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Archive for the ‘Aortic Valve: TAVR, TAVI vs Open Heart Surgery’ Category

Becoming a Cardiothoracic Surgeon: An Emerging Profile in the Surgery Theater and through Scientific Publications 

Author and Curator: Aviva Lev-Ari, PhD, RN

Article ID #65: Becoming a Cardiothoracic Surgeon: An Emerging Profile in the Surgery Theater and through Scientific Publications. Published on 7/8/2013

WordCloud Image Produced by Adam Tubman

Two components of an Emerging Profile of a Young Cardiothoracic Surgeon were researched by the Author for the case of  Dr. Isaac George, Assistant Professor of Surgery, Division of Cardiothoracic Surgery, Department of Surgery, New York Presbyterian Hospital/Columbia University Medical Center , New York, NY.

The two components being:

1. the Cardiothoracic Surgery Theater

2. the Scientific Publications

I noted with interest Dr. George’s second publication, to be about a very well known surgeon in the US and Europe, John Benjamin Murphy. written by Dr. George and two other colleagues,  George I, Hardy MA, Widmann WD. published in Curr Surg. 2004 Sep-Oct;61(5):439-41.

Dr. Murphy, is best remembered for the eponymous clinical sign that is used in evaluating patients with acute cholecystitis. His career spanned general surgery, orthopedics, neurosurgery, and cardiothoracic surgery, which helped him to gain international prominence in the surgical profession. Mayo Clinic co-founder William James Mayo called him “the surgical genius of our generation.”

http://en.wikipedia.org/wiki/John_Benjamin_Murphy 

[Musana, Kenneth and Steven H. Yale (May 2005). “John Benjamin Murphy (1857–1916)”. Clinical Medicine & Research. Retrieved 2008-05-16.]

I assume that Dr. Murphy’s contributions to Thoracic surgery were of interest to Dr. George to inspire him to write on the subject and elect that Specialty in Surgery.

Murphy was first in the U.S. to induce (1898) artificial immobilization and collapse of the lung in treatment of pulmonary tuberculosis. He was a pioneer in the use of bone grafting and made contributions to the understanding and management of ankylosis as well as independently proposing artificial pneumothorax to manage unilateral lung disease in tuberculosis.

      • «It is the purpose of every man’s life to do something worthy of the recognition and appreciation of his fellow men. . . . By their superior intellectual qualifications, their fidelity to purpose and above all their indefatigable labour the few become leaders.»

Journal of the American Medical Association, Chicago, 1911, 57: 1.

SOURCE Whonamedit? A dictionary of medical eponyms, John Benjamin Murphy

I came across Dr. Isaac George’s name while researching clinical indications for Inhaled Nitric Oxide in June 2013, upon the recent publication of Leaders in Pharmaceutical Business Intelligence FIRST e-Book on  Amazon (Biomed e-Books) [Kindle  Edition]

Perspectives on Nitric Oxide in  Disease  Mechanisms
http://www.amazon.com/dp/B00DINFFYC

Dr. George’s article on Outcomes After Inhaled Nitric Oxide Therapy was particularly useful in my own research on the topic,

Clinical Indications for Use of Inhaled Nitric Oxide (iNO) in the Adult Patient Market: Clinical Outcomes after Use of iNO in the Institutional Market,  Therapy Demand and Cost of Care vs. Existing Supply Solutions

Being myself in Analytics and quantitative model design, 1976-2004, I found of particular interest the range of quantitative methodologies used in the following article by Isaac George, assuming that his days at MIT, came very handy in 2006:

George, Isaac, Xydas, Steve, Topkara, Veli K., Ferdinando, Corrina, Barnwell, Eileen C., Gableman, Larissa, Sladen, Robert N., Naka, Yoshifumi, Oz, Mehmet C.
Clinical Indication for Use and Outcomes After Inhaled Nitric Oxide Therapy
Ann Thorac Surg 2006 82: 2161-2169

As a result of studying this article, I became aware that it has impacted  favorably my 6/2013, Editorial decision, for  a forthcoming book on Cardiovascular Disease in 2013. The Editorial decision regarding the selection and representation of  prominent Cardiothoracic Surgery Theater in the US, and my personal decision to select a Young Cardiothoracic Surgeon

Dr. Isaac George, Assistant Professor of Surgery, Division of Cardiothoracic Surgery, Department of Surgery, New York Presbyterian Hospital/Columbia University Medical Center, New York, NY

Education Profile and Medical Training of a Cardiac Surgeon


Isaac George, MD

Positions and Appointments

2012-present Attending Surgeon, Heart Valve Center
NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY
2012-present Assistant Professor of Surgery
Division of Cardiothoracic Surgery, Department of Surgery, New York Presbyterian Hospital/Columbia University Medical Center , New York, NY

Clinical Specialties

Adult aortic and mitral valve surgery
Transcatheter aortic and mitral valve implantation
Hybrid coronary artery bypass surgery
Complex aortic surgery
Complex valvular surgery
Heart failure and transplant surgery
Reoperative cardiac surgery
Thoracic aortic endograft implantation

Research Interests

Director, Cardiac Surgery Research Lab

1. Regulation of myostatin signaling in human cardiomyopathy

2. TGFB regulation in non-syndromic aortic aneurysm formation

3. Valve interstitial cell activation mechanisms after surgical and transcatheter valve replacement

4. Clinical outcomes after valve and hybrid surgery

Education and Training

2011-2012 Interventional Cardiology/Hybrid Cardiac Surgery Fellowship
New York Presbyterian Hospital – Columbia University Medical Center, New York, NY
2011 Ventricular Assist Device/Cardiac Transplant Fellowship, Minimally Invasive, Cardiac Surgery
New York Presbyterian Hospital – Columbia University Medical Center, New York, NY
2009-2011 Fellow, Cardiothoracic Surgery
New York Presbyterian Hospital – Columbia University Medical Center, New York, NY
2008-2009 Post-Doctoral Clinical Fellow, Cardiothoracic Surgery
New York Presbyterian Hospital – Columbia University Medical Center, New York, NY
2006-2008 Resident, General Surgery
New York Presbyterian Hospital – Columbia University Medical Center, New York, NY
2004-2006 Research Fellow, Cardiothoracic Surgery
New York Presbyterian Hospital – Columbia University Medical Center, New York, NY
2002-2004 Resident, General Surgery
New York Presbyterian Hospital – Columbia University Medical Center, New York, NY
2001-2002 Internship, General Surgery
New York Presbyterian Hospital – Columbia University Medical Center, New York, NY
1997-2001 MD, Medicine
Duke University School of Medicine, Durham, NC
1993-1997 BS, Mechanical Engineering
Massachusetts Institute of Technology, Cambridge, MA

Board Certifications

American Board of Thoracic Surgery, 2012-
American Board of Surgery, 2008-
Certification, Pediatric Advanced Life Support, 2008-
Certification, Advanced Trauma Life Support, 2006-
MD, State of New York, 2005-
Certification, Advanced Cardiac Life Support/Basic Life Support, 2001-
United States Medical Licensing Examination Step 3, 2004
United States Medical Licensing Examination Step 2, 2001
United States Medical Licensing Examination Step 1, 2000

Professional Honors

2008 Blakemore Prize – Best Resident Research Award, Columbia University College of Physicians and Surgeons

2007 Blakemore Award – Best Resident Research Award, Columbia University College of Physicians and Surgeons

2006 Blakemore Award – Best Resident Research Award, Columbia University College of Physicians and Surgeons

2004 New Era Cardiac Surgery Conference Scholarship

1995 Pi Tau Sigma, Mechanical Engineering Honor Society

1993 Duke University Comprehensive Cancer Center Fellowship

Professional Societies and Committees

2011 Faculty, Transcatheter Cardiovascular Therapeutics (TCT) Annual Symposium

2010- Candidate Member, Society of Thoracic Surgeons

2010- Fellow-in-Training, American College of Cardiology, Surgeons Council

2005-06 American Society of Artificial Internal Organs

2004- Member, American Heart Association

1997-01 Member, American Medical Association

SOURCE http://asp.cpmc.columbia.edu/facdb/profile_list.asp?uni=ig2006&DepAffil=Surgery

The decision to focus on Cardiothoracic Surgery @Presbeterian as described in Dr. Isaac George’s research had yielded one Sub-Chapter (4.1) in Chapter 4

Cardiac Surgery, Cardiothoracic Surgical Procedures and Percutaneous Coronary Intervention (PCI)/Coronary Angioplasty  – Heart and Cardiovascular Medical Devices in Use in Operating Rooms and in Catheterization Labs in the US

in Volume Three in a forthcoming three volume Series of e-Books on Cardiovascular Diseases

Cardiovascular Diseases: Causes, Risks and Management

This very Sub-Chapter represents milestones in Dr. Isaac George – Becoming a Cardiothoracic Surgeon: An Emerging Profile through Scientific Publications, This profile is now in: 

 

Volume Three

Management of Cardiovascular Diseases

Justin D. Pearlman MD ME PhD MA FACC, Editor

Leaders in Pharmaceutical Business Intelligence, Los Angeles

Aviva Lev-Ari, PhD, RN

Editor-in-Chief BioMed E-Book Series

Leaders in Pharmaceutical Business Intelligence, Boston

avivalev-ari@alum.berkeley.edu

Chapter 5

Invasive Procedures by Surgery versus Catheterization

 

5.1 Cardiothoracic Surgery 

5.1.1 Becoming a Cardiothoracic Surgeon: An Emerging Profile in the Surgery Theater and through Scientific Publications

Aviva Lev-Ari, PhD, RN

5.2: Catheter Interventions

5.2.2 Survivals Comparison of Coronary Artery Bypass Graft (CABG) and Percutaneous Coronary Intervention (PCI) / Coronary Angioplasty

Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

5.3: Transcatheter (Percutaneous) Valves

5.3.1 Transcatheter Aortic Valve Replacement (TAVR): Postdilatation to Reduce Paravalvular Regurgitation During TAVR with a Balloon-expandable Valve

Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

5.3.2 Trans-apical Transcatheter Aortic Valve Replacement in a Patient with Severe and Complex Left Main Coronary Artery Disease (LMCAD)

Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

5.4: Transcatheter (Percutaneous) Pumps

5.4.1  Ventricular Assist Device (VAD): Recommended Approach to the Treatment of Intractable Cardiogentic Shock

Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

5.4.2 Phrenic Nerve Stimulation in Patients with Cheyne-Stokes Respiration and Congestive Heart Failure

Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

Content Analysis of  Surgeon Isaac George, MD – Publications on PubMed

SOURCE

Original classification by Aviva Lev-Ari, PhD, RN, 7/8/2013

Title

Journal

Year

CABG
Stent

Valves
Bio

material
TAVR MVR

End stage

HF

AMI

shock

Congen
Genet

Animal

Model

Heart &
Heart-Lung
Transpl

Stent exteriorization

CCI

13

X

Left Main Coronary

CCI

13

X

TAVR-MVR

JACC

13

X

Paravalvular

CVI

13

X

Cardiogenic Shock

Heart-Lung

12

X

Cheyne-Stokes

Chest

12

X

Myostatin

PlusOne

11

X

Aortic Root & RV

ATS

11

X

Beta-Adrenergic

CV Research

11

X

Erythropoietin

LV  Systolic

J CV

Pharmacol

10

X

Myostatin & HF

Eur J

Heart Failure

10

X

Stentless in valve conduit

ATS

09

X

BNP peptide-

infusion-post MI

Am J Physiol-

Heart Circ

Physiology

09

X

Marginal donor heart

ATS

09

X

Device-surface & Immunogenic

J Thoracic

CV Surg

08

X

Myocardial

electromagnetic

J Cell Physiol

08

X

Clenbuterol-

muscle-mass

J Heart- Lung Transplant

08

X

Bradycardic LV

J Pharmacol Exper Therap

07

X

Ischemia- post

Heart Transplant

J Thoracic

CV Surgery

07

X

Octogen CABG

ATS

07

X

Ventricular synchrony

Eup J Cardio-thoracic Surg

07

X

Inhaled NO

ATS

06

X

X

Adult heart-donor-

to-pediatric

J Thoracic

CV Surg

06

X

Clenbuterol

on LVAD

J Heart-Lung Transplant

06

X

LV-CA stent

Heart Surg

Forum

06

X

LVAD myocarditis

J Thoracic

CV Surg

06

X

MI-Ischemia

Am J Physiol-

Ht-Circ Physiol

06

X

It is the unique combination of Animal Model Research, Biomaterial, Surgical Procedures and Molecular Cardiology, N=33.

Cardiothoracic Surgeon: An Emerging Profile in the Surgery Theater

Isaac George, MD – Clinical Specialties 

  • Adult aortic and mitral valve surgery
  • Transcatheter aortic and mitral valve implantation
  • Hybrid coronary artery bypass surgery
  • Complex aortic surgery
  • Complex valvular surgery
  • Heart failure and transplant surgery
  • Reoperative cardiac surgery
  • Thoracic aortic endograft implantation

 

VIDEOS on CardioThoracic Surgery @ Department of Cardiothoracic Surgery at NewYork-Presbyterian Hospital/Weill Cornell Medical Center in New York City

VIEW VIDEO on the new Heart Center @ Presbyterian Hospital

http://videos.nyp.org/videos/introduction-to-the-vivian-and-seymour-milstein-family-heart-center

VIEW VIDEO on the two Hybrid OR with Siemens Artis Zeego Technology

http://videos.nyp.org/videos/tour-a-hybrid-or-with-siemens-artis-zeego-technology

VIEW VIDEO on Mininally Invesive and Conventional Therapy for Aortic Dissection and Aneurysms – Hybrid Surgery Case

http://videos.nyp.org/videos/thoracic-innovations-in-minimally-invasive-and-conventional-therapy-for-aortic-dissection-and-aneurysms

VIEW VIDEO on Mitral Valve Repair and Replacement – Dr. Karl H. Krieger

Dr. Karl H. Krieger, the Vice Chairman of the Department of Cardiothoracic Surgery at NewYork-Presbyterian Hospital/Weill Cornell Medical Center in New York City, discusses treatment for Mitral Valve Disease. Specifically, Dr. Krieger compares the options of Mitral Valve Repair with Mitral Valve Replacement.

This video with Dr. Krieger is from a web cast at the Ronald O. Perelman Heart Institute at NewYork-Presbyterian.

VIEW VIDEO on Left Ventricular Assist Devices (LVADs) – Dr. Jonathan Chen

Dr. Jonathan Chen, the Site Chief for Pediatric Cardiac Surgery at NewYork-Presbyterian Hospital/Weill Cornell Medical Center in New York City, explains how Left Ventricular Assist Devices (LVADs) work and how they can benefit patients with heart failure.

LVADs are implantable devices that help the heart pump blood. They can be used as a temporary therapy, allowing patients’ hearts to rest while they recover from cardiac events such as heart attacks, or while they wait for hearts to become available for transplants. For some patients whose hearts are unlikely to recover and are not candidates for heart transplants, the devices may be used as a permanent therapy. Heart failure, especially in severe forms, can force patients to lead restricted lives because often even very limited physical activity, such as walking from one room to another, will leave them breathless.

Dr. Chen is a pediatric cardiothoracic surgeon, yet the information in the video is applicable to adult patients as well.

VIEW VIDEO on Transcatheter Aortic Valve Implantation @ Presbyterian Hospital

http://videos.nyp.org/videos/chapter-3-transcatheter-aortic-valve-implantation

Heart, Heart-Lung Transplantation @ Presbyterian Hospital

Organ transplantation that prolongs and dramatically improves quality of life is nearly a daily occurrence at Columbia University Medical Center.

The success of solid organ transplantation – with improved surgical techniques, replacement organ procurement, and medical management – is advancing each year. Many of these advances have resulted from scientific and clinical research conducted at Columbia University Medical Center.

A Brief History of Transplantation at Columbia

Transplantation: Where we’ve been, where we’re going

Transplantation: Where we've been, where we're going
Eric A. Rose, MD, former chairman of the department of surgery, left center, performing the first successful pediatric heart transplant in 1984. Transplant pioneer Keith Reemtsma, MD, who is overseeing the operating field (top of photo).

When he transplanted a chimpanzee kidney into a human patient in the late 1960’s, the late Keith Reemtsma, MD, then Department of Surgery Chairman at Tulane University, revolutionized treatment of end-stage organ failure and initiated an era of unprecedented exploration into organ transplantation that would affect the lives of patients around the world.

Transferring to Columbia-Presbyterian Medical Center in 1971, Dr. Reemtsma recruited Mark A. Hardy, MD, who laid another cornerstone of organ transplant medicine by founding the program for dialysis and kidney transplantation. Dr. Hardy based the new program on the principle of collaborative clinical care between surgeons and nephrologists. During a time when renal transplant programs were managed by one or the other discipline but never by both simultaneously, the medical community regarded the concept as folly. Yet the program grew steadily, as did the program’s immune tolerance research initiatives to induce the transplant recipient’s body to accept a donor organ. This multidisciplinary cooperation also led to major contributions in immunogenetics, immunosuppression, and treatment of autoimmune diseases and lymphoma — and it ultimately became the overarching principle for all the NewYork-Presbyterian Hospital transplant services.

Mark A. Hardy, MD

Mark Hardy
Eric Rose
Eric A. Rose, MD
Lloyd Ratner
Lloyd E. Ratner, MD

Colleagues universally give credit to Eric A. Rose, MD, who co-founded the heart transplantation program with Dr. Reemtsma, for his successful transformation of the program into the outstanding center it is today. A parade of achievements marks the history of the heart transplant program, including the first mechanical bridge-totransplantation using intra-aortic balloon pumps in the 1970’s, and the first successful pediatric heart transplant, performed by Dr. Rose in 1984. Under the guidance of Dr. Rose and his successors, the program has pioneered research in immunosuppressant medications, mechanical assist devices, and minimally invasive surgical procedures. It currently performs over 100 heart transplants yearly, with among the highest success rates in the nation.

