CARDIOVASCULAR RESEARCH EDUCATION PREVENTION … … · Prof. Mohamed Ayman Abdel Hay Prof. Moustafa Nawar. Prof. Salah El Tahan Prof. Tarek El Zawawy ----- Board Members: Ahmed Abdel

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

---------------------------------------------------------------------------------

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

---------------------------------------------------------------------------

CardioAlex.18 Abstracts Committee:

Head of The Committee:

Prof. Mahmoud Hassanein

Abstracts Committee Members:

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Ashraf Reda Ihab Attia Sameh Arab

Adel Allam Magdy Abdel Hamid Samir Rafla

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http://www.icomgroup.org/

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.


Content




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.


Content




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.


Content




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.


Cardiovascular Research Prove Journal 0

SECTION (1): ABSTRACTS

PRESENTED @ CARDIOALEX.18

CVREP Journal Vol. (2) Issue (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.



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.

--------------------------------------------------------------------------------------------------------------------



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



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.

------------------------------------------------------------------------------------------------------------ -------------------------------------------



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

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



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.

----------------------------------------------------------------------------------------------------------------------------- ----------------------------



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.



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.



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



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.



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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SECTION 2: RESUMES, ARTICLES AND

TOPICS PRESENTED @ CARDIOALEX.18



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.



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.



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.



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.



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



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.



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.



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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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

.



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.



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

https://www.bmj.com/content/351/bmj.h5392



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.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4549780/#B46

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4549780/figure/F1/



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.



“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.



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].



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



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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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.



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



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



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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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



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.

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

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.



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



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



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.



Section (3): CASE PRESENTATIONS



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



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.



Section (4): CASE REPORTS



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.



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


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.

Documents

CARDIOVASCULAR RESEARCH EDUCATION PREVENTION … … · Prof. Mohamed Ayman Abdel Hay Prof. Moustafa Nawar. Prof. Salah El Tahan Prof. Tarek El Zawawy ----- Board Members: Ahmed Abdel