplasty of mitral and pulmonary stenosis in
which caution should be carried on to dilate the
mitral first to avoid pulmonary edema and bleeding
risk.
Vol. (2) Issue (1) CVREP Journal
Cardiovascular Research Prove Journal 45
The Silent Creeper Waleed Waheed Etman
Cardiac masses have been
considered a diagnostic and
therapeutic challenge being most
commonly discovered accidently
and late. The incidence of
secondary cardiac tumor is about
7.1% in cancer patients with
about 2.3% among general population.
Hepato-cellular carcinoma (HCC) is the third-
leading cause of cancer-related mortality
worldwide. HCC rarely causes invasion of the
inferior vena cava or the heart.
We, however, present a case of HCC with
secondary cardiac invasion who remained
undiagnosed with HCC until being examined by
echocardiography.
Case report:
A 64 year old female patient without any past
medical history presented to our out-patient clinic
complaining of abdominal distension since 3
weeks.
On examination, a mid-diastolic murmur,
increasing in intensity with inspiration, was heard
at the lower one third of the sternum. Abdominal
examination revealed diffuse distension of the
abdomen with the presence of mild - moderate
ascites.
Trans-thoracic echocardiography was done
revealing a huge right atrial mass with partial
obstruction to the tricuspid valve.
Trans-esophageal echocardiography was done
at the same session revealing a huge mass entering
the right atrium from the inferior vena cava. Tri-
phasic Multi-slice Computed Tomography was
done revealing diffuse cirrhosis of the liver with a
bulky HCC originating from the left hepatic lobe
with invasion of the inferior vena cava and direct
extension to the right atrium and with an intra-
luminal thrombus.
The patient suffered from atrial flutter with
unstable hemodynamics and received a DC shock.
Unfortunately, few hours later, the patient suffered
from atrial flutter with unstable hemodynamics
followed by asystole.
Conclusion: Beside echocardiography remains the mainstay for
the diagnosis of cardiac masses.
Patients with HCC and inferior vena cava
infiltration should always have a follow up
echocardiography for early detection of right atrial
extension and further showers of pulmonary
embolism.