Also in 2004, Lloyd E. Ratner, MD, succeeded Dr. Hardy as director of the renal and pancreas transplant program. One of the first to perform laparoscopic donor operations, Dr. Ratner has found creative solutions to overcome immune barriers to kidney transplantation. The program now routinely uses extended-criteria donor organs, performs transplants among incompatible donors, and is a leader in coordinating “donor swaps” to maximize availability of compatible donor organs. Since Dr. Ratner’s arrival, Columbia has been designated one of ten regional islet resource centers in the U.S. that isolate and transplant pancreatic cells to treat type 1 diabetes as part of a limited protocol controlled by the FDA. Recent progress in visualization of pancreatic islets using PET technology, under the guidance of Paul Harris, PhD, has been recognized by the scientific community as a milestone in this developing field.

NYPH/Columbia received UNOS approval for pancreatic transplantation in January 2008. Our premier kidney transplant program is facilitating rapid growth of the new pancreatic transplantation program, which overlaps both in its patient population and its surgical and medical expertise. The northeast region of the U.S. has been consistently underserved as far as access to pancreatic transplantation, with relatively few centers serving a disproportionately large metropolitan population. The expanding program at NewYork-Presbyterian now provides much-needed access to patients with end-stage pancreatic disease in New York state, particularly those with the most complex medical and surgical challenges.

Transplantation of cells, rather than organs, is emerging as a therapy with enormous potential. Transplantation of either a patient’s own or a foreign donor’s bone marrow cells, for example, offers hope of regenerating the heart so that patients with heart failure may be able to avoid heart transplantation.

In introducing the transplantation programs, it would be remiss to neglect mention of the yet another dimension in which they excel — education. Physician training is a top priority, and NYPH/Columbia has trained many of the greatest transplant surgeons over the last 20 years, including many of the leaders of transplant programs throughout the U.S.

http://columbiasurgery.org/transplant/history.html

Transplant Initiative

At NewYork-Presbyterian Hospital/Columbia University Medical Center, the Transplant Initiative (TI) has been launched to drive the growth of both clinical and research aspects of transplantation. This multi-year undertaking will involve Departments of Medicine, Pathology, Pediatrics, and Surgery and all of the solid organ transplantation programs, both adult and pediatrics. It is led by its Executive Director, Jean C. Emond, MD.

Although NYP/Columbia is already a national leader in clinical transplantation with respect to volume and patient outcomes, this initiative will further leverage the diverse expertise of its transplant scientists and clinicians.

Heart Transplantation

Approximately 2,200 heart transplants are now performed each year in more than 150 heart transplant centers in the United States. The surgeons and cardiologists of Columbia University Medical Center of NYPH have a long and distinguished history of advancing “standards of care” and the survival rates of our patients by using innovative surgical techniques, by applying our basic scientific research in immunosuppression to the clinical setting, and by inventing and perfecting life-sustaining cardiac assist devices that prolong life while waiting for organ availability.

Lung and Heart-Lung Transplantation

Columbia University Medical Center’s lung and heart-lung transplantation program, which began in 1985, is fast approaching its 200th transplant. Performing more than 30 transplants each year, the lung and heart-lung transplant teams have earned a national reputation for excellence. Our world-renowned transplantation researchers have helped lead the way to improvements in care that, nationwide, have increased the long-term survival rate for lung transplantation by 50% over the past seven years. Among those improvements are new immunosuppressive agents, new antibiotics, refined surgical techniques, and a more comprehensive understanding of follow-up care.

http://columbiasurgery.org/transplant/

It is the combination of basic research at the molecular cardiology level, biomaterial, surgical procedures and PUBLICATION of Cases and research results that found me in Dr. George’s territory as a renewed inspiration.

For Author’s training & experience @ MGH – Cardiac Floor – Ellison 11, BWH – CCU, Tower 3 – 12Fl, BIDMC – Acute Surgery, Farr 9, and Texas Heart Institute, Perfusion, Faulkner Hospital – ICU

http://pharmaceuticalintelligence.com/founder/scientific-and-medical-affairs-chronological-cv/

and in Part II, Section IV in

http://pharmaceuticalintelligence.com/2013/07/14/vascular-surgery-position-statement-in-2013-and-contributions-of-a-vascular-surgeon-at-peak-career-richard-paul-cambria-md-chief-division-of-vascular-and-endovascular-surgery-co-director-thoracic/

Surgeon Isaac George, MD – Training in the OR @ Presbyterian Hospital

2011-2012 Interventional Cardiology/Hybrid Cardiac Surgery Fellowship
New York Presbyterian Hospital – Columbia University Medical Center, New York, NY
2011 Ventricular Assist Device/Cardiac Transplant Fellowship, Minimally Invasive, Cardiac Surgery
New York Presbyterian Hospital – Columbia University Medical Center, New York, NY
2009-2011 Fellow, Cardiothoracic Surgery
New York Presbyterian Hospital – Columbia University Medical Center, New York, NY
2008-2009 Post-Doctoral Clinical Fellow, Cardiothoracic Surgery
New York Presbyterian Hospital – Columbia University Medical Center, New York, NY
2006-2008 Resident, General Surgery
New York Presbyterian Hospital – Columbia University Medical Center, New York, NY
2004-2006 Research Fellow, Cardiothoracic Surgery
New York Presbyterian Hospital – Columbia University Medical Center, New York, NY
2002-2004 Resident, General Surgery
New York Presbyterian Hospital – Columbia University Medical Center, New York, NY
2001-2002 Internship, General Surgery
New York Presbyterian Hospital – Columbia University Medical Center, New York, NY

SOURCE

http://asp.cpmc.columbia.edu/facdb/profile_list.asp?uni=ig2006&DepAffil=Surgery

Surgeon Isaac George, MD – Publications on PubMed

http://www.ncbi.nlm.nih.gov/pubmed

Select item 234757651.

Stent exteriorization facilitates surgical repair for large-bore sheath complications.

George I, Shrikhande G, Williams MR.

Catheter Cardiovasc Interv. 2013 Mar 8. doi: 10.1002/ccd.24918. [Epub ahead of print]

PMID:

23475765

[PubMed – as supplied by publisher]

Related citations

Select item 234131722.

Management of significant left main coronary disease before and after trans-apical transcatheter aortic valve replacement in a patient with severe and complex arterial disease.

Paradis JM, George I, Kodali S.

Catheter Cardiovasc Interv. 2013 Feb 14. doi: 10.1002/ccd.24865. [Epub ahead of print]

PMID:

23413172

[PubMed – as supplied by publisher]

Related citations

Select item 233478683.

Concomitant transcatheter aortic and mitral valve-in-valve replacements using transfemoral devices via the transapical approach: first case in United States.

Paradis JM, Kodali SK, Hahn RT, George I, Daneault B, Koss E, Nazif TM, Leon MB, Williams MR.

JACC Cardiovasc Interv. 2013 Jan;6(1):94-6. doi: 10.1016/j.jcin.2012.07.018. No abstract available.

PMID:

23347868

[PubMed – in process]

Related citations

Select item 233398414.

Efficacy and safety of postdilatation to reduce paravalvular regurgitation during balloon-expandable transcatheter aortic valve replacement.

Daneault B, Koss E, Hahn RT, Kodali S, Williams MR, Généreux P, Paradis JM, George I, Reiss GR, Moses JW, Smith CR, Leon MB.

Circ Cardiovasc Interv. 2013 Feb;6(1):85-91. doi: 10.1161/CIRCINTERVENTIONS.112.971614. Epub 2013 Jan 22.

PMID:

23339841

[PubMed – in process]

Related citations

Select item 226080345.

A stepwise progression in the treatment of cardiogenic shock.

Pollack A, Uriel N, George I, Kodali S, Takayama H, Naka Y, Jorde U.

Heart Lung. 2012 Sep-Oct;41(5):500-4. doi: 10.1016/j.hrtlng.2012.03.007. Epub 2012 May 16.

PMID:

22608034

[PubMed – indexed for MEDLINE]

Related citations

Select item 223022996.

Transvenous phrenic nerve stimulation in patients with Cheyne-Stokes respiration and congestive heart failure: a safety and proof-of-concept study.

Zhang XL, Ding N, Wang H, Augostini R, Yang B, Xu D, Ju W, Hou X, Li X, Ni B, Cao K, George I, Wang J, Zhang SJ.

Chest. 2012 Oct;142(4):927-34.

PMID:

22302299

[PubMed – in process]

Related citations

Select item 219316167.

Myostatin is elevated in congenital heart disease and after mechanical unloading.

Bish LT, George I, Maybaum S, Yang J, Chen JM, Sweeney HL.

PLoS One. 2011;6(9):e23818. doi: 10.1371/journal.pone.0023818. Epub 2011 Sep 13.

PMID:

21931616

[PubMed – indexed for MEDLINE]

Free PMC Article

Related citations

Select item 216199558.

Aortic root and right ventricular outflow tract reconstruction using composite biological valved conduits after failed Ross procedure.

Russo MJ, Easterwood R, Williams MR, George I, Stewart AS.

Ann Thorac Surg. 2011 Jun;91(6):e87-9. doi: 10.1016/j.athoracsur.2011.01.035.

PMID:

21619955

[PubMed – indexed for MEDLINE]

Related citations

Select item 214937019.

β-adrenergic receptor blockade reduces endoplasmic reticulum stress and normalizes calcium handling in a coronary embolization model of heart failure in canines.

George I, Sabbah HN, Xu K, Wang N, Wang J.

Cardiovasc Res. 2011 Aug 1;91(3):447-55. doi: 10.1093/cvr/cvr106. Epub 2011 Apr 14.

PMID:

21493701

[PubMed – indexed for MEDLINE]

Free Article

Related citations

Select item 2088161410.

Erythropoietin derivate improves left ventricular systolic performance and attenuates left ventricular remodeling in rats with myocardial infarct-induced heart failure.

Xu K, George I, Klotz S, Hay I, Xydas S, Zhang G, Cerami A, Wang J.

J Cardiovasc Pharmacol. 2010 Nov;56(5):506-12. doi: 10.1097/FJC.0b013e3181f4f05a.

PMID:

20881614

[PubMed – indexed for MEDLINE]

Related citations

Select item 2034855011.

Myostatin activation in patients with advanced heart failure and after mechanical unloading.

George I, Bish LT, Kamalakkannan G, Petrilli CM, Oz MC, Naka Y, Sweeney HL, Maybaum S.

Eur J Heart Fail. 2010 May;12(5):444-53. doi: 10.1093/eurjhf/hfq039. Epub 2010 Mar 27.

PMID:

20348550

[PubMed – indexed for MEDLINE]

Free PMC Article

Related citations

Select item 1993228712.

Stentless bioprosthesis in a valved conduit: implications for pulmonary reconstruction.

George I, Shah JN, Bacchetta M, Stewart A.

Ann Thorac Surg. 2009 Dec;88(6):2022-4. doi: 10.1016/j.athoracsur.2009.04.145.

PMID:

19932287

[PubMed – indexed for MEDLINE]

Related citations

Select item 1985873513.

Long-term effects of B-type natriuretic peptide infusion after acute myocardial infarction in a rat model.

George I, Xydas S, Klotz S, Hay I, Ng C, Chang J, Xu K, Li Z, Protter AA, Wu EX, Oz MC, Wang J.

J Cardiovasc Pharmacol. 2010 Jan;55(1):14-20. doi: 10.1097/FJC.0b013e3181c5e743.

PMID:

19858735

[PubMed – indexed for MEDLINE]

Free PMC Article

Related citations

Select item 1952537314.

Prolonged effects of B-type natriuretic peptide infusion on cardiac remodeling after sustained myocardial injury.

George I, Morrow B, Xu K, Yi GH, Holmes J, Wu EX, Li Z, Protter AA, Oz MC, Wang J.

Am J Physiol Heart Circ Physiol. 2009 Aug;297(2):H708-17. doi: 10.1152/ajpheart.00661.2008. Epub 2009 Jun 12.

PMID:

19525373

[PubMed – indexed for MEDLINE]

Free PMC Article

Related citations

Select item 1932412915.

Matching high-risk recipients with marginal donor hearts is a clinically effective strategy.

Russo MJ, Davies RR, Hong KN, Chen JM, Argenziano M, Moskowitz A, Ascheim DD, George I, Stewart AS, Williams M, Gelijns A, Naka Y.

Ann Thorac Surg. 2009 Apr;87(4):1066-70; discussion 1071. doi: 10.1016/j.athoracsur.2008.12.020.

PMID:

19324129

[PubMed – indexed for MEDLINE]

Free PMC Article

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Association of device surface and biomaterials with immunologic sensitization after mechanical support.

George I, Colley P, Russo MJ, Martens TP, Burke E, Oz MC, Deng MC, Mancini DM, Naka Y.

J Thorac Cardiovasc Surg. 2008 Jun;135(6):1372-9. doi: 10.1016/j.jtcvs.2007.11.049.

PMID:

18544389

[PubMed – indexed for MEDLINE]

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Myocardial function improved by electromagnetic field induction of stress protein hsp70.

George I, Geddis MS, Lill Z, Lin H, Gomez T, Blank M, Oz MC, Goodman R.

J Cell Physiol. 2008 Sep;216(3):816-23. doi: 10.1002/jcp.21461.

PMID:

18446816

[PubMed – indexed for MEDLINE]

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Clenbuterol increases lean muscle mass but not endurance in patients with chronic heart failure.

Kamalakkannan G, Petrilli CM, George I, LaManca J, McLaughlin BT, Shane E, Mancini DM, Maybaum S.

J Heart Lung Transplant. 2008 Apr;27(4):457-61. doi: 10.1016/j.healun.2008.01.013.

PMID:

18374884

[PubMed – indexed for MEDLINE]

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Bradycardic therapy improves left ventricular function and remodeling in dogs with coronary embolization-induced chronic heart failure.

Cheng Y, George I, Yi GH, Reiken S, Gu A, Tao YK, Muraskin J, Qin S, He KL, Hay I, Yu K, Oz MC, Burkhoff D, Holmes J, Wang J.

J Pharmacol Exp Ther. 2007 May;321(2):469-76. Epub 2007 Feb 2.

PMID:

17277196

[PubMed – indexed for MEDLINE]

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The effect of ischemic time on survival after heart transplantation varies by donor age: an analysis of the United Network for Organ Sharing database.

Russo MJ, Chen JM, Sorabella RA, Martens TP, Garrido M, Davies RR, George I, Cheema FH, Mosca RS, Mital S, Ascheim DD, Argenziano M, Stewart AS, Oz MC, Naka Y.

J Thorac Cardiovasc Surg. 2007 Feb;133(2):554-9.

PMID:

17258599

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Discharge to home rates are significantly lower for octogenarians undergoing coronary artery bypass graft surgery.

Bardakci H, Cheema FH, Topkara VK, Dang NC, Martens TP, Mercando ML, Forster CS, Benson AA, George I, Russo MJ, Oz MC, Esrig BC.

Ann Thorac Surg. 2007 Feb;83(2):483-9.

PMID:

17257973

[PubMed – indexed for MEDLINE]

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Clinical indication for use and outcomes after inhaled nitric oxide therapy.

George I, Xydas S, Topkara VK, Ferdinando C, Barnwell EC, Gableman L, Sladen RN, Naka Y, Oz MC.

Ann Thorac Surg. 2006 Dec;82(6):2161-9.

PMID:

17126129

[PubMed – indexed for MEDLINE]

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Effect of passive cardiac containment on ventricular synchrony and cardiac function in awake dogs.

George I, Cheng Y, Yi GH, He KL, Li X, Oz MC, Holmes J, Wang J.

Eur J Cardiothorac Surg. 2007 Jan;31(1):55-64. Epub 2006 Nov 1.

PMID:

17081764

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Ray optics model for triangular hollow silicon waveguides.

Isaac G, Khalil D.

Appl Opt. 2006 Oct 10;45(29):7567-78.

PMID:

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Adult-age donors offer acceptable long-term survival to pediatric heart transplant recipients: an analysis of the United Network of Organ Sharing database.

Russo MJ, Davies RR, Sorabella RA, Martens TP, George I, Cheema FH, Mital S, Mosca RS, Chen JM.

J Thorac Cardiovasc Surg. 2006 Nov;132(5):1208-12.

PMID:

17059945

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Effect of clenbuterol on cardiac and skeletal muscle function during left ventricular assist device support.

George I, Xydas S, Mancini DM, Lamanca J, DiTullio M, Marboe CC, Shane E, Schulman AR, Colley PM, Petrilli CM, Naka Y, Oz MC, Maybaum S.

J Heart Lung Transplant. 2006 Sep;25(9):1084-90.

PMID:

16962470

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Delusional Misidentification Syndromes: Separate Disorders or Unusual Presentations of Existing DSM-IV Categories?

Atta K, Forlenza N, Gujski M, Hashmi S, Isaac G.

Psychiatry (Edgmont). 2006 Sep;3(9):56-61.

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20975828

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Direct left ventricle-to-coronary artery stent restores perfusion to chronic ischemic swine myocardium.

Yi GH, George I, He KL, Lee MJ, Cahalan P, Zhang G, Gu A, Klotz S, Burkhoff D, Wang J.

