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PROFESSIONAL EVENT SPEAKERS


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A new medical model of perioperative diagnosis and treatment for complex congenital heart disease - application of multi-modal diagnosis and treatment technology based on three-dimensional printing

Li Dianyuan, Department of cardiovascular Surgery, China

The diagnosis of complex congenital heart disease is challenging due to its complex anatomical structure. The existing diagnostics rely on the rich clinical experience of ultrasound doctors, radiologists and surgeons to clarify the structural malformations and spatial relationships of complex congenital heart diseases. Our research objective is to explore the role of multi-modal diagnosis and treatment system based on three-dimensional (3-D) printing technology in perioperative diagnosis, surgical treatment and postoperative evaluation of complex congenital heart disease (CHD). Especially in our country where with low diagnostic level of ultrasound and cardiac CT, can our new medical model based on 3-d printing improve the diagnosis and treatment level of complex congenital heart disease in those regions? From July 2017 to July 2019, data of 44 cases of complicated CHD (including total endocardial cushion defect, transposition of the great arteries, double outlet right ventricle, coronary artery fistula etc. 11 diseases) in Beijing and Sichuan were collected, and STL data generated by cardiac CT reconstruction were transmitted to 3-D printer. 1:1 solid heart model was printed with color partition module and myocardial and blood pool rendering technology (Figure 1). Combined with echocardiography and cardiac CT examination, preoperative diagnosis, surgical strategy development and results of surgical treatment were conducted by cardiologists, sonographers, radiologists and surgeons. 40 patients received surgical treatment, including 30 cases of corrective surgery and 10 cases of palliative surgery. Intraoperative exploration of cardiac malformations in all patients was consistent with the 3-D printed model. Echocardiography diagnosis in 5 patients was misdiagnose from sugical exploartion, with a misdiagnosis rate of 12.5%. And 2 patients’ CT images didn't recognize cardiac anomalies structure, which in 3-D print model was clearly visible. The misdiagnosis rate of CT was 5%. The operation method was consistent with the preoperative reservation method. These results show that 3-D printing technology has unique advantages in the application of complex CHD diagnosis and treatment, such as anatomical simulation and three-dimensional display of spatial relationship of heart structure, etc. (Figure 2). In regions with low diagnostic level of ultrasound and cardiac CT, complex CHD is easy to be misdiagnosed. 3D printing technology can effectively improve the diagnosis and treatment level of complicated CHD in those regions, which is worth further promotion.

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Dextrocardia with Atrial Septal Defect (ASD), Scoliosis and Spina Bifida : A Case Report

S O Abed, HKBP Nommensen University, Department of Pediatric Cardiology , Medan, Indonesia

Dextrocardia is anomaly in the position of the heart, the heart is in the right hemithorax with the right and caudal base-apex of the heart. Dextrocardia is usually a single congenital disorder or can be accompanied by malposition of other organs such as liver and spleen.

Case Illustration: A 1-month-old baby entered the hospital with complaints of dyspnea. The patient appeared to be sick with pulse 130x / minute, respiratory rate 62x / minute, temperature 36.5 0C, SPO2 70%. Physical examination showed tachypnea, intercostal retraction, systolic sigh and spina bifida. Radiography examination showed dextrocardia and scoliosis. A echocardiography examination showed ASD with a hole size 0.3 mm. The given treatment were Neonatal Intensive Care Unit, CPAP with 7 liter PEEP and 40% FIO2, NACL IVFD 0.9% 25cc / hour, then replaced with dextrose 5% NACL 0.225, Ampicillin injection 235 mg / 12 hours and breast milk 25 cc / 3 hour / OGT.

Discussion: Dextrocardia is a congenital disorder caused by malformation characterized by the position of the heart on the right. In this case, dextrocardia with ASD was found. From the history carried out on the patient's parents found several risk factors that cause congenital abnormalities, such as the first found genetic factor derived from the baby's family, exposure to pollutants and a history of poor nutrition during pregnancy.