Heart Surg Forum. 2006;9(5):E744-9.

PMID:

16809127

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Ventricular assist device use for the treatment of acute viral myocarditis.

Topkara VK, Dang NC, Barili F, Martens TP, George I, Cheema FH, Bardakci H, Ozcan AV, Naka Y.

J Thorac Cardiovasc Surg. 2006 May;131(5):1190-1. No abstract available.

PMID:

16678619

[PubMed – indexed for MEDLINE]

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A polymerized bovine hemoglobin oxygen carrier preserves regional myocardial function and reduces infarct size after acute myocardial ischemia.

George I, Yi GH, Schulman AR, Morrow BT, Cheng Y, Gu A, Zhang G, Oz MC, Burkhoff D, Wang J.

Am J Physiol Heart Circ Physiol. 2006 Sep;291(3):H1126-37. Epub 2006 Apr 14.

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Predictors and outcomes of continuous veno-venous hemodialysis use after implantation of a left ventricular assist device.

Topkara VK, Dang NC, Barili F, Cheema FH, Martens TP, George I, Bardakci H, Oz MC, Naka Y.

J Heart Lung Transplant. 2006 Apr;25(4):404-8. Epub 2006 Feb 28.

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16563969

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John Benjamin Murphy.

George I, Hardy MA, Widmann WD.

Curr Surg. 2004 Sep-Oct;61(5):439-41. No abstract available.

PMID:

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[PubMed – indexed for MEDLINE]

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Multiple-scattering lidar retrieval method: tests on Monte Carlo simulations and comparisons with in situ measurements.

Bissonnette LR, Roy G, Poutier L, Cober SG, Isaac GA.

Appl Opt. 2002 Oct 20;41(30):6307-24.

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Discharge to home rates are significantly lower for octogenarians undergoing coronary artery bypass graft surgery.

Bardakci H, Cheema FH, Topkara VK, Dang NC, Martens TP, Mercando ML, Forster CS, Benson AA, George I, Russo MJ, Oz MC, Esrig BC.

Ann Thorac Surg. 2007 Feb;83(2):483-9.

PMID:

17257973

[PubMed – indexed for MEDLINE]

Related citations

Select item 1712612922.

Clinical indication for use and outcomes after inhaled nitric oxide therapy.

George I, Xydas S, Topkara VK, Ferdinando C, Barnwell EC, Gableman L, Sladen RN, Naka Y, Oz MC.

Ann Thorac Surg. 2006 Dec;82(6):2161-9.

PMID:

17126129

[PubMed – indexed for MEDLINE]

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Select item 1708176423.

Effect of passive cardiac containment on ventricular synchrony and cardiac function in awake dogs.

George I, Cheng Y, Yi GH, He KL, Li X, Oz MC, Holmes J, Wang J.

Eur J Cardiothorac Surg. 2007 Jan;31(1):55-64. Epub 2006 Nov 1.

PMID:

17081764

[PubMed – indexed for MEDLINE]

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Select item 1706858824.

Ray optics model for triangular hollow silicon waveguides.

Isaac G, Khalil D.

Appl Opt. 2006 Oct 10;45(29):7567-78.

PMID:

17068588

[PubMed]

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Select item 1705994525.

Adult-age donors offer acceptable long-term survival to pediatric heart transplant recipients: an analysis of the United Network of Organ Sharing database.

Russo MJ, Davies RR, Sorabella RA, Martens TP, George I, Cheema FH, Mital S, Mosca RS, Chen JM.

J Thorac Cardiovasc Surg. 2006 Nov;132(5):1208-12.

PMID:

17059945

[PubMed – indexed for MEDLINE]

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Select item 1696247026.

Effect of clenbuterol on cardiac and skeletal muscle function during left ventricular assist device support.

George I, Xydas S, Mancini DM, Lamanca J, DiTullio M, Marboe CC, Shane E, Schulman AR, Colley PM, Petrilli CM, Naka Y, Oz MC, Maybaum S.

J Heart Lung Transplant. 2006 Sep;25(9):1084-90.

PMID:

16962470

[PubMed – indexed for MEDLINE]

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Select item 2097582827.

Delusional Misidentification Syndromes: Separate Disorders or Unusual Presentations of Existing DSM-IV Categories?

Atta K, Forlenza N, Gujski M, Hashmi S, Isaac G.

Psychiatry (Edgmont). 2006 Sep;3(9):56-61.

PMID:

20975828

[PubMed]

Free PMC Article

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Select item 1680912728.

Direct left ventricle-to-coronary artery stent restores perfusion to chronic ischemic swine myocardium.

Yi GH, George I, He KL, Lee MJ, Cahalan P, Zhang G, Gu A, Klotz S, Burkhoff D, Wang J.

Heart Surg Forum. 2006;9(5):E744-9.

PMID:

16809127

[PubMed – indexed for MEDLINE]

Related citations

Select item 1667861929.

Ventricular assist device use for the treatment of acute viral myocarditis.

Topkara VK, Dang NC, Barili F, Martens TP, George I, Cheema FH, Bardakci H, Ozcan AV, Naka Y.

J Thorac Cardiovasc Surg. 2006 May;131(5):1190-1. No abstract available.

PMID:

16678619

[PubMed – indexed for MEDLINE]

Related citations

Select item 1661713930.

A polymerized bovine hemoglobin oxygen carrier preserves regional myocardial function and reduces infarct size after acute myocardial ischemia.

George I, Yi GH, Schulman AR, Morrow BT, Cheng Y, Gu A, Zhang G, Oz MC, Burkhoff D, Wang J.

Am J Physiol Heart Circ Physiol. 2006 Sep;291(3):H1126-37. Epub 2006 Apr 14.

PMID:

16617139

[PubMed – indexed for MEDLINE]

Free Article

Related citations

Select item 1656396931.

Predictors and outcomes of continuous veno-venous hemodialysis use after implantation of a left ventricular assist device.

Topkara VK, Dang NC, Barili F, Cheema FH, Martens TP, George I, Bardakci H, Oz MC, Naka Y.

J Heart Lung Transplant. 2006 Apr;25(4):404-8. Epub 2006 Feb 28.

PMID:

16563969

[PubMed – indexed for MEDLINE]

Related citations

Select item 1547509032.

John Benjamin Murphy.

George I, Hardy MA, Widmann WD.

Curr Surg. 2004 Sep-Oct;61(5):439-41. No abstract available.

PMID:

15475090

[PubMed – indexed for MEDLINE]

Related citations

Select item 1239618033.

Multiple-scattering lidar retrieval method: tests on Monte Carlo simulations and comparisons with in situ measurements.

Bissonnette LR, Roy G, Poutier L, Cober SG, Isaac GA.

Appl Opt. 2002 Oct 20;41(30):6307-24.

PMID:

12396180

[PubMed]

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Read Full Post »

After Cardiac Transplantation: Sirolimus acts as immunosuppressant Attenuates Allograft Vasculopathy

Writer and Curator: Larry H Bernstein, MD, FCAP

and

Curator: Aviva Lev-Ari, PhD, RN 

 

Sirolimus as primary immunosuppression attenuates allograft vasculopathy with improved late survival and decreased cardiac events after cardiac transplantation

Topilsky Y, Hasin T, Raichlin E, Boilson BA, Schirger JA, et al.
Circulation. 2012 Feb 7;125(5):708-20.    http://dx.doi.org/10.1161/CIRCULATIONAHA.111.040360. Epub 2011 Dec 29

BACKGROUND: We retrospectively analyzed the potential of sirolimus as a primary immunosuppressant

  1. in the long-term attenuation of cardiac allograft vasculopathy progression and
  2. the effects on cardiac-related morbidity and mortality.
METHODS:  Forty-five cardiac transplant recipients were converted to sirolimus 1.2 years (0.2, 4.0) after transplantation with complete calcineurin inhibitor withdrawal. Fifty-eight control subjects 2.0 years (0.2, 6.5 years) from transplantation were maintained on calcineurin inhibitors.
  • Age,
  • sex,
  • ejection fraction, and
  • time from transplantation to baseline intravascular ultrasound study were not different (P>0.2 for all) between the groups;
  • neither were secondary immunosuppressants and
  • use of steroids.

Three-dimensional intravascular ultrasound studies were performed at baseline and 3.1 years (1.3, 4.6 years) later.

RESULTS:  Plaque index progression (plaque volume/vessel volume) was attenuated in the sirolimus group (0.7±10.5% versus 9.3±10.8%; P=0.0003) owing to
  1. reduced plaque volume in patients converted to sirolimus early (<2 years) after transplantation (P=0.05) and
  2. improved positive vascular remodeling (P=0.01) in patients analyzed late (>2 years) after transplantation.
Outcome analysis in 160 consecutive patients maintained on 1 therapy was performed regardless of performance of intravascular ultrasound examinations.
  1. Five-year survival was improved with sirolimus (97.4±1.8% versus 81.8±4.9%; P=0.006),
  2. There was freedom from cardiac-related events (93.6±3.2% versus 76.9±5.5%; P=0.002).
CONCLUSIONS:  Substituting calcineurin inhibitor with sirolimus as primary immunosuppressant
  1. attenuates long-term cardiac allograft vasculopathy progression and
  2. may improve long-term allograft survival owing to favorable coronary remodeling.
Because of the lack of randomization and retrospective nature of our analysis, the differences in outcome should be interpreted cautiously, and prospective clinical trials are required.

Related articles

Other related articles published on this Open Access Online Scientific Journal include the following:

Svelte Drug-Eluting Stent Utilizing New Class of Bioabsorbable Drug Coating Attains 0% Clinically-Driven Events Through 12-Months in First-In-Man Study
Aviva Lev-Ari, PhD, RN
Biomaterials Technology: Models of Tissue Engineering for Reperfusion and Implantable Devices for Revascularization
Larry h Benstein, MD, FCAP
Vascular Repair: Stents and Biologically Active Implants
Larry h Benstein, MD, FCAP
New Drug-Eluting Stent Works Well in STEMI
Aviva Lev-Ari, PhD, RN
Coronary Artery Disease – Medical Devices Solutions: From First-In-Man Stent Implantation, via Medical Ethical Dilemmas to Drug Eluting Stents
Aviva Lev-Ari, PhD, RN
Table 1 Illustration

Table 1 Illustration (Photo credit: Libertas Academica)

Photograph of the Taxus drug-eluting stent, fr...

Photograph of the Taxus drug-eluting stent, from the web site of the U.S. Food and Drug Administration. (Photo credit: Wikipedia)

Read Full Post »

CVD Core

CVD Core

Reporter: Aviva Lev-Ari, PhD, RN

Article ID #62: CVD Core. Published on 6/26/2013

WordCloud Image Produced by Adam Tubman

When this post will be ready it needs be place

under below link 

http://pharmaceuticalintelligence.com/biomed-e-books/cardiovascular-diseases-causes-risks-and-management/introduction-to-the-three-volume-series-core-research-on-cardiovascular-diseases/

See in red my comments, below

Cardiovascular Diseases: Causes, Risks and Management

Justin D. Pearlman MD PhD MA FACC, Editor

Cardiovascular diseases comprise problems of the heart and blood vessels, including rhythm, blood supply, blood pressure, birth defects, or damage from cholesterol, tobacco, street drugs, radiation, viruses, bacteria, or fungi.

Thus the category includes heart failure (inadequate pump function), heart or vessel infection (endocarditis, vasculitis), birth defects (congenital heart disease)

Cardiovascular Diseases: Causes, Risks and Management

Justin D. Pearlman MD ME PhD MA FACC, Editor

 

Leaders in Pharmaceutical Business Intelligence

Aviva Lev-Ari, PhD, RN

Director and Founder

Editor-in-Chief

Other e-Books  in the  BioMedicine Series

Perspectives on Nitric Oxide in Disease Mechanisms

Human Immune System in Health and in Disease

Metabolic Genomics & Pharmaceutics

Infectious Disease & New Antibiotic Targets

Cancer Biology and Genomics for Disease Diagnosis

Nanotechnology in Drug Delivery

Genomics Orientations for Personalized Medicine 

This book is a comprehensive review of Innovations in Cardiovascular Medicine, including the latest discoveries in

  • Cardiac Medical Imaging,
  • Regenerative Medicine,
  • Pharmacotherapy,
  • Medical Devices for Cardiac Repair,
  • Genomics, and opportunities for Targeted Therapy.

It is written by experts in their respective subspecialties. The e-Book’s articles have been published on the Open Access Online Scientific Journal, since April 2012.  All new articles on this subject will continue to be incorporated with periodical updates.

http://www.pharmaceuticalIntelligence.com

The Journal is a scientific, medical and business, multi-expert authoring environment for information syndication in domains of Life Sciences, Medicine, Pharmaceutical and Healthcare Industries, BioMedicine, Medical Technologies & Devices. Scientific critical interpretations and original articles are written by PhDs, MDs, MD/PhDs, PharmDs, Technical MBAs as Experts, Authors, Writers (EAWs) on an Equity Sharing basis.

The Editor, Justin D. Pearlman MD ME PhD MA FACC, has many different perspectives developed during the years, including:

  • Chief of Cardiology,
  • non-invasive imaging,
  • molecular biology,
  • mathematics,
  • imaging research

contributed a number of firsts:

  • non-endemic Chagas diagnosis,
  • intensity projection angiography,
  • magnetization tagging,
  • myocardial injury mapping by magnetic resonance contrast retention,
  • myocardial viability by MRI,
  • atheroma lipid liquid crystal characterization,
  • outpatient inotropic infusion therapy,
  • angiogenesis imaging,
  • multimodal in vivo stem cell imaging,
  • real-time velocity beam MRI,
  • in vivo microscopic MRI,
  • dobutamine stress echocardiography for low gradient valve disease,
  • alternative stress tests,
  • diagnostic electrocardiography in magnetic environments,
  • statistical methods to solve error propagation of large array genomics,
  • discovery of monocyte role in native coronary collateral development,
  • image tracked stem cell treatment of  heart attacks,
  • singularity editing in differential topology.

 

Preface to the Three Volume Series

Cardiovascular disease has been a leading cause of death and disability and so it has also been a major focus for intense research, development, and progress. Knowledge of the causes, risks, and best practices for management continually change. That is why a dynamic electronic living textbook presents an exciting opportunity to help you keep current with the ephemeral leading edge. This book is an outgrowth of the commitment of Leaders in Pharmaceutical Business Intelligence to present the most exciting timely and pertinent advances of our day, in a continual medium to stay fresh and up to date. We hope diverse multispecialty perspectives will help you in your quest to understand, adapt and advance the leading edge of cardiovascular disease causes, risks and best practices management.

On the Diagnosis of Cardiovascular Disease: causes, manifestations, consequences and priorities

Doctors aim to spend their time on prevention, diagnosis, and disease management. More and more the time is diverted to expanding demands for documentation and bureaucratic navigation. This article focuses on the art of diagnosis, with examples based on cardiovascular diseases. Diagnosis cannot be achieved without a knowledge of the causes (etiology) of ailments, a necessary but not sufficient component of diagnosis. The causes broadly relate to nature and nurture, how our biological system develops and functions (nature), and its interactions with the outside world driven in part by behavior, diet, exposures, and activities (nurture). The nature of our individuality has been traced to the human genome, a map of code for protein products that build our structures and mediate our body part functions. Numerous blood tests have been devised to check the expression and activity level of such genomic products to identify disease and characterize its stage. The role of diet, behavior, exposures, activities or lack thereof is well established as a complicit factor in disease development and progression.

The art of diagnosis is designed to find out what is wrong. Literally, it is a flow of knowing, based on knowledge of causes of ailments, probabilities (prevalence), consequences, manifestations, priorities (which would be most urgent) and tests: CPCMPT. Review of those elements generates a list of concerns, often expressed as a “differential diagnosis” which is  a prioritized list of plausible explanations for the observations, patient’s report of symptoms and findings from patient examination. The second stage of diagnosis, called the “work-up,” selects and applies tests to stratify the list of possibilities further as well as to characterize the manifestations and stage of disease. Technically, analysis of biological samples, imaging studies and intervention trials each represent tests; however, they are often viewed as distinct tools with just the former labeled as tests (biological samples include blood tests, urine tests, sputum or saliva samples, and biopsies). The primary goal of the work-up is to establish one or more specific diagnoses as the cause of ailment. The secondary goal of the work-up is to characterize the manifestations and stage of disease to define expectations and clarify options for the disease management. The third goal is to develop a management a plan to slow or stop the ailment, decrease risks of complications, slow or stop progression of disease manifestations or otherwise minimize functional impairment.

The manifestations of disease are categorized as signs and symptoms.

  • Signs are observable evidence of consequences,
  • Symptoms are subjective complaints.

A major component of diagnostic skill is the ability to identify and characterize correctly signs and symptoms of all relevant disease conditions. A second major component of diagnostic skill is the ability to select appropriate tests and interpret their significance in context, in keeping with the patient’s presentation.

When someone sees a doctor about chest pain, coronary artery disease is a prominent consideration. The most common causes of chest pain are mechanical (muscle and bone, e.g., muscle spasms, muscle and bone inflammation), but those conditions are not generally life-threatening. The consequences of blocked arteries – arrhythmia, permanent weakness of the heart, blood clots, pulmonary emboli, stroke, cardiogenic shock, death – raise the stakes and push coronary disease high in priority even when the probabilities are low. The prioritization of the differential diagnosis list has multiple considerations: urgency (how quickly it can worsen), severity of consequences, and the probabilities of a macrovascualar event (prevalence, risk factors). A ten percent risk of coronary disease typically takes precedence over a 70% likelihood of muscle spasm in terms of diagnostic testing.

The road map for the construction of our individuality as humans has been fully mapped: the human genome. Genetic variation means we are not fully determined by the mix of genes inherited from our parents. In addition to the genetic material on our 48 chromosomes, and the genetic material in mitochondria inherited from the mother, there are spontaneous changes in the genetic code, and there are modifications that affect gene expression (which codes produce gene products, quantities, rates, and post-production modifications).

The causes of cardiovascular disease are defined by Murphy’s law: what can go wrong will. However, on the nature side, most malfunctions are too severe to reach the light of day, so there is a limited list of disease mechanisms associated with sufficient viability to reach medical attention. Those mechanisms can be summarized by a mnemonic: diseases can develop new metals in-flame, a-fact externs generated (disease mechanisms: congenital, developmental, neoplastic, metabolic, inflammatory, infectious, extrinsic (e.g. stab wound), and degenerative). A taxonomy of cardiovascular diseases can be constructed in various ways: (1) itemize the major cardiovascular functions and subclassify the dysfunctions, (2) itemize by principle anatomic involvement and subclassify by pathology, (3) classify by mechanism of disease, etiology. Compendiums of cardiovascular disease may be found in: (1) French’s Differential Diagnosis, (2) Robbins and Angel Pathology, (3) Guyton’s Textbook of Physiology, as well as cardiovascular disease textbooks such as Hurst, Braunwald, Mayo Clinic, Cleveland Clinic…

Diagnosis takes many forms. The paranoid inclusive approach, manifested as “medical student syndrome”, considers any semblance of a sign or symptom vaguely similar to a disease manifestation as a frightening prospect worthy of detailed pursuit. The minimalist pragmatic approach commonly attributed to general practitioners focuses on reassurance, and pursuit of persisting complaints that match a common ailment. That approach has been summarized by the advice: when you hear hoof beats think of horses, not zebras. Specialists, on the other hand, are taught to consider all possibilities, with due consideration to urgency and treatability, so that zebras are not punished.

The healthcare system promotes the idea of generalists serving as the front line, identifying who can be managed simply, with specialists serving as finishers for more complex cases or cases requiring special skills. A flaw in that model is the need for detailed knowledge of zebras and subtle findings that may represent an urgent issue at the front line for triage. If the generalist does not know that mild symptoms from mitral valve disease or aortic valve disease may require urgent detailed assessment, patients may be referred to a specialist too late to prevent consequences that requires an earlier intervention.

Parsimony in diagnosis refers to identifying the fewest number of diagnoses that explain all the findings. The concept has been attributed to Osler, and it builds on a guiding procedure voiced in the middle ages by Occum, known as Occum’s razor: when deciding between two explanations, favor the one that requires the fewest assumptions. Parsimony is a useful guide for diagnosis of a previously healthy patient who develops a number of findings that are temporally coherent. After age 65 (official geriatrics age), physicians are taught to abandon parsimony and expect more diagnoses than findings.

A study of difficult diagnoses lead to the concept of a pivotal finding as one that has a narrow differential list. The diagnostic process is prone to errors, including cognitive biases, which may benefit from computer assistance. Intuition and analytics can be applied to reduce cognitive bias. The author developed a just-in-time social networking system within a software package called Missive(c) that enables rapid access to such tools, combining efficiency in documentation with improved quality of analysis and reports (faster and better).

Among older Americans, more are hospitalized for heart failure than for any other medical condition (diastolic failure=stiff heart, systolic failure= inadequate pumping).

Genomics – the study of the genetic basis for disease – is rapidly expanding knowledge about etiology (cause of disease), and it helps identify opportunities for accurate diagnosis and treatment. The American Heart Association journal CIRCULATION has published 348 relevant articles related to cardiovascular genomics from 2010-2013.  For example, just on the subtopic of atherosclerosis (hardening of arteries), genomics offers major progress. The genetic factors that affect arterial stiffness are strongly related to a very common underlying health concern, hypertension (high blood pressure). The counterpart to genetics is environment (nature versus nurture), but genetics carries the trump cards because it determines the sensitivities to environment.

anatomy

physiology

laboratory tests

interventional trials

Boundaries of the Domain: Cardiovascular Diseases: Causes, Risks and Management – Volume 1,2,3

 

The scope of cardiovascular disease scholarly contributions will grow to include: anatomy, surgery, molecular biology, ethics, imaging (echo, nuclear, PET, MRI, OCT, CT), congenital, stress tests, ECG, electrophysiology/rhythm/channelopathies, pacing, resynchronizing, AICD, cardiomyopathies, syncope, valve disease, aorta, renal artery, thrombosis, venous diseases, vasculitis, endothelium, metabolic syndrome, dyslipidemia, risk factors, biomarkers, hypertension, embolism, pulmonary hypertension, cardiac tumors, women’s health, CAD, Angina,  Stem cells, complications of MI, thrombolysis, rehabilitation, reflexes, hormones, diastology, pharmaceuticals, myocarditis, hypertrophy, failure, shock, hemodynamics, interventions, contrast nephropathy, and contrast systemic fibrosis, as well as other relevant topics you may suggest.

An overview of the Core Research on Cardiovascular Diseases is based on the following NINE articles: 

Have only the article title as a live link of the following 9 [originally were on CVD Zero, title and links, now only links]

  1. http://pharmaceuticalintelligence.com/2013/05/15/diagnosis-of-cardiovascular-disease-treatment-and-prevention-current-predicted-cost-of-care-and-the-promise-of-individualized-medicine-using-clinical-decision-support-systems-2/ 
  2. http://pharmaceuticalintelligence.com/2013/05/04/cardiovascular-diseases-decision-support-systems-for-disease-management-decision-making/ 
  3. http://pharmaceuticalintelligence.com/2013/03/07/genomics-genetics-of-cardiovascular-disease-diagnoses-a-literature-survey-of-ahas-circulation-cardiovascular-genetics-32010-32013/
  4. http://pharmaceuticalintelligence.com/2013/05/17/synthetic-biology-on-advanced-genome-interpretation-for-gene-variants-and-pathways-what-is-the-genetic-base-of-atherosclerosis-and-loss-of-arterial-elasticity-with-aging/ 
  5. http://pharmaceuticalintelligence.com/2013/05/11/arterial-elasticity-in-quest-for-a-drug-stabilizer-isolated-systolic-hypertension-caused-by-arterial-stiffening-ineffectively-treated-by-vasodilatation-antihypertensives/ 
  6. http://pharmaceuticalintelligence.com/2013/05/24/imaging-biomarker-for-arterial-stiffness-pathways-in-pharmacotherapy-for-hypertension-and-hypercholesterolemia-management/ 
  7. http://pharmaceuticalintelligence.com/2013/04/28/genetics-of-conduction-disease-atrioventricular-av-conduction-disease-block-gene-mutations-transcription-excitability-and-energy-homeostasis/
  8. http://pharmaceuticalintelligence.com/2013/05/07/on-devices-and-on-algorithms-arrhythmia-after-cardiac-surgery-prediction-and-ecg-prediction-of-paroxysmal-atrial-fibrillation-onset/ 
  9. http://pharmaceuticalintelligence.com/2013/05/22/acute-and-chronic-myocardial-infarction-quantification-of-myocardial-viability-fdg-petmri-vs-mri-or-pet-alone

The main points are

[bring here ONLY the INTRODUCTION and the Summary of each, THEN The EDITOR will provide perspective on the Research and the current STate of Cardiology in the US in 2013/2014]

A. Now you provide ONLY links to 

Volume #

Contributors to Volume #

eTOCS in Volume #

REPEAT A. for each Volume

Volume One: Causes of Cardiovascular Diseases

Table of Contents

Hardening of the arteries is described as atherosclerosis, or porridge-like wall changes with scarring, which leads to heart attacks, high blood pressure, stroke, and organ injury mediated by ischemia (insufficient nutrient blood supply). The causes are both nature (genetic) and nurture (behavior, diet). Specifics of the causes guide diagnosis and management.

Chapter 1.2: Genomics

The completion of the human genome map was a major accomplishment, as gene products make signals, receptors and building blocks that establish health and disease. However, it is just a stepping stone, not explaining why, where, or how the gene products are regulated and  interact.

Chapter 1.3: Cardiovascular Imaging

Imaging applies a principle of physics (light transmission, sound transmission, xray transmission, magnetic resonance, radioactivity) to provide a map of interior structures and/or activities. Image processing (computing) derives further information than simple display of an observed tissue-sensitive parameter. In the case of computed tomography (CT), magnetic resonance (MRI), positron-emission tomography (PET), and single-photon emission tomography (SPECT),  computer reformatting of image data is essential.

Volume Two: Risk Assessment of Cardiovascular Diseases

Contributors

Table of Contents

Cardiovascular disease is the leading cause of death and disability, affecting more than four times as many people as all forms of cancer combined.

Chapter  2.2: Testing for cardiovascular risk

The volunteer population of Framingham Massachusetts provided decades of data clarifying determinants of risk for cardiovascular diseases. That data helped establish the usefulness of cholesterol screening, and lead to the search for additional tests to identify risk and guide management.

Chapter 2.3: Biomarkers

Biomarkers are chemistry levels (concentrations in the blood) that identify injury or risk for injury.

Volume Three: Management of Cardiovascular Diseases

Contributors

Chapter  3.1: Therapeutic Genomics

As the mysteries of the human genome products are unraveled, we get closer to identifying key components. One of them is Thymosin beta 4 (Tβ4) , which plays an essential role in cardiac and blood vessel development and regeneration. It may lead to breakthroughs in angiogenesis and vasculogenesis, or new vessel development, mimicking the behavior of the lucky few who develop new vessels, or collaterals, as a natural bypass system, without requiring a surgeon to provide a blood supply to avoid or limit heart attacks.

Chapter 3.2: Image guidance of Therapy

The US government is helping to sponsor new imaging methods, while they also inhibit it by adding new taxes.

Chapter 3.3: Drug therapy

Emerging new therapies are presented, along with the biological basis.

Chapter 3.4: Cardiovascular Interventions

Technological advances enable minimally invasive solutions to problems previously addressed by surgery or autopsy.

Introduction 

 

Contributors above, need a LINK to the appropriate contributors in each volume. Table of Contents of each volume above need a LINK to the eTOCS of each volume.  

Please UPDATE all links ABOVE to the appropriate locations in the respective volumes, after implementing the carry over, remove links below EXCEPT CVD1,2,3 and remove this comment of mine in RED, here

REFERENCES for CVD CORE

A.  Diagnosis of Cardiovascular Disease and Cost of Care

Bernstein, HL and A. Lev-Ari 5/15/2013 Diagnosis of Cardiovascular Disease, Treatment and Prevention: Current & Predicted Cost of Care and the Promise of Individualized Medicine Using Clinical Decision Support Systems

http://pharmaceuticalintelligence.com/2013/05/15/diagnosis-of-cardiovascular-disease-treatment-and-prevention-current-predicted-cost-of-care-and-the-promise-of-individualized-medicine-using-clinical-decision-support-systems-2/ 

B. Cardiovascular Diseases: Disease Management Decision Making – use of CDSS

Pearlman, JD and A. Lev-Ari 5/4/2013 Cardiovascular Diseases: Decision Support Systems for Disease Management Decision Making

http://pharmaceuticalintelligence.com/2013/05/04/cardiovascular-diseases-decision-support-systems-for-disease-management-decision-making/ 

C. Genomics & Genetics of Cardiovascular Disease Diagnoses

Lev-Ari, A. and L H Bernstein 3/7/2013 Genomics & Genetics of Cardiovascular Disease Diagnoses: A Literature Survey of AHA’s Circulation Cardiovascular Genetics, 3/2010 – 3/2013

http://pharmaceuticalintelligence.com/2013/03/07/genomics-genetics-of-cardiovascular-disease-diagnoses-a-literature-survey-of-ahas-circulation-cardiovascular-genetics-32010-32013/

D.  Genetic Base of Atherosclerosis and Loss of Arterial Elasticity with Aging

Lev-Ari, A. 5/17/2013 Synthetic Biology: On Advanced Genome Interpretation for Gene Variants and Pathways: What is the Genetic Base of Atherosclerosis and Loss of Arterial Elasticity with Aging

http://pharmaceuticalintelligence.com/2013/05/17/synthetic-biology-on-advanced-genome-interpretation-for-gene-variants-and-pathways-what-is-the-genetic-base-of-atherosclerosis-and-loss-of-arterial-elasticity-with-aging/ 

E.  Hypertension and Vascular Compliance: 2013 Thought Frontier – An Arterial Elasticity Focus

Pearlman, JD and A. Lev-Ari 5/11/2013 Hypertension and Vascular Compliance: 2013 Thought Frontier – An Arterial Elasticity Focus

http://pharmaceuticalintelligence.com/2013/05/11/arterial-elasticity-in-quest-for-a-drug-stabilizer-isolated-systolic-hypertension-caused-by-arterial-stiffening-ineffectively-treated-by-vasodilatation-antihypertensives/ 

F.  Arterial Stiffness: Pharmacotherapy for Hypertension and Hypercholesterolemia Management

Pearlman, JD and A. Lev-Ari 5/24/2013 Imaging Biomarker for Arterial Stiffness: Pathways in Pharmacotherapy for Hypertension and Hypercholesterolemia Management

http://pharmaceuticalintelligence.com/2013/05/24/imaging-biomarker-for-arterial-stiffness-pathways-in-pharmacotherapy-for-hypertension-and-hypercholesterolemia-management/ 

G. Genetics of Conduction Disease

Lev-Ari, A. 4/28/2013 Genetics of Conduction Disease: Atrioventricular (AV) Conduction Disease (block): Gene Mutations – Transcription, Excitability, and Energy Homeostasis

http://pharmaceuticalintelligence.com/2013/04/28/genetics-of-conduction-disease-atrioventricular-av-conduction-disease-block-gene-mutations-transcription-excitability-and-energy-homeostasis/

H.  Arrhythmia after Cardiac Surgery Prediction and ECG Prediction of Paroxysmal Atrial Fibrillation Onset

Pearlman, JD and A. Lev-Ari 5/7/2013 On Devices and On Algorithms: Arrhythmia after Cardiac Surgery Prediction and ECG Prediction of Paroxysmal Atrial Fibrillation Onset

http://pharmaceuticalintelligence.com/2013/05/07/on-devices-and-on-algorithms-arrhythmia-after-cardiac-surgery-prediction-and-ecg-prediction-of-paroxysmal-atrial-fibrillation-onset/ 

I.  Myocardial Infarction: Quantification of Myocardial Perfusion Viability

Pearlman, JD and A. Lev-Ari 5/22/2013 Acute and Chronic Myocardial Infarction: Quantification of Myocardial Perfusion Viability – FDG-PET/MRI vs. MRI or PET alone

http://pharmaceuticalintelligence.com/2013/05/22/acute-and-chronic-myocardial-infarction-quantification-of-myocardial-viability-fdg-petmri-vs-mri-or-pet-alone/

Read Full Post »

Survivals Comparison of Coronary Artery Bypass Graft (CABG) and Percutaneous Coronary Intervention (PCI) / Coronary Angioplasty

Larry H. Bernstein, MD, Writer
And
Aviva Lev-Ari, PhD, RN, Curator

 

This is a summary of several studies, mostly reviewing one decade of work at Texas Heart Institute, Houston, TX.

Seminal treatments of the evolving methods, leading to a recent review of options for

  • Survival comparison of CABD vs PCI
  • Mitral valve repair or mitral valve replacement for the treatment of ischemic mitral regurgitation. This might further consolidate a series of articles in these chapters.

SOURCES

1. Bypass, Angioplasty Similar in Survival 10 Years After Heart Procedures, Survival Rates Differ Little. K Doheny. WebMD Health News   Oct. 15, 2007
3. Will Stent Revascularization Replace Coronary Artery Bypass Grafting? JM Wilson Tex Heart Inst J. 2012; 39(6): 856–859
4. Coronary Artery Bypass Surgery versus Coronary Stenting. Risk-Adjusted Survival Rates in 5,619 Patients. RP Villlareal,V-V Lee, MA Elayda, JM Wilson.  Tex Heart Inst J. 2002; 29(1): 3–9.
5. Should all ischemic mitral regurgitation be repaired? When should we replace?  DJ LaPar, IL Kron. Curr Opin Cardiol. 2011 March; 26(2): 113–117
6. Hybrid Cath Lab Combines Nonsurgical, Surgical Treatments

Bypass, Angioplasty Similar in Survival 10 Years After Heart Procedures

The survival rates 10 years after coronary artery bypass surgery and angioplasty are similar, according to a new analysis of nearly 10,000 heart patients. Five years after the procedures, 90.7% of the bypass patients and 89.7% of the angioplasty patients were still alive, says  Mark A. Hlatky, MD, senior author of the analysis and a professor of health research and policy and professor of medicine at Stanford University School of Medicine in Palo Alto.

Hlatky and colleagues stress that their analysis only applies to a select group of heart patients: those for whom either procedure would be considered a reasonable choice. For patients who are eligible for either heart intervention, “either is feasible,” Hlatky tells WebMD. The report is released early online and will be published in the Nov. 20 issue of the Annals of Internal Medicine.