Conclusion: Dextrocardia is anomaly in the position of the heart, the heart is in the right hemithorax with the base and apex of the jaws directed to the right and caudal. In this case dextrocardia with ASD was found. This disorder is caused by risk factor, genetic factor, exposure to pollutants and a history of poor nutrition during pregnancy. Appropriate management is to stabilize the patient's condition and then refer to the surgical installation.

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Coronary restenosis- what we have learned?

Dr Murari Prasad Barakoti, MD, DM, FIC Consultant in Cardiology, ADK Hospital, Male, Maldives

Percutaneous coronary intervention (PCI) technology developed over past four decades revolutionized the treatment pattern of obstructive coronary artery disease. Despite significant advancement in the technique, equipment and pharmacotherapy, target lesion failure in the form of restenosis remains the Achilles heel of a PCI approach.

When Andreaz Gruntzig introduced percutaneous transluminal coronary intervention for the first time, despite the very selective use of procedures to proximal, short, non-calcified and concentric lesion subsets, the procedural success was low and complications rate high.

The advent of bare metal stent put a new horizon in the early 90s and improved outcomes over plain balloon angioplasty. However, soon it become realized that benefits of metallic scaffolds still have a major setback with significantly high incidence of restenosis within the stented segments.

Then it was the drug eluting stent technology that became the default strategy for the most of the coronary interventions. With successive generations with better platforms, different antiproliferative agents, newer polymer, improved stent design and thinner metallic struts, that lead to superior results in terms of target lesion failure and revascularization, myocardial infarction and stent thrombosis.

Despite all the technological advancement, stent failure in the form of in-stent restenosis occurs in 5- 10% cases of PCI procedures in a year and certain lesion subsets have particularly higher incidence rate of events. Every interventional cardiologist has to face this entity on a routine basis and there is no clear solution for this. Better lesion assessment with the help of intracoronary imaging will provide better insights and permits more focused therapy to treat such disease. The repeat revascularization procedure often requires additional therapy in form of repeat stent or application of drug coated balloons. Recurrent restenosis has nothing to offer percutaneously by repeated metal stents, rather to go for coronary artery bypass surgery.

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A Rare Case of Chest Tightness Caused by Descending Aorta to Right Inferior Pulmonary Artery Fistula

Chieh Jen Wu, Veterans General Hospital- Kaohsiung, Taiwan

Descending aorta to right inferior pulmonary artery fistula is a rare type of artery fistula and most frequently discovered accidently without symptoms. Descending aorta to right inferior pulmonary artery fistula with myocardial ischemia has never been reported before. This article presents an 84-year-old male patient who suffered chest pain with diagnosis of angina pectoris and abnormal shunting from the descending aorta to the right inferior pulmonary artery. The syndrome was found after aorta computed tomography 6 years ago. Initially, the patient received a coronary stent implant. Nevertheless, the patient continues to experience chest tightness and symptoms of dyspnea with heart failure. Consequently, the growth of myocardial ischemia leads to necessary coronary bypass surgery. Before surgical bypass, endovascular embolization of the abnormal fistula by coli was carried out. All the collateral circulations were shut down and his chest pain symptoms with heart failure sign improved. Due to myocardial ischemia caused by descending aorta to right inferior pulmonary artery fistula, the physician should be aware that the descending aorta to right inferior pulmonary artery fistula could cause the symptoms that mimic angina pectoris since it has never been reported. The possibility of angina pectoris caused by descending aorta to right inferior pulmonary artery fistula should be kept in mind to avoid unnecessary coronary stent implant or surgical intervention to prevent potentially harmful inappropriate treatment.

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Dr. Prof. Dasari Prasada Rao

Indo US Hospital India

Dasari Prasada Rao (Born 21 January 1950) Is An Indian Cardiothoracic Surgeon. He Was Noteworthy In Introducing The First Open Heart Surgery To The State Of Andhra Pradesh In India And Pioneered For Advanced Medical Care At Affordable Costs. Dasari Prasada Rao Has Won Numerous Awards Including In 2001 The Padma Shri Award, A Civilian Award Bestowed By The Government Of India.