CABG vs. Angioplasty

The researchers evaluated the results of 23 clinical trials in which 5,019 patients (average age 61 years; 73% men) were randomly assigned to get angioplasty with or without stents (PCI), and 4,944 were assigned to get coronary artery bypass graft surgery (CABG) In angioplasty, interventional cardiologists push a balloon-like device into the coronary arteries and inflate the balloon to widen the vessel. An expandable wire mesh tube called a stent may be inserted to keep the vessel open. Some stents are coated with drugs meant to help prevent the artery from clogging up. In 2005, about 645,000 angioplasty procedures were done in the U.S. In bypass surgery, cardiac surgeons harvest a segment of a healthy blood vessel from another part of the body and use it to bypass the clogged artery or arteries, rerouting the blood to improve blood flow to the heart. About 261,000 bypass procedures were done in the U.S. in 2005.

Findings

Besides similar survival rates overall, the researchers found no significant survival differences between the two procedures for patients with diabetes, although earlier research had seemed to favor bypass surgery. Similar numbers of patients suffered heart attacks within five years of the procedures. While 11.9 of those who got angioplasty had a heart attack within five years, 10.9% of those who got bypass did. Repeat procedures were more common in angioplasty patients. While 46.1% of angioplasty patients who didn’t get a stent needed repeat procedures, 40.1% of those who got a stent did. But just 9.8% of surgery patients needed another procedure.  The study didn’t include information on drug-coated stents.

Second Opinions

The new analysis is “very complete,” says Kim A. Eagle, MD, director of the Cardiovascular Center and Albion Walter Hewlett Professor of Internal Medicine at the University of Michigan, Ann Arbor. The study shows, he says, that if either procedure is considered appropriate for an individual patient, the decision can rest on patient attitudes and preferences. Patients preferences might be based on lower need to repeat in favor of surgery, or on avoidance of surgery in favor of angioplasty. But it is important to note, acoording to Curtis Hunter at Santa-Monica-UCLA, that the studies cover the least sick with heart disease, so the two procedures are shown to be equal in a very small subset of the patients.

Coronary Artery Bypass Surgery versus Coronary Stenting – Risk-Adjusted Survival Rates in 5,619 Patients  THIJ. 2002

We used the Texas Heart Institute Cardiovascular Research Database to retrospectively identify patients who had undergone their 1st revascularization procedure with coronary artery bypass surgery (CABG; n=2,826) or coronary stenting (n=2,793) between January 1995 and December 1999. Patients were classified into 8 anatomic groups according to the number of diseased vessels and presence or absence of proximal left anterior descending coronary artery disease. Mortality rates were adjusted with proportional hazards methods to correct for baseline differences in severity of disease and comorbidity.
We found that in-hospital mortality was significantly greater in patients undergoing CABG than in those undergoing stenting (3.6% vs 0.75%; adjusted OR 8.4; P <0.0001). At a mean 2.5-year follow-up, risk-adjusted survival was equivalent (CABG 91%, stenting 95%; adjusted OR 1.26; P = 0.06). When subgroups matched for severity of disease were compared, no differences in risk-adjusted survival were seen. A survival advantage of stenting was noted in 3 categories of patients: those >65 years of age (OR 1.33, P = 0.049), those with non-insulin-requiring diabetes (OR 2.06, P = 0.002), and those with any noncoronary vascular disease (OR 1.59, P = 0.009).
In this nonrandomized observational study, CABG had a higher periprocedural mortality rate than did percutaneous stenting. At 2.5 years, however, the survival advantage of stenting was no longer evident. These data suggest that there is no intermediate-term survival advantage of CABG over stenting in patients who have multivessel disease with lesions that can be treated percutaneously. (Tex Heart Inst J 2002;29:3–9)

Fig. 1 Adjusted and unadjusted survival rates in all patients treated with CABG or PCI-stenting
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC101260/table/t3-2/?report=previmg

survival rates  of CABG or PCI-stenting

TABLE III. Multivariate Correlates of Intermediate-Term (2.5-Year) Mortality
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC101260/table/t3-2/?report=previmg

Fig. 2 Adjusted odds ratios comparing the results of CABG and PCI-stenting in the 8 anatomic subgroups.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC101260/bin/2FF2.jpg

Adjusted odds ratios comparing the results of CABG and PCI-stenting in the 8 anatomic subgroups

TABLE IV. Intermediate-Term (2.5-Year) Survival According to Treatment in Each of the 8 Anatomic Groups
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC101260/bin/2TT4.jpg

Intermediate-Term (2.5-Year) Survival According to Treatment in Each of the 8 Anatomic Groups

Fig. 3 Adjusted odds ratios comparing the results of CABG and PCI-stenting in the various prespecified subsets.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC101260/bin/2FF3.gif

Adjusted odds ratios comparing the results of CABG and PCI-stenting in the various prespecified subsets.

Will Drug-Eluting Stents Replace Coronary Artery Bypass Surgery?

Abstract

Introduction
The growth of the PCI industry and the consequent decline in the number of patients referred for CABG has produced much speculation about the future role of each type of intervention. Because the new drug-eluting stents allow PCI to be performed with lower rates of early restenosis than do bare-metal stents or percutaneous transluminal coronary angioplasty (PTCA) alone, 2–8 some have predicted that surgical revascularization will soon be obsolete.

CABG vs Pharmaco-Therapy

Randomized clinical trials performed during the 1970s and early 1980s clearly established the advantages of CABG over medical therapy in patients with triple-vessel CAD, left main coronary artery stenosis, double-vessel CAD with proximal left anterior descending (LAD) coronary artery stenosis, or left ventricular dysfunction. Problems arose subsequently because of the limitations built into the trial so that the results were biased in favor of medical therapy.  These were:
  • stringent exclusion criteria that eliminated a large percentage of potential participants
  • left main CAD and an ejection fraction of less than 0.40, eliminated patients for whom CABG would have been beneficial
  • the high rate of crossover from the medical to the surgical groups

The numerous technical and technological advances made since these trials were completed limit the degree to which their results resemble those of the CAD treatments used today. The maximal medical therapy used during the trials did not routinely include lipid-lowering agents, β-blockers, angiotensin-converting enzyme (ACE) inhibitors, clopidogrel, or some of the other drugs currently used for CAD. Nor did the CABG groups benefit from advances that were subsequently made in preoperative imaging, perfusion and myocardial protection, anesthesia, and perioperative and intensive care practices. CABG did not then include the use of left internal mammary artery (LIMA) grafts, much less other arterial conduits. Finally, PCIs, including balloon angioplasty and stenting, were not included in these trials.

CABG vs PTCA

Randomized trials comparing PTCA with CABG revealed dramatically higher re-intervention rates in the PTCA groups and better angina relief in the CABG groups, although there were no significant differences in death or myocardial infarction rates. The Duke database study. 9 showed better survival rates with PTCA than with CABG in patients with single-vessel CAD, whereas CABG produced better survival than did PTCA in patients with severe, triple-vessel CAD.
These results are not necessarily representative of the results obtainable today with PTCA and CABG, for several reasons.
1.  stents were not used in the PTCA patients in these trials
2.  operative mortality rates for the CABG groups were higher than the rates currently found in the Society of Thoracic Surgeons (STS) database
3.  the inclusion/exclusion criteria of these studies eliminated a high percentage of those patients who might have benefited more from CABG than from PTCA

CABG vs Stents

The introduction of coronary artery stenting resulted in better outcomes than those produced by balloon angioplasty or by other adjuncts, including rotational atherectomy, brachytherapy, and laser angioplasty.  Since then, stent designs and delivery techniques have advanced considerably. The use of coronary stents has greatly decreased the necessity of emergent CABG for technical failure of PCI and for dissection or rupture of coronary arteries during PCI. Another major advance in the application of PCI is the use of the antiplatelet agent clopidogrel in addition to aspirin after PCI, as well as the use of glycoprotein (GP) IIb/IIIa receptor inhibitors during the procedure. These adjuncts have significantly reduced the incidence of acute and subacute thrombosis after PTCA with stenting.
Randomized trials comparing PTCA plus stenting with PTCA alone have shown that stenting significantly reduces rates of restenosis and re-intervention, as well as the frequency of emergent CABG.  On the other hand, randomized trials of stenting versus surgery have produced less conclusive results regarding the mid-term survival and freedom from adverse events.  For example, the Stent or Surgery (SOS) trial reported a greater need for repeat revascularization in the stent group (21%) than in the CABG group (6%) and a survival advantage in the CABG group (hazard ratio, 2.91; 95% CI, 1.29–6.53; P = 0.01) during the 3-year follow-up period. Additionally, angina and the use of anti-angina medications were less common in the CABG group at 1-year follow-up.
The ARTS and ERACI trials also reported an increased need for revascularization in the stent groups but did not show a survival advantage in the CABG groups. This was due in part to a higher operative mortality rate in the CABG group than reported in the STS database. Like the PCI versus CABG trials mentioned previously, these randomized trials involved a select group of patients with relatively low expected mortality rates and relatively high expected technical success with PCI.
Observational data in retrospective analyses of large patient databases comparing CABG with PCI plus stenting does indicate that, because of the greater invasiveness of surgical revascularization, CABG produces greater operative mortality than does PCI. However, in patients with multivessel CAD, the risk-adjusted survival rates at 2.5 years of follow-up are no better for PCI than for CABG, and 3 recent risk-adjusted observational studies showed that the CABG patients had a significant survival advantage at 3- to 8-year follow-up.   The CABG patients had significantly more preoperative risk factors than did the PCI patients in each study, so that unadjusted, the CABG groups in each study included significantly more patients with triple-vessel disease and fewer patients with double-vessel disease than did the PCI groups. Again, we have a moving target with recent advances in both surgery and PCI technology.

Disadvantages of Stenting

The Achilles’ heel of PCI is restenosis and the need for repeat revascularization. Stents have decreased the rate of acute and subacute  periprocedural thrombosis. The newer, drug-eluting stents (DESs) have improved in-stent restenosis rates, especially in the carefully selected patient populations studied in the early DES trials. In the RAVEL trial, the early reports of zero in-stent restenosis compared favorably with the 27% in-stent restenosis rates in the bare-metal stent control group at 6-month follow-up. However, the RAVEL trial excluded patients with lesions longer than 18 mm, ostial targets, calcified or thrombosed targets, or target arteries less than 2.5 mm in diameter.
The media frenzy that followed the release of these findings created a public demand for these new “miracle” stents that apparently did not re-occlude. Stories of CAD patients refusing conventional PCI and CABG —instead, adding their names to the list of patients waiting for U.S. Food and Drug Administration (FDA) approval of DESs—appeared to change the practice patterns of cardiologists and cardiac surgeons overnight.  And then there were the calls for class-action lawsuits and recall of various DES models. After the FDA approved the Cordis Cypher™ DES (Cordis Corporation, a Johnson & Johnson company; Miami Lakes, Fla), a few reports of subacute thrombosis and hypersensitivity reactions prompted the FDA to release a public health notification on 29 October 2003.
The SIRIUS trial had slightly less strict exclusion criteria than did the RAVEL trial, admitting patients with target lesions 2.5 to 3.5 mm in diameter and 15 to 30 mm long, as well as patients with diabetes mellitus (who constituted 26% of the total group).  The SIRIUS trial also differed from the RAVEL trial in that the reported end-point was in-segment restenosis, rather than in-stent restenosis. The results showed a significant advantage of DESs over bare-metal stents for preventing in-segment restenosis (9.2% vs 32.3%) and target failures (10.5% vs 19.5%), but major adverse cardiac events were more frequent in the DES group than in the bare-metal stent group (3.7% vs 1.0%). Interestingly, the 6-month restenosis rates of the bare-metal stents in the RAVEL and SIRIUS control groups were much higher than the 19% 12-month restenosis rate associated with bare-metal stents in an earlier study comparing bare-metal stents with PTCA. In fact, the restenosis rates in the RAVEL and SIRIUS control groups more closely resembled the 40% restenosis rate reported for the PTCA control group in the earlier study.
The practical advantages of DESs over bare-metal stents are evident; nonetheless, we still do not have sufficient mid-term or long-term clinical data to argue that PTCA with DESs is preferable to CABG in “real-world” patients who require revascularization. Although DESs will likely provide better outcomes than bare-metal stents for many patients for whom stenting is indicated, a general extrapolation of existing data to justify the use of DESs in patients for whom CABG is currently indicated is unknown, perhaps undeterminable because the lesion and patient characteristics that lead to the failure of PCI are multifactorial, and the size of the population with lesions having unfavorable characteristics , such as,
  • longer
  • total occlusion
  • branch
  • small-diameter
  • calcified
  • multiple
  • left main
  • ostial, and
  • diffuse lesions
are being treated with PCI more often, as well as diabetics, multiple lesions, and patients with multiple comorbidities.

Advantages of CABG

Over the last 4 decades, surgical coronary artery revascularization techniques and technology have advanced significantly. As a result, despite an increasingly older and sicker patient population, CABG outcomes continue to improve. Observed operative mortality rates have decreased because advances in preoperative evaluation, including more precise coronary artery and myocardial imaging and diagnostic techniques, have allowed more appropriate patient selection and surgical planning. In addition, preoperative, intraoperative, and postoperative monitoring and therapeutic interventions have made CABG safer, even for critically ill and high-risk patients. Improvements in cardiopulmonary perfusion and careful myocardial protection, as well as the use of off-pump and on-pump beating- heart techniques in selected patients, have also decreased perioperative morbidity and mortality rates.

LIMA-to-LAD Long-Term Patency

The long-term benefits of CABG with regard to survival and quality of life are dependent on prolonged graft patency. The LIMA-to-LAD bypass, which is now performed in more than 90% of CABG procedures, shows excellent patency in 10- to 20-year angiographic follow-up studies, setting the gold standard with which other revascularization strategies should be compared. Tatoulis et al. reported that LIMA-to-LAD grafts had a 97.1% patency rate in patients who underwent angiography for cardiac symptoms. Those authors also found high patency rates at 5-year (98%), 10-year (95%), and 15-year (88%) follow-up. However, there are not yet long-term data on bare-metal stents or DESs, and by the time 10- or 20-year data are available, DESs probably will have been replaced by a newer, more advanced technology.
Because of the reported success of the LIMA-to-LAD bypass, other types of arterial conduits are also being used much more frequently. Conduit selection has become an area of great interest to cardiac surgeons, and conduit studies are expanding our understanding of the mechanisms of graft failure and ways to improve bypass graft patency. For example, studies have shown that patients who undergo CABG with both LIMA and right internal mammary artery (RIMA) conduits have better results than those who undergo CABG with one IMA and one or more saphenous vein grafts.

Techniques to Improve Conduit Patency

To maximize the odds of long-term graft patency, surgeons carefully harvest the graft as a pedicled or skeletonized conduit using “no touch” techniques. Using careful anastomotic technique to avoid excessive turbulence at the anastomosis site will prolong graft patency, and the quality of the conduit is crucial. Long-term graft patency depends not only on the conduit chosen but also on the target artery and the degree of stenosis proximal to the anastomosis. Maintaining flow patterns in the native artery, including residual flow (that is, competitive flow) and outflow, is important to avoid stasis in the graft, turbulence at the anastomosis, and vasospasm, especially in arterial conduits. Studies have shown an inverse relationship between the degree of proximal stenosis and graft patency. Targeting the LAD produces the highest patency rates. The characteristics of the target artery also determine graft patency, including –
1. the diameter of the target artery,
2. the presence or absence of diffuse disease within the artery,
3. whether or not the artery requires endarterectomy
Surgeons can avoid atheroembolic events by handling the aorta carefully or not at all. They can also improve safety by
1. using aggressive myocardial protection techniques;
2. avoiding the induction of inflammatory mediators; and
3. carefully controlling
  • blood pressure,
  • body temperature, and
  • electrolyte and glucose levels.
Although there have been major innovations that have enabled surgeons to perform cardiac surgery (including CABG) less invasively, minimally invasive surgical procedures are useful only if they are at least as efficacious as conventional surgery. New technology is being developed to enhance the evolving field of minimally invasive coronary bypass surgery.

Hybrid Coronary Revascularization

As PCI technology improves and techniques of LIMA-to-LAD grafting become less invasive, hybrid coronary revascularization is becoming a distinct possibility. For example, a minimally invasive, off-pump, direct LIMA-to-LAD anastomosis can be combined with DES placement in a focal mid-right-coronary-artery lesion in a patient with complex proximal LAD lesions. Hybrid coronary revascularization procedures are currently being performed, with promising early results. A few centers now have hybrid operating rooms with cardiac surgical and coronary angiographic capabilities that make it possible to perform simultaneous hybrid coronary revascularizations.

Although coronary artery bypass grafting (CABG) remains the treatment of choice for certain types of coronary artery disease (CAD), percutaneous coronary intervention (PCI)—particularly coronary angioplasty with stenting—has become the most popular nonmedical treatment approach to CAD. Some have speculated that, with the advent of drug-eluting stents (DESs), PCI will replace CABG entirely. However, the complete disappearance of CABG is both unlikely and unwarranted, for several reasons. Published randomized trials of CABG, PCI, and medical approaches to CAD compared only highly selected subgroups of patients because of strict exclusion criteria that often favored the PCI cohorts. Therefore, their results do not constitute sufficient evidence for the superiority of PCI over CABG in all CAD patients requiring revascularization. As PCI indications broaden to include more complex lesions and more high-risk patients, outcomes will not remain as favorable. In addition, although PCI is less invasive than surgery, CABG offers more complete revascularization and better freedom from repeat revascularization. Furthermore, no long-term patency data on DESs yet exist, whereas excellent 10- and 20-year patency rates have been reported for the left internal mammary artery-to-left anterior descending artery graft used in most CABG procedures. While PCI has been changing, CABG has not been stagnant; recently, advances in many aspects of the CABG procedure have improved short- and long-term outcomes in CABG patients. Both CABG and PCI technologies will continue to advance, not necessarily exclusive of one another, but no data yet exist to suggest that DESs will render CABG obsolete any time soon. 

Will Stent Revascularization Replace Coronary Artery Bypass Grafting?

When we discuss revascularization outcomes, we are talking about 3 major endpoints: death, myocardial infarction, and symptom control. With respect to death, we know that revascularization benefits patients who have severe multivessel disease and left ventricular dysfunction or other physiologic indicators of high risk. 2-vessel disease with proximal left anterior descending coronary artery (LAD) stenosis has been accepted as an indication for revascularization, even though the supporting data come from a small subgroup in a single trial. There has been no success in proving that endovascular treatment has a positive impact on stable CAD, but it is relevant because we leave the native arteries relatively intact. Attempts to improve graft performance beyond the relatively spectacular performance of the pedicled internal mammary artery (IMA) graft to the LAD have been disappointing.

Fig. 1 Graph of graft patency shows deterioration rates over 10 years and the comparative superiority of using the internal mammary artery (IMA) instead of the saphenous vein (SVG).http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3528239/bin/25FF1.gif

graft patency of IMA vs SVG

Percutaneous Transluminal Coronary Angioplasty

When angioplasty was introduced, the hope was for a method of revascularization that would rival coronary artery bypass grafting. However, the results were mixed. Angioplasty worked well in patients with no major risk factors, such as diabetes mellitus, but failed miserably in diabetic patients. In fact, the Bypass Angioplasty Revascularization Investigation (BARI)  taught us this: if revascularization is needed, regardless of physiologic markers of high risk, the use of percutaneous coronary intervention (PCI) is potentially harmful in comparison with an IMA bypass for the LAD.

Stents and Short-Term Outcomes

The use of stents drastically reduced the probability of emergent surgery after attempted; however, the probability of new lesion formation or restenosis after intervention did not decrease.

Fig. 2 Diagrams  show the calculated success (after percutaneous revascularization) of A) percutaneous transluminal coronary angioplasty (PTCA), and B) bare-metal and C) drug-eluting stenting in patients with 3-vessel coronary artery disease (CAD).
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3528239/bin/25FF2.gif

At the same time, surgeons got better. Myocardial preservation techniques improved, and the use of the pedicled IMA graft changed the game. As a result, successful revascularization, meaning long-term success, became the domain of the surgeon. We at the Texas Heart Institute/St. Luke’s Episcopal Hospital (THI/SLEH) examined our long-term outcomes after stenting or surgery, and we initially reported that stenting was just as beneficial as surgery. This was in accord with the results of several trials: whenever placing a stent was feasible, stent therapy and surgery had the same outcome.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3528239/bin/25TT1.jpg

success after PTCA vs bare-metal and drug-eluting stents

Stents and Long-Term Outcomes

Later, when we looked at longer-term follow-up data and the effects of multiple procedures, this picture began to change. Stented patients underwent more procedures. When the risk of one surgical procedure was compared with that of multiple endovascular procedures, the outcomes became more similar, especially in patients with bifurcation lesions or lesions with severe calcification. Drug-eluting stents, with their promise of no restenosis, substantially increased interventional cardiologists’ reach, but not their grasp. In patients with multivessel disease and high-risk lesions, DES placement was almost as risky as surgery and did not yield the same long-term benefit.

Nevertheless, we found locally that the introduction of the DES, with its lower risk of restenosis, was treated as a blessing to proceed with stenting (Table I). This did not follow the data, but cardiologists continued anyway, given the promise of less restenosis. Early risk was discounted, glycoprotein IIb/IIIa inhibitor use declined overnight, and the rate of endovascular procedural complications rose to meet that of surgery without the promise of an IMA graft in our future.

Table I. Independent Predictors of 30-Day Major Adverse Cardiac Events and 3-Year Survival after Drug-Eluting Stent Placement
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3528239/bin/25TT1.jpg

Comparing Stenting and Surgery

For decades, methods have been sought to quantify lesion complexity in order to compare the early and late risks associated with stenting versus surgery. Although no perfect system has been devised, the SYNTAX was an important step forward. The SYNTAX score is a simple, computer-based tool for evaluating the risk of complications or failure after PCI. And there are other tools for estimating the same complications after surgery. These estimates enable cardiologists to give patients objective advice regarding the revascularization method that has the best short- and long-term probability of success.
In the patient with non-life-threatening disease (that is, not left main or severe multivessel CAD with left ventricular dysfunction or severely impaired function), stent revascularization has become a reasonable, although not ideal, alternative to surgical revascularization. However, this is true only if stenting is confined to patients whose anatomy and physiology are suited to it—considerations that are well quantified in the SYNTAX score. Whenever questions arise as to the most appropriate therapy, the SYNTAX score should be weighed against clinical characteristics that affect surgical risk. This will guide discussions between the cardiologist, cardiovascular surgeon, patient, and treating physician.
I think that our THI risk is more useful than the other available scores. It uses simple clinical data and can be easily calibrated to the geographic location of its use. Other scores require data that might not be available at the time of clinical decision-making or at all—making such predictions hazardous, at best.

Conclusion

With regard to the chosen mode of revascularization, it is perhaps safe to say that the decision goes beyond the individual physician and must become collective. When a patient has multivessel disease, a reasoned approach must be taken, using these predictive tools and considering the patient’s wishes. Treatment decisions should include all interested parties: the patient, cardiologist, cardiovascular surgeon, and anesthesiologist. The time of ad hoc angioplasty for the patient with multivessel CAD has passed.

Should all ischemic mitral regurgitation be repaired? When should we replace?   Curr Opin Cardiol. 2011

Abstract

Purpose of review

Ischemic mitral regurgitation (IMR) is a major source of morbidity and mortality. Although mitral valve repair has become recently popularized for the treatment of IMR, select patients may derive benefits from replacement. The purpose of this review is to describe current surgical options for IMR and to discuss when mitral valve replacement (MVR) may be favored over mitral valve repair.

Recent findings

Current surgical options for the treatment of IMR include surgical revascularization alone, mitral valve repair, or MVR. Although surgical revascularization alone may benefit patients with mild–moderate IMR, most surgeons advocate the performance of revascularization in combination with either mitral valve repair or replacement. In the current era, mitral valve repair has proven to offer improved short-term and long-term survival, decreased valve-related morbidity, and improved left ventricular function compared with MVR. However, MVR should be considered for high-risk patients and those with specific underlying mechanisms of IMR.

Summary

In the absence of level one evidence, mitral valve repair offers an effective and durable surgical approach to the treatment of mitral insufficiency and remains the operation of choice for IMR. MVR, however, is preferred for select patients. Future randomized, prospective clinical trials are needed to directly compare these surgical techniques.

Introduction

Ischemic mitral regurgitation (IMR) describes insufficiency of the mitral valve in the setting of myocardial ischemia, resulting from coronary artery disease. Although IMR may present in the acute setting, usually as a papillary rupture (Carpentier type II), it is usually a consequence of chronic myocardial ischemia that typically presents weeks following a complete infarction. IMR describes mitral insufficiency in the absence of degenerative (structural) mitral valve disease. The underlying pathophysiologic mechanisms of IMR are often complex, resulting from several different structural changes involving left ventricular geometry, the mitral annulus, and the valvular/subvalvular apparatus. Although changes to any one component may result in detectable mitral valve insufficiency, moderate-to-severe IMR requiring surgical correction often involves the complex interplay of several co-existent anatomic changes. These underlying mechanisms result in clinically significant valve incompetence due to the combined effects of decreased ventricular function and restricted motion of the valve itself due to tethering.
IMR is a major source of patient morbidity and mortality. Although the frequency of IMR differs based upon imaging modality, estimates have suggested that nearly 20–30% of patients experience mitral insufficiency following myocardial infarction. Furthermore, its intimate association with heart failure and poor outcomes for suboptimal medical management further complicates the management of clinically significant IMR. Recent evidence suggests that moderate or severe mitral regurgitation may be associated with a three-fold increase in the adjusted risk of heart failure and a 1.6-fold increase in risk-adjusted mortality at 5-year follow-up. In addition, unfavorable patient profiles and co-existing comorbid disease, including renal failure, chronic obstructive pulmonary disease, diabetes, and impaired left ventricular function, further complicate the clinical picture for those with IMR. Consequently, surgical correction of this condition is often required.
The purpose of this review is to analyze published results for the surgical correction of IMR and to provide current opinion regarding the selection of mitral valve procedure in the setting of myocardial ischemia. Herein, we review current surgical options for IMR and discuss when MVR may be favored over mitral valve repair.

Surgical options for ischemic mitral regurgitation: surgical revascularization alone

Surgical revascularization alone with CABG may be beneficial for some patients. Although CABG alone may be performed in cases of mild-to-moderate IMR, for the treatment of severe IMR, evidence supports performance of CABG with a mitral valve. In fact, a lack of evidence exists to support the performance of CABG alone for severe IMR. In one retrospective review of propensity-matched cohorts, Diodato et al. suggested that addition of a mitral valve procedure to patients undergoing CABG for moderately severe to severe IMR did not increase mortality or improve survival over the performance of CABG alone. This study, however, was limited by small sample sizes (51 CABG + mitral valve repair vs. 51 CABG alone) and 3-year follow-up. To the contrary, substantial evidence exists to support the performance of surgical revascularization alone in cases of mild-to-moderate IMR.
A study by Aklog et al. investigated the role of CABG alone in the correction of moderate IMR. In their series of 136 patients with moderate IMR, they demonstrated that performance of revascularization alone conferred improvement of mitral regurgitation in 51% of patients with complete resolution in an additional 9%. Despite these results, 40% of patients remained with 3–4+ mitral regurgitation, leading the authors to conclude that CABG alone may not be the optimal therapy for most patients and suggest that concomitant mitral annuloplasty may improve results. Other series similarly suggest that complete resolution of functional IMR is uncommon following revascularization alone. Despite the presence of residual mitral regurgitation following revascularization, the impact of performance of CABG without a valve procedure on long-term survival remains ill defined. Currently, on-going prospective evaluation may help to define the potential role of revascularization alone for patients with moderate IMR. Until the completion of these trials, however, evidence supports the performance of surgical revascularization combined with a mitral valve procedure for moderate-to-severe mitral regurgitation.

Surgical revascularization with a mitral valve procedure

The majority of patients with moderate-to-severe IMR require surgical revascularization with a concomitant mitral valve procedure (MVR or mitral valve repair). Historically, these procedures have been associated with high morbidity and mortality as well as poor long-term. However, improved surgical techniques and postoperative management have improved contemporary outcomes. Those favoring mitral valve repair promote its beneficial effects on survival, preserved ventricular function, and the avoidance of long-term anticoagulation, whereas those favoring MVR argue that it ensures long-term freedom from recurrent mitral insufficiency.

Mitral valve replacement vs. mitral valve repair

The use of MVR for IMR eliminates the possibility of recurrent IMR. In addition, previous literature suggests improvements in surgical technique for MVR 29–32. For patients with IMR, MVR with preservation of the subvalvular apparatus using a chordal sparing technique has been shown to be beneficial 33. David and Ho 33 demonstrated a significant survival benefit for patients undergoing MVR with preservation of chordae tendineae (89%) compared with complete excision of the mitral valves (59%) in a cohort of 51 patients with IMR. In addition, Cohn et al. suggested disproportionate survival benefits favoring MVR in a cohort of 150 patients with both functional and structural IMR, concluding that survival following performance of mitral valve procedures for IMR was more dependent on underlying pathophysiology rather than surgical technique. More recently, series have suggested equivalent results for the MVR and mitral valve repair. Mantovani et al. report that prosthetic MVR and mitral valve repair offer very similar results for chronic IMR, demonstrating similar operative mortality and 5-year actuarial survival for both techniques. In a similar report, Magne et al.•• compared short-term and long-term outcomes for 370 patients undergoing mitral valve repair (n = 186) and MVR (n = 184) for IMR. Although operative mortality was lower for mitral valve repair compared with MVR (9.7 vs. 17.4%, P = 0.03), 6-year survival was similar for both operations (73 ± 4 vs. 67 ± 4%, P = 0.17). Type of procedure was also not an independent predictor of mortality following risk adjustment. As a result, the authors suggest that mitral valve repair is not superior to MVR for patients with IMR.
In contrast, other series favor the performance of mitral valve repair for functional IMR. Although several repair techniques exist, restrictive annuloplasty remains the most commonly performed operation 37• and has been shown to be beneficial in both functional and chronic IMR 38•. The purported benefits of improved survival, decreased valve-related morbidity, and improved left ventricular function have been previously established, and several series have reported lower hospital mortality with mitral valve repair compared with MVR.
The Cleveland Clinic published a landmark review of 482 patients undergoing mitral valve procedures for IMR to study the influence of mitral valve procedure type on survival 1. In this series, propensity-matched cohorts were compared: mitral valve repair (n = 397) vs. MVR (n = 85). Concomitant CABG was performed in 95% of operations, and annuloplasty for repair occurred in 98% of cases. After matching, patients were risk stratified into five quintiles. Group 1 represented the highest-risk patients with higher degrees of heart failure and emergent operations, and group 5 represented the lowest-risk patients. Subsequent survival analysis revealed that overall 5-year survival was poor for patients with IMR (58% mitral valve repair vs. 36% MVR, P = 0.08). Moreover, within matched quintiles, the highest-risk patients (quintile 1) had the worst survival, but survival was similar (P = 0.4) despite mitral valve procedure type. In contrast, survival favored mitral valve repair over replacement for quintiles III–V (P = 0.003).
In the absence of published randomized trials, two recently published meta-analyses provide more robust comparisons of the influence of surgical mitral valve repair or replacement. Shuhaiber and Anderson  compared outcomes of 29 studies, including over 10 000 patients. Study groups were stratified based upon mitral valve etiology into ischemic, degenerative/myxomatous, rheumatic, and mixed groups. Summary analyses indicated worse overall survival for MVR (early mortality odds ratio = 2.24 and total survival hazard ratio = 1.58) compared with repair. Mitral valve repair was also associated with lower rates of thromboembolism. Moreover, a nonsignificant trend toward lower 30-day mortality favored mitral valve repair for those with IMR. The most recent meta-analysis to date compared short-term and long-term survival of mitral valve repair vs. replacement specifically for IMR ••. In this analysis, nine studies were included based upon stringent exclusion criteria to ensure direct comparisons of survival for mitral valve procedures exclusively performed for IMR. Interestingly, in this series, although patients undergoing MVR were older, those undergoing repair often had higher rates of hypertension and diabetes with lower ejection fractions. Further, the proportion of patients with severe ventricular dysfunction was similar between procedure groups. These findings conflict with a common assumption that an inherent selection bias exists within published studies for the performance of mitral valve repair in healthier patients. Nevertheless, MVR was associated with worse short-term mortality (odds ratio = 2.667) and long-term mortality (hazard ratio = 1.35) compared with mitral valve repair, and the authors advocate that choice in mitral procedure should be based upon individual patient profile.

When not to repair ischemic mitral regurgitation?

Within the context of published literature and current dogma among practicing surgeons, the fundamental question of when not to repair an ischemic mitral valve remains. For several years, accumulated evidence supports the performance of mitral valve repair over replacement for the surgical treatment of functional IMR. The aforementioned benefits of repair include improved long-term survival, durability and efficacy, improved ventricular function, and avoidance of chronic anticoagulation therapy. Nevertheless, MVR still plays a select role in the treatment of IMR.
With respect to the performance of MVR, the use of bioprosthetic valves and the avoidance of mechanical valve replacement are preferred. This choice is largely driven by the avoidance of complications due to long-term anticoagulation use as well as by the belief that it is unlikely that the majority of patients requiring MVR are likely to encounter bioprosthetic deterioration in their lifetime. In addition, MVR with techniques to preserve the subvalvular apparatus should be performed when possible.

Summary

Undoubtedly, the debate regarding when to perform repair or replacement for IMR remains unsettled. In the recent era, mitral valve repair has proven efficacious and remains the preferred surgical strategy for most cases of IMR. MVR should be considered for severe tethering, complex or uncertain mechanisms of mitral insufficiency, regurgitation due to papillary muscle rupture, and perhaps for the sickest and highest-risk patients.
The present review was supported by Award Number 2T32HL007849-11A1 (D.J.L.) from the National Heart, Lung, and Blood Institute. The content is solely the responsibility of the authors.
Hybrid Cath Lab Combines Nonsurgical, Surgical Treatments  2008
A new cardiac treatment facility that couples the benefits of interventional cardiology with cardiothoracic surgery for critically ill newborns, children and adults has opened at Rush University Medical Center, Chicago.  Toshiba’s new biplane hybrid cardiac suite, which is one of only three facilities of its kind in the U.S., is equipped with the latest in continuous, real-time imaging technology and radio frequency identification (RFID) technology which allows “all-in-one-room” care. The suite allows collaboration between the surgeon and interventional cardiologist on complex heart problems. For example, fixing a very large hole in the heart can be done by inserting a catheter through a small incision in the chest rather than relying on major surgery to open the chest to reach the heart. “Now, interventional cardiologists and cardiothoracic surgeons working together in this suite will reduce the amount of time required to correct complex heart problems and reduce the emotional and physical stress placed on a patient and their family – which translates into less pain, less scarring and a faster recovery time,” Ziyad Hijazi, M.D., director of the new Rush Center for Congenital and Structural Heart Disease. The hybrid suite is equipped with the latest technology for minimally invasive interventional cardiology that involves the use of a catheter and an image-guidance system to thread tiny instruments through blood vessels to repair the heart. Through these special catheters, physicians at Rush can implant stents, artificial heart valves and insert patches for holes in the heart. In many complex cardiac cases, patients who would otherwise have no other option but to undergo open-heart bypass surgery can now have minimally invasive procedures that would otherwise not be available to them. “We can now communicate with colleagues and obtain their expertise in real time for very complex situations,” said Dr. Hijazi. “If physicians decide another procedure is needed, even surgery, the suite can be converted into an operating room and the surgical team can be assembled in the new suite ”Patients at Rush will stay in one place in the new hybrid cardiac suite where all the imaging technology and implantable devices that might be needed are stored and located. The additional ability it gives us to provide surgical treatments allows us to provide the most comprehensive care in the most sensitive manner for patients with often extremely fragile conditions.”  The new hybrid cardiac catheterization suite has the most advanced imaging technologies and can still get a precise, optimal image of any region of the heart regardless of the size or complexity of congenital heart disease. The imaging system also features eight-inch cardiac flat panel detectors designed to deliver distortion-free images. The suite also includes intravascular ultrasound machines, which takes real-time images to allow physicians to see the progress of the procedure taking place inside the patient’s body. A high-tech, automated clinical resource management system located in the suite stores and tracks the medication, surgical tools, medical devices, and implantable devices and supplies using the latest RFID enabled technology.