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Carcinoid heart disease in patients with neuroendocrine tumors: Prevalence and predisposing factors

Marc-Alexander Ohlow, Central Clinic Bad Berka, Germany

Background: By releasing vasoactive substances into the circulation, neuroendocrine tumors can cause right-sided valvular heart disease. Factors associated with the development of carcinoid heart disease (CHD) are poorly understood. The incidence is reported to be as high as 50%.

Methods: Our sample from 2012 and 2013 included all consecutive patients with neuroendocrine tumors referred to our institution undergoing echocardiographic studies.

Results: Among 532 patients treated in our center during the study period (54% male, mean age 62 years, mean duration from diagnosis to baseline echo: 63 months) 63 patients (11.8%) were found to have CHD. 43/63 (68%) had CHD already at baseline of whom 13 had to be referred to surgery for valve replacement after baseline echo, and 20/63 (31%) developed CHD during follow-up. Patients with CHD were more likely to have episodic flushing (38% vs 22%; p=0.006), the primary tumor located in the ileum (62% vs 34%; p=0.004) with frequent liver and peritoneal/soft tissue metastases. Serotonin was elevated in all CHD patients (100% vs 40%; p<0.001). Progressive disease according to the RESCIST criteria was more prevalent among CHD patients (60% vs 41%; p=0.004). CHD patients received more frequently somatostatin analogs (52% vs 40%; p=0.04) and underwent more frequently hepatic artery embolization (24% vs 14%; p=0.04). Echocardiographic follow-up (mean 38 months) was available for 469 (88%) of the patients and demonstrated dilated chambers of the right heart (right atrium 39 vs 35 mm; right ventricle 36 vs 32 mm), and higher RV pressure (32 vs 26 mmHg; p<0.0001 for all). A total of 21/63 (33%) CHD patients had to be referred to cardiac surgery (13/21 [62%] for isolated tricuspid valve replacement (TVR), 8/21 [38%] for TVR+pulmonary valve replacement). There were no patients with involvement of the mitral- or aortic valve, the prevalence of intracardiac metastases was 5.6%. All-cause mortality (28.6% vs 15.4%; p=0.01) and mean survival (101 vs 128 months; p=0.03) was significantly different between in CHD and non-CHD patients.

Conclusions: The prevalence of CHD in our series was significantly lower than previously reported. Somatostatin analogs and hepatic dearterialization did not prevent development of CHD. All-cause mortality and mean survival was significantly reduced in CHD patients.

Mortality and mean survival were significantly reduced in CHD patients

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Coronary Flow Regulation and it’s signaling by adenosine.

S.Jamal Mustafa, West Virginia University USA

Adenosine acts through its receptors (A1, A2A, A2B, and A3) via G-proteins and causes an increase in coronary flow (CF) mostly through A2A AR. However, the role of other ARs in the modulation of CF is not well understood. Using knockouts (KO), we investigated the role for each AR in the regulation of CF. Using the isolated heart from A3 KO mice; we reported an increase in A2A-mediated CF.  Similarly, we found an increase in CF in A1 KO mice with A2A agonist (CGS-21680; CGS). In addition, in A2A KO mice response to CGS was abolished, thus confirming the KO. On the other hand, A2A KO mice showed a decrease in CF to NECA (non-selective agonist). BAY60-6583 (A2B selective agonist; BAY) was without an effect on CF in A2B KO mice; however, it increased CF significantly in A2A KO. CGS also caused a significant increase in CF in A2B KO mice. In addition, exogenous adenosine-induced increase in CF in wild type, A2A KO, and A2B KO mice were significantly reduced with catalase. BAY-induced increase in CF in WT was significantly inhibited with glibenclamide. Overall, our data support stimulatory roles for A2A and A2B and inhibitory roles for A1 and A3 in the regulation of CF.  These observations provide new evidence for the presence of all four ARs in CF regulation. We propose, that activation of A2A/B may release H2O2 which then activates KATP channels, leading to vasodilation. These studies may lead to better understanding of the role of ARs in coronary disease and better therapeutic approaches.

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Dr. ANUPAM SHRIVASTAVA

Thesis In Cardiology (RD University,Jabalpur, MP INDIA),

·         Dr Shrivastava has expertise in treating the artery blockages at 98-100 % success rate without operation through latest External Counter pulsation (ECP) and American technology ACT (Artery Clearance Therapy). 