Hybrid Cath Lab/ORs Are the Way of the Future

Recent developments in cardiac surgery and interventional cardiology with new percutaneous alternatives for aneurysm repair, valve replacements, shunt closure devices and aortic arch reconstruction have led to the creation of integrated, hybrid cath lab/operating rooms (OR) that allow both surgical and intravascular procedures. These rooms offer both surgical equipment and high-end angiographic equipment. Creating such rooms requires special planning and design from both surgical and interventional cardiologists working closely together. Cath labs have high-quality fluoroscopy equipment, but generally are smaller rooms and lack the sterile requirements and equipment needed for surgical procedures. ORs tend to use lower quality mobile C-arms, which are not ideal for interventional procedures. The hybrids aim to provide the best of both worlds. The trend toward hybrid labs has been reinforced by digital angiography manufacturers partnering with surgical equipment companies to create easy-to-integrate hybrid room solutions with coordinated installation. Philips partners with both Skytron and Steris. Toshiba partners with MAQUET. GE Healthcare, Siemens and Toshiba also offer hybrid installations. Philips said while some hospitals want to combine interventional procedures with minimally invasive surgeries, they also want a properly equipped room in case emergency surgery is needed.
Philips said hybrids also allow hospitals with lower PCI numbers to get a bigger bang for their buck by allowing the same room to serve the needs of surgeons. Penn Presbyterian Medical Center in Philadelphia, PA, created a hybrid lab with help from Siemens, which opened in November. Wilson Szeto, M.D., cardio-thoracic surgeon, and William Matthai, M.D., interventionalist, both from Penn Presbyterian said hybrid labs are ideally suited for procedures that require both percutaneous and surgical interventions, percutaneous valve replacements, deploying percutaneous septal occluders or installing aortic stent grafts. Interventionalists can also be called in after cardiac surgery to perform a completion angiography.

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46. Gillinov AM, Wierup PN, Blackstone EH, et al. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg. 2001;122:1125–1141. [PubMed]
47. Grigioni F, Enriquez-Sarano M, Zehr KJ, et al. Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation. 2001;103:1759–1764. [PubMed]
48. Lamas GA, Mitchell GF, Flaker GC, et al. Clinical significance of mitral regurgitation after acute myocardial infarction. Survival and Ventricular Enlargement Investigators. Circulation. 1997;96:827–833. [PubMed]
49. Bursi F, Enriquez-Sarano M, Nkomo VT, et al. Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation. Circulation. 2005;111:295–301. [PubMed]
50. Adams DH, Filsoufi F, Aklog L. Surgical treatment of the ischemic mitral valve. J Heart Valve Dis. 2002;11 (Suppl 1):S21–S25. [PubMed]
51. Filsoufi F, Salzberg SP, Adams DH. Current management of ischemic mitral regurgitation. Mt Sinai J Med. 2005;72:105–115. [PubMed]
52. Micovic S, Milacic P, Otasevic P, et al. Comparison of valve annuloplasty and replacement for ischemic mitral valve incompetence. Heart Surg Forum. 2008;11:E340–E345. [PubMed]
53. Aklog L, Filsoufi F, Flores KQ, et al. Does coronary artery bypass grafting alone correct moderate ischemic mitral regurgitation? Circulation. 2001;104 (12 Suppl 1):I68–I75. [PubMed]
54. Lam BK, Gillinov AM, Blackstone EH, et al. Importance of moderate ischemic mitral regurgitation. Ann Thorac Surg. 2005;79:462–470. discussion 462–470. [PubMed]
55. Ryden T, Bech-Hanssen O, Brandrup-Wognsen G, et al. The importance of grade 2 ischemic mitral regurgitation in coronary artery bypass grafting. Eur J Cardiothorac Surg. 2001;20:276–281. [PubMed]
56•. Goland S, Czer LS, Siegel RJ, et al. Coronary revascularization alone or with mitral valve repair: outcomes in patients with moderate ischemic mitral regurgitation. Tex Heart Inst J. 2009;36:416–424. This series documents current outcomes for the performance of CABG alone with/without concomitant mitral valve repair for ischemic mitral regurgitation. The authors report similar 5-year survival rates for both techniques; however, revascularization with repair resulted in significantly reduced mitral regurgitation grade, improved left ventricular function, and functional class compared with revascularization alone. This study provides an important comparison of these two techniques in the current surgical era. [PMC free article] [PubMed]
57••. Magne J, Girerd N, Senechal M, et al. Mitral repair versus replacement for ischemic mitral regurgitation: comparison of short-term and long-term survival. Circulation. 2009;120(11 Suppl):S104–S111. In this study, the authors compare postoperative outcomes for mitral valve repair and replacement for ischemic mitral regurgitation. Despite lower operative mortality following mitral valve repair, long-term survival was equivalent between surgical groups. This study adds important long-term comparisons of mitral valve procedures to accumulating data examining surgical treatments for ischemic mitral regurgitation. [PubMed]
58. Silberman S, Klutstein MW, Sabag T, et al. Repair of ischemic mitral regurgitation: comparison between flexible and rigid annuloplasty rings. Ann Thorac Surg. 2009;87:1721–1726. discussion 1726–1727. This study provides a contemporary comparison between the use of flexible and rigid annuloplasty rings for the surgical treatment of IMR. The authors report significantly improved clinical and hemodynamic results for rigid mitral annuloplasty rings compared with flexible rings. [PubMed]
59•. Tekumit H, Cenal AR, Uzun K, et al. Ring annuloplasty in chronic ischemic mitral regurgitation: encouraging early and midterm results. Tex Heart Inst J. 2009;36:287–292. This study reports early and midterm results for the use of flexible annuloplasty rings for the surgical treatment of chronic IMR. The authors demonstrate that use of flexible mitral valve annuloplasty conferred a reduction in left ventricular diameter with improved New York Heart Association functional class. This study reports current, encouraging results and provides a context for future investigations comparing flexible and rigid annuloplasty rings for chronic IMR. [PMC free article] [PubMed]
60. Shuhaiber J, Anderson RJ. Meta-analysis of clinical outcomes following surgical mitral valve repair or replacement. Eur J Cardiothorac Surg. 2007;31:267–275. [PubMed]
61••. Vassileva CM, Boley T, Markwell S, Hazelrigg S. Meta-analysis of short-term and long-term survival following repair versus replacement for ischemic mitral regurgitation. Eur J Cardiothorac Surg. 2010 [Epub ahead of print] This meta-analysis provides a comparison of nine published series specifically addressing the performance of mitral valve repair vs. replacement for IMR. The authors demonstrate worse short-term and long-term mortality for MVR. Their analysis offers an up-to-date and robust comparison of these two surgical techniques. [PubMed]

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Cardiac Surgery Theatre in China vs. in the US: Cardiac Repair Procedures, Medical Devices in Use, Technology in Hospitals, Surgeons’ Training and Cardiac Disease Severity”    http://pharmaceuticalintelligence.com/2013/01/08/cardiac-surgery-theatre-in-china-vs-in-the-us-cardiac-repair-procedures-medical-devices-in-use-technology-in-hospitals-surgeons-training-and-cardiac-disease-severity/

Heart Remodeling by Design – Implantable Synchronized Cardiac Assist Device: Abiomed’s Symphony                                                                                     http://pharmaceuticalintelligence.com/2012/07/23/heart-remodeling-by-design-implantable-synchronized-cardiac-assist-device-abiomeds-symphony/
Acute Chest Pain/ER Admission: Three Emerging Alternatives to Angiography and PCI    http://pharmaceuticalintelligence.com/2013/03/10/acute-chest-painer-admission-three-emerging-alternatives-to-angiography-and-pci/
Dilated Cardiomyopathy: Decisions on implantable cardioverter-defibrillators (ICDs) using left ventricular ejection fraction (LVEF) and Midwall Fibrosis: Decisions on Replacement using late gadolinium enhancement cardiovascular MR (LGE-CMR)
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FDA Pending 510(k) for The Latest Cardiovascular Imaging Technology
PCI Outcomes, Increased Ischemic Risk associated with Elevated Plasma Fibrinogen not Platelet Reactivity
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First case in the US: Valve-in-Valve (Aortic and  Mitral) Replacements with Transapical Transcatheter Implants – The Use of Transfemoral Devices

Writer: Larry H Bernstein, MD, FCAP

and

Curator: Aviva Lev-Ari, PhD, RN

 

UPDATED on 9/24/2018

TCT: Long-Term Data Reassuring for Valve-in-Valve TAVR

New valve performs well through 3 years

by Nicole Lou, Contributing Writer, MedPage Today

Transcatheter valve-in-valve replacement had lasting benefits in a high-risk patient population requiring valve reintervention, registry data showed.

Starting with 365 patients who got valve-in-valve transcatheter aortic valve replacement (TAVR), death took its toll in 12.1%, 22.2%, and 32.7% by 12, 24, and 36 months, respectively. Stroke and repeat valve replacement had plateaued to 5.1% and 0.6% over 24 months, rising to 6.2% and 1.9% at the 36-month mark.

Valve performance was sustained the whole time, as effective orifice area had a significant boost from baseline to discharge, staying stable thereafter out to 3 years; mean gradient dropped after the procedure and similarly stayed unchanged over time, according to John Webb, MD, of St. Paul’s Hospital in Vancouver, at the Transcatheter Cardiovascular Therapeutics (TCT) conference.

Among survivors, early improvements in functional status were also maintained over the 3-year period, Webb said. Most patients started off in New York Heart Association class 3 and 4 and were reclassified as class 1 and 2 after TAVR. Quality of life also was better, as shown in improved Kansas City Cardiomyopathy Questionnaire overall summary scores: 43.1 at baseline to 70.8 at 30 days (P<0.0001), and staying stable out to 3 years.

The results were not influenced by surgical valve size, failure mode, approach, or residual gradient.

These data are “certainly reassuring out 2-3 years” but the concern lies in anticipation of lower-risk and younger patients who are expected to start getting TAVR in the future, commented Stephan Windecker, MD, of the University of Bern in Switzerland, who was a panelist at the TCT late-breaker trial session.

There are some concerns regarding coronary obstruction, Webb acknowledged. “This is true in surgical valves and it would be every bit as true in transcatheter valves, if not more so.”

Primary Source

Transcatheter Cardiovascular Therapeutics

Source Reference: Webb JG “Late follow-up from the PARTNER aortic valve-in-valve registry” TCT 2018.

SOURCE

https://www.medpagetoday.com/meetingcoverage/tct/75261?xid=nl_mpt_ACC_Reporter_2018-09-23&eun=g5099207d2r

 

UPDATED on 4/13/2014

Replacement of the Mitral Valve: Using the Edwards’ Sapien Aortic Valve Device

http://pharmaceuticalintelligence.com/2014/04/10/replacement-of-the-mitral-valve-using-the-edwards-sapien-aortic-valve-device/

 

 

June 23, 2013

The following is a report of the first case in the US of both aortic and mitral valve transcatheter replacements using transfemoral devices via the transapical approach. 

It is part of a series on the cardiovascular team at the Columbia Univarsity Medical Center/New York Presbyterian Hospital and the Cardiovascular Research Foundation in the Partner trial.

Concomitant Transcatheter Aortic and  Mitral Valve-in-Valve Replacements Using Transfemoral Devices Via the Transapical Approach

Paradis J-M, Kodali SK, Hahn RT, George I, Daneault B, et al.
ColumbiaUniversityMedicalCenter/NewYork-Presbyterian Hospital, New York, NY fJACC:CARDIOVASCULARINTERVENTIONS  2013;6(1):94-96
http://dx.doi.org/10.1016/j.jcin.2012.07.018

Case Presentation

This is an 85 year old man with congestive heart failure (CHF) NYHA class III/IV and hemolytic anemia. He had a previous history of S. viridans bacterial endocarditis that caused severe aortic and mitral regurgitations. Both aortic and mitral valves were replaced in 2002.  A recenttTransesophageal echocardiogram (TEE) showed the left ventricular ejection fraction (LVEF) was 55%.    This was related to severe mitral regurgitation caused by a flail leaflet, and its internal diameters measured 21-23.8 mm.  There was, in addition, severe stenosis of the Carpentir-Edwards valve in the aortic position with an aortic valve area (AVA) of only 0.9 cm, which was 24 mm internal diameter measured by 3-D TEE.

Action Taken

The patient was felt to require reoperative aortic and mitral valve replacements, but he was deemed inoperable by 2 cardiothoracic surgeons.  Therefore they decided to proceed with transapical transcatheter double valve-in-valve implantation using 2 commercially available RetroFlex 3 transfemoral devices (Edwards Lifesciences, Irvine, CA).  A 26-mm Edwards SAPIEN transcatheter heart valve (THV) was placed within the Carpentier-Edwards valve in the aortic position without pre-dilatation under rapid ventricular pacing.  An Edwards SAPIEN 26-mm THV was then deployed within the Hancock modified bioprosthesis in the mitral position with a 2-step inflation technique.  TEE after deplonment of both valves showed excellent function.  The new aortic prosthetic valve had an AVA of 2.08 cm, peak and mean gradients of 12 and 6 mm Hg, respectively, and no aortic insufficiency.  The mitral valve area was 1.65 cm, and there was only trace mitral regurgitation.

Figure 1.TEE Showing the Mitral Bioprosthetic Valve

Transesophageal echocardiogram (TEE) demonstrating (A) color Doppler through the mitral bioprosthetic  valve. Severe intraprosthetic  mitral regurgitation caused by a flail leaflet generates an eccentric regurgitant jet (see Online Video1).The effective regurgitant orifice was calculated  to be 0.42cm. (B) Measurements of the internal dimensions of the mitral bioprosthesis using 3-dimensional reconstruction imaging.

Concomitant Transcatheter Aortic and Mitral Valve-in-Valve Repla

Figure 2.TEE Showing  the Aortic Bioprosthetic Valve.

Transesophageal echocardiogram (TEE) showing (A) planimetry of the orifice and (B) measurement of the internal diameter of the aortic bioprosthesis.

Concomitant Transcatheter Aortic and Mitral Valve-in-Valve Repla

Figure 3.The 4 Prosthetic Heart Valves.

Final fluoroscopic images showing the 4 prosthetic heart valves (Hancock modified,Carpentier-Edwards, and 2 Edwards SAPIEN transcatheter heart valves) in different angulations

Concomitant Transcatheter Aortic and Mitral Valve-in-Valve Repla

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Trans-apical Transcatheter Aortic Valve Replacement in a Patient with Severe and Complex Left Main Coronary Artery Disease (LMCAD)

Writer: Larry H Bernstein, MD, FCAP

and

Curator: Aviva Lev-Ari, PhD, RN

Significant, defined as a greater than 50 percent narrowing, left main coronary artery disease (LMCAD) is found in 4 to 6 percent of all patients who undergo coronary arteriography [1]. When present, it is associated with multivessel coronary artery disease (MVCAD) about 70 percent of the time [2,3].

Most patients are symptomatic and at high risk of cardiovascular events, since occlusion of this vessel compromises flow to at least 75 percent of the left ventricle, unless it is protected by collateral flow or a patent bypass graft to either the left anterior descending or circumflex artery. Studies performed before revascularization with coronary artery bypass graft surgery (CABG) became the standard of care revealed a poor prognosis for these patients, with three-year survival as low as 37 percent [4]. CABG, when directly compared to medical therapy, is associated with significantly better cardiovascular outcomes, including mortality [5].

Percutaneous coronary intervention (PCI) with stenting has generally been restricted to such patients considered inoperable or at high risk for CABG, or with prior CABG and at least one patent graft to the left anterior descending or circumflex artery (so-called “protected” left main disease). Graft patency is important in this setting in the event of acute or late closure after PCI. However, evidence is increasing to support the use of PCI with stenting in some cases. (See ‘PCI versus CABG’ below.)

Asymptomatic patients with left main lesions felt to not be hemodynamically significant should be managed with preventative therapies. Patients with anginal symptoms attributable to lesions elsewhere should be managed with therapies similar to those used in other patients with coronary artery disease. (See “Overview of the care of patients with stable ischemic heart disease”.)

This topic will discuss most aspects of the management of patients with LMCAD. The approach to patients with multivessel coronary artery disease without LMCAD is discussed elsewhere. (See “Bypass surgery versus percutaneous intervention in the management of stable angina pectoris: Recommendations”.)

http://www.uptodate.com/contents/management-of-left-main-coronary-artery-disease

 

Management of significant left main coronary disease before and after trans-apical transcatheter aortic valve replacement in a patient with severe and complex arterial disease.