·         Heart Care Heart Centre, One of the top heart specialty centre with ultra-modern technologies of cardiology run by Sr. consultant cardiologist Dr.Anupam Shrivastava.

·         Founded in 1993 by Dr. Anupam Shrivastava "Heart Care" today become name of successful treatment and trust. It is an exclusive centre in Madhya Pradesh which has unique facility for Non-Invasive treatment of CAD.

·         On 6th June 1993, Heart Care was Inaugurated by world famous Cardiologist Dr. (Prof)  Lekha Pathak, Director of Cardiology in J.J. Hospital and Nanavati Hospital, Mumbai.

·         Having all Non-invasive cardio-diagnostic and treatment facilities (See Facilities)

·         Have international fame in view of treating patients of Angina, heart attack, heart blockage, hypertension and related problems.

·         First Digital Heart Centre of Central India

·         Centrally Located, Easily Approachable having positive past record of treating many thousand heart patients successfully

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Approach to vasopressor medications in shock states

Khaled Mohamed mohamed aly, M.sc. faculty of medicine Cairo university- Egypt

Introduction

 Vasopressors are medications that causes vasoconstriction; some of them have additional inotropic effect. By maintaining end-organ perfusion; the role of vasopressors remains critical to prevent irreversible organ injury and failure, and their use is usually accompanied by fluid resuscitation for adequate patient outcomes. Vasopressor agents are used clinically in the treatment of arterial hypotension in shock states. Shock is best defined as inadequate blood flow to meet the metabolic needs of the tissues. The most common reasons for shock are the cardiac output is low relative to the global demand, despite increased O2 extraction by the tissues; or perfusion pressure is inadequate such that blood flow distribution to metabolically active tissues is inadequate, despite an otherwise adequate cardiac output.

Conclusions

Shock requires timely fluid resuscitation and vasopressor therapy that constitutes the cornerstone of therapy. Prompt recognition of reversible factors of refractory shock, such as metabolic and electrolyte derangements, source control for septic shock and lung-protective mechanical ventilation for respiratory failure are important therapeutic adjuncts; norepinephrine is indicated in septic shock.

In cardiogenic shock complicating AMI, current guidelines based on expert opinion recommend dopamine or dobutamine as first-line agents with moderate hypotension (systolic blood pressure 70 to 100 mm Hg) and norepinephrine as the preferred therapy for severe hypotension (systolic blood pressure <70 mm Hg).

Norepinephrine is considered the first-line vasopressor in vasodilatory shock, dobutamine the firstline inotrope in shock associated with decreased cardiac output, and their combination in vasodilatory shock with decreased cardiac output. Epinephrine is the first-line catecholamine in anaphylactic shock; in cardiopulmonary resuscitation and also as second line in shock that is unresponsive to other catecholamines. Vasopressin is emerging as a therapy in resistant vasodilatory shock. 

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Acute SVC Obstruction Following Cardiac Surgery: Stenting vs. Surgical Intervention

Putri Yubbu Department of Paediatrics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Malaysia

Acute Superior vena cava(SVC) obstruction is a rare but recognized complication following cardiac surgery that may result in significant clinical sequelae if not treated early. Transcatheter stenting is rapidly becoming the treatment of choice, considering its reduced post-procedure morbidity and faster recovery time. In early postoperative vascular lesions, primary stenting is preferred over balloon angioplasty to prevent fresh suture line disruption. In paediatric, small patient sizes, as well as the need for future vessel growth, complicate the use of stents in this group of patients. We present three cases of successful relief from severe SVC obstruction that occurred early after cardiac surgical repair. Case 1 and 2, are a 2-month-old girl and 10-month-old-boy with large perimembranous ventricular septal defect (VSD) who underwent VSD closure but was complicated by SVC tear during cannulation. Case 3 is a 35-year-old gentleman with a sinus venosus atrial septal defect, who underwent Warden procedure but developed SVC obstruction at SVC-right atrium anastomosis site. The presentation and management of these patients will be highlighted in these three cases.

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