Source

Columbia University Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York.

Abstract

We report the case of an 81-year-old woman with symptomatic severe aortic stenosis, extremely significant peripheral arterial disease, and obstructive coronary artery disease who underwent percutaneous coronary intervention via a transaxillary conduit immediately before a trans-apical transcatheter aortic valve replacement performed with a transfemoral device. After deployment of the transcatheter heart valve, there was a left main coronary obstruction and the patient required an emergent PCI. This multifaceted case clearly underlines the importance of a well functioning heart team including the interventional cardiologist, the cardiovascular surgeon, and the echocardiographer. © 2013 Wiley Periodicals, Inc.

Copyright © 2013 Wiley Periodicals, Inc.

This is an interesting surgical case presented by the Columbia University Cardiovascular Surgery team, illustrating the importance of combined team skills in the most difficult of cases.  It is part of a series on cardiovascular surgery.

Management of significant left main coronary disease before and after trans-apical transcatheter aortic valve replacement in a patient with severe and complex arterial disease.

Paradis JM, George I, and Kodali S
Catheterization and Cardiovascular Interventions  (2013)

Introduction

Transcatheter aortic valve replacement (TAVR) with the Edwards SAPIEN transcatheter heart valve (THV) (Edwards Lifesciences, Irvin, CA) has been shown to reduce mortality when compared to medical therapy alone for patients with symptomatic severe aortic stenosis deemed unsuitable for surgical aortic valve replacement due to multiple co-morbidities. The Edwards SAPIEN THV, sizes 23 and 26 mm, and the RetroFlex 3 transfemoral delivery system, have been recently approved by the US Food and Drug Administration (FDA) for commercial use outside of the PARTNER clinical trial for patients considered inoperable.  However, an alternative site needs to be selected for patients with peripheral arteries inadequate for transfemoral TAVR.  Although not fully validated, the transapical approach or the transaortic route using a balloon expandable THV,  appears to be appropriate for this specific purpose.  Significant coronary artery disease (CAD) is often found in patients with severe aortic stenosis. in > 50% of patients with aortic stenosis over 70 years of age and in > 65% of patients who are  over 80 years of age. There is no established guideline for managing significant CAD in the context of TAVR, including the appropriate revascularization strategy as well as the timing of interventions.

Case Report

An 81-year-old woman  presented with symptomatic severe aortic stenosis, extremely significant peripheral arterial disease, and obstructive coronary artery disease. She had a six-month history prior to admission of progressive exertional shortness of breath and fatigue, and a long history fo hypertension, hyperlipidemia, obesity, and severe peripheral vascular disease.  In 2003, she underwent a coronary artery bypass graft (CABG) surgery, with grafting of the left internal mammary artery (LIMA) to the left anterior descending (LAD) artery, a saphenous vein graft (SVG) to the first obtuse marginal (OM) branch, and a SVG to the right coronary artery (RCA). Due to associated severe mitral regurgitation, a mitral valve ring annuloplasty was also performed. A transthoracic echocardiogram (TTE) revealed severe aortic stenosis with a peak gradient across the aortic valve of 63 mm Hg, a mean gradient of 39 mm Hg, and an aortic valve area of 0.8 cm2.  The left ventricular ejection fraction (LVEF) was 64% while the pulmonary artery systolic pressure was measured at 28 mm Hg.  Extreme calcification and tortuosity precluded the advancement of any wire, catheter, or sheath, contributing to two attempts at cardiac catheterization prior to transfer with a total occlusion of the distal abdominal aorta, at the level of the aorto-iliac bifurcation, and the left main, proximal LAD, proximal left circumflex, and the proximal RCA all had greater than 70% coronary lesions. In addition, ostial total occlusions were seen in both SVGs.
left main coronary artery
After transfer, a cardiac catheterization through the right radial artery was attempted without success due to calcification and tortuosity in the arterial bed.  An 80% distal left main lesion was clearly identified with a Judkins left 3.5 guiding catheter.  There was non-flow limiting coronary disease in the left circumflex and competitive retrograde flow seen in the LIMA graft, but they still were unable to cannulate the RCA and the SVGs. It was determined that the patient was inoperable, on grounds of her significant frailty, reoperative status and overall comorbid state (Society of Thoracic Surgeons (STS) risk score of 11%). Furthermore, due to the occlusion of the distal aorta, the patient was unsuitable for a TAVR via the transfemoral approach.
They chose to approach her PCI via a conduit on the right axillary artery and perform a concomitant TAVR from a trans-apical approach due to the serious limiting condition of the patient.  She underwent percutaneous coronary intervention via a transaxillary conduit immediately before a trans-apical transcatheter aortic valve replacement performed with a transfemoral device.  Excellent flow from the conduit was noted. A 7 French (Fr) sheath was connected to the end of the conduit, which was kept long to allow better maneuverability (Fig. 1). A Rosen wire was passed with some difficulty to the aortic root, and was switched to a stiff wire in an attempt to straighten the vessel.
PowerPoint Presentation
Fig. 1. Transaxillary conduit used during the procedure. A 7 French sheath was connected to an 8 mm dacron graft, which was previously sewn to the axillary artery.
After deployment of the transcatheter heart valve, there was a left main coronary obstruction and the patient required an emergent PCI.  This multifaceted case clearly underlines the importance of a well functioning heart team including the interventional cardiologist, the cardiovascular surgeon, and the echocardiographer. A Xience
V everolimus eluting stent 3.5 mm  18 mm was implanted starting 2 mm distal to the ostium of the left main, extending in the proximal portion of the left circumflex artery. After one post-dilatation with a non-compliant balloon, the final angiographic result was excellent.
They used a Retroflex 3 transfemoral delivery sheath to perform the trans-apical TAVR. They estimated the size and length of the ventricular cavity, and then placed markers on the delivery sheath (prior to insertion) indicating the appropriate length of sheath to remain outside the heart (Fig. 2).
PowerPoint Presentation
Fig. 2. Marker placed on the RetroFlex 3 transfemoral sheath to safely guide its insertion inside the left ventricular cavity during the trans-apical transcatheter aortic valve replacement.
A 23 mm Edwards SAPIEN valve was selected and deployed under fluoroscopic and transesophageal echocardiographic guidance. Immediately after deployment, turbulent flow was noted within the left main with the color Doppler on TEE, indicating a new obstruction of the left main, which a left coronary angiogram showed to be a severe proximal lesion.  Through the trans-axillary conduit, a  guiding catheter was laboriously brought in the ascending aorta and cannulated the left main artery which permitted a predilation and a stent insertion in the ostial portion of the left main.  She was discharged to a rehabilitation facility 7 days after the procedure.
On follow-up TTE, the LVEF was 55% without any significant wall motion abnormality. There was no aortic regurgitation, and the peak and mean gradients were 14.9 mm Hg and 8.0 mm Hg, respectively. The patient is still doing well more than 6 months after the procedure. She is now in NYHA class 2 and has not had any recurrent hospitalization for congestive heart failure.
Discussion
This report is a case of a complex percutaneous coronary intervention of the left main coronary artery via a right axillary conduit followed immediately by an off label commercial transapical TAVR using the Retro-Flex 3 trans-femoral introducer sheath, complicated finally by a new left main coronary obstruction mandating another PCI. It is the first description of a TAVR procedure preceded and followed by a left main trans-axillary PCI. The role of TEE (color Doppler) in the diagnosis of a very rare TAVR complication is also noteworthy. In a recent meta-analysis of 3,519 patients from 16 studies using the Valve Academic Research Consortium (VARC) definitions, the pooled estimate rate of coronary
obstruction following TAVR was only 0.7%. Obviously, the early recognition and treatment of this hazard is imperative.
The surgical management of this patient also warrants discussion. The hybrid surgical approach of accessing the axillary artery via a conduit provides numerous advantages:
(1) the ascending aorta, coronaries, and aortic valve are easily accessible;
(2) transition to cardiopulmonary bypass or extra-corporeal membrane oxygenation, if needed, is quick; and
(3) long-term morbidity is minimal for the patient when compared to aorto-iliac, aortic, or femoral conduits.
Finally, the heart team approach not only allowed the realization of a difficult coronary
stent implantation through an unusual transaxillary graft followed by a transapical TAVR in a patient with significant peripheral arterial disease, but also permitted the early  recognition and management of a potentially fatal left main obstruction. Considerations such as team-based care, close communication between the different specialties
involved and careful planning for outlining management of potential complications are therefore essential for the success of a TAVR program.

REFERENCES

 1. Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010;363:1597–1607.
2. Iung B. Interface between valve disease and ischaemic heart disease. Heart 2000;84:347–352.
3. Wenaweser P, Pilgrim T, Guerios E, Stortecky S, Huber C, Khattab AA, et al. Impact of coronary artery disease and percutaneous coronary intervention on outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation.
EuroIntervention 2011;7:541–548.
4. Genereux P, Head SJ, Van Mieghem NM, Kodali S, Kirtane AJ, Xu K, et al. Clinical outcomes after transcatheter aortic valve replacement using valve academic research consortium definitions: A weighted meta-analysis of 3,519 patients from 16 studies.
J Am Coll Cardiol 2012;59:2317–2326.
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heart with coronary arteries

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Micrograph of an artery that supplies the hear...

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Investigational Devices: Edwards Sapien Transcatheter Aortic Valve Transapical Deployment

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http://pharmaceuticalintelligence.com/2012/06/04/investigational-devices-edwards-sapien-transcatheter-heart-valve/

Lev-Ari, A. 2/12/2013 Clinical Trials on transcatheter aortic valve replacement (TAVR) to be conducted by American College of Cardiology and the Society of Thoracic Surgeons

http://pharmaceuticalintelligence.com/2013/02/12/american-college-of-cardiologys-and-the-society-of-thoracic-surgeons-entrance-into-clinical-trials-is-noteworthy-read-more-two-medical-societies-jump-into-clinical-trial-effort-for-tavr-tech-f/

Lev-Ari, A. 8/13/2012 Coronary Artery Disease – Medical Devices Solutions: From First-In-Man Stent Implantation, via Medical Ethical Dilemmas to Drug Eluting Stents http://pharmaceuticalintelligence.com/2012/08/13/coronary-artery-disease-medical-devices-solutions-from-first-in-man-stent-implantation-via-medical-ethical-dilemmas-to-drug-eluting-stents/

Lev-Ari, A. 7/18/2012 Percutaneous Endocardial Ablation of Scar-Related Ventricular Tachycardia

http://pharmaceuticalintelligence.com/2012/07/18/percutaneous-endocardial-ablation-of-scar-related-ventricular-tachycardia/

Lev-Ari, A. 6/22/2012 Competition in the Ecosystem of Medical Devices in Cardiac and Vascular Repair: Heart Valves, Stents, Catheterization Tools and Kits for Open Heart and Minimally Invasive Surgery (MIS)

http://pharmaceuticalintelligence.com/2012/06/22/competition-in-the-ecosystem-of-medical-devices-in-cardiac-and-vascular-repair-heart-valves-stents-catheterization-tools-and-kits-for-open-heart-and-minimally-invasive-surgery-mis/

Lev-Ari, A. 6/19/2012 Executive Compensation and Comparator Group Definition in the Cardiac and Vascular Medical Devices Sector: A Bright Future for Edwards Lifesciences Corporation in the Transcatheter Heart Valve Replacement Market

http://pharmaceuticalintelligence.com/2012/06/19/executive-compensation-and-comparator-group-definition-in-the-cardiac-and-vascular-medical-devices-sector-a-bright-future-for-edwards-lifesciences-corporation-in-the-transcatheter-heart-valve-replace/

Lev-Ari, A. 6/22/2012 Global Supplier Strategy for Market Penetration & Partnership Options (Niche Suppliers vs. National Leaders) in the Massachusetts Cardiology & Vascular Surgery Tools and Devices Market for Cardiac Operating Rooms and Angioplasty Suites

http://pharmaceuticalintelligence.com/2012/06/22/global-supplier-strategy-for-market-penetration-partnership-options-niche-suppliers-vs-national-leaders-in-the-massachusetts-cardiology-vascular-surgery-tools-and-devices-market-for-car/

 We reported on the following Medical Devices News:

Lev-Ari A. 4/6/2012.  Investigational-devices-edwards-sapien-transcatheter-heart-valve. 

http://pharmaceuticalintelligence.com/2012/06/04/investigational-devices-edwards-sapien-transcatheter-heart-valve/

Cardiac Surgery Theatre in China vs. in the US: Cardiac Repair Procedures, Medical Devices in Use, Technology in Hospitals, Surgeons’ Training and Cardiac Disease Severity”    http://pharmaceuticalintelligence.com/2013/01/08/cardiac-surgery-theatre-in-china-vs-in-the-us-cardiac-repair-procedures-medical-devices-in-use-technology-in-hospitals-surgeons-training-and-cardiac-disease-severity/

Acute Chest Pain/ER Admission: Three Emerging Alternatives to Angiography and PCI    http://pharmaceuticalintelligence.com/2013/03/10/acute-chest-painer-admission-three-emerging-alternatives-to-angiography-and-pci/

FDA Pending 510(k) for The Latest Cardiovascular Imaging Technology
http://pharmaceuticalintelligence.com/2013/01/28/fda-pending-510k-for-the-latest-cardiovascular-imaging-technology/

PCI Outcomes, Increased Ischemic Risk associated with Elevated Plasma Fibrinogen not Platelet Reactivity
http://pharmaceuticalintelligence.com/2013/01/10/pci-outcomes-increased-ischemic-risk-associated-with-elevated-plasma-fibrinogen-not-platelet-reactivity/

The ACUITY-PCI score: Will it Replace Four Established Risk Scores — TIMI, GRACE, SYNTAX, and Clinical SYNTAX
http://pharmaceuticalintelligence.com/2013/01/03/the-acuity-pci-score-will-it-replace-four-established-risk-scores-timi-grace-syntax-and-clinical-syntax/

Coronary artery disease in symptomatic patients referred for coronary angiography: Predicted by Serum Protein Profiles
http://pharmaceuticalintelligence.com/2012/12/29/coronary-artery-disease-in-symptomatic-patients-referred-for-coronary-angiography-predicted-by-serum-protein-profiles/

Ablation Devices Market to 2016 – Global Market Forecast and Trends Analysis by Technology, Devices & Applications
http://pharmaceuticalintelligence.com/2012/12/23/ablation-devices-market-to-2016-global-market-forecast-and-trends-analysis-by-technology-devices-applications/

Heart Renewal by pre-existing Cardiomyocytes: Source of New Heart Cell Growth Discovered
http://pharmaceuticalintelligence.com/2012/12/23/heart-renewal-by-pre-existing-cardiomyocytes-source-of-new-heart-cell-growth-discovered/

To Stent or Not? A Critical Decision
http://pharmaceuticalintelligence.com/2012/10/23/to-stent-or-not-a-critical-decision/

Transcatheter Aortic-Valve Replacement for Inoperable Severe Aortic Stenosis

http://pharmaceuticalintelligence.com/2012/09/03/transcatheter-aortic-valve-replacement-for-inoperable-severe-aortic-stenosis/

New Definition of MI Unveiled, Fractional Flow Reserve (FFR)CT for Tagging Ischemia

http://pharmaceuticalintelligence.com/2012/08/27/new-definition-of-mi-unveiled-fractional-flow-reserve-ffrct-for-tagging-ischemia/

New Drug-Eluting Stent Works Well in STEMI
http://pharmaceuticalintelligence.com/2012/08/22/new-drug-eluting-stent-works-well-in-stemi/

Expected New Trends in Cardiology and Cardiovascular Medical Devices
http://pharmaceuticalintelligence.com/2012/08/17/expected-new-trends-in-cardiology-and-cardiovascular-medical-devices/

Read Full Post »

Transcatheter Aortic Valve Replacement (TAVR): Postdilatation to Reduce Paravalvular Regurgitation During TAVR with a Balloon-expandable Valve

Reviewer: Larry H Bernstein, MD, FCAP

and

Curator: Aviva Lev-Ari, PhD, RN

This report is one in a series on advances in cardiovascular surgery.  This report particularly focuses on the safety and efficacy of transcatheter aortic valve replacement (TAVR), a major study carried out at Columbia University Medical Center, involving reduction of paravalvular regurgitation post TAVI.

Circ Cardiovasc Interv. 2013 Feb;6(1):85-91. doi: 10.1161/CIRCINTERVENTIONS.112.971614. Epub 2013 Jan 22.

Efficacy and safety of postdilatation to reduce paravalvular regurgitation during balloon-expandable transcatheter aortic valve replacement.

Daneault B, Koss E, Hahn RT, Kodali S, Williams MR, Généreux P, Paradis JM, George I, Reiss GR, Moses JW, Smith CR, Leon MB.

Source

Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY 10032, USA.

Abstract

BACKGROUND:

Paravalvular regurgitation (PVR) is common after transcatheter aortic valve replacement (TAVR) and may be associated with adverse outcomes. Postdilatation (PD) has been proposed to treat PVR without being formally studied. We performed a study to evaluate the safety and efficacy of PD after balloon expandable TAVR.

METHODS AND RESULTS:

Consecutive cases of TAVR were reviewed for clinical outcomes. Procedural transesophageal echocardiography imaging was reviewed for a subgroup of consecutive patients. PVR areas seen on a short-axis view were measured immediately after deployment, after PD, and at the completion of the study. Stent dimensions measured using angiography and the Paieon’s C-THV system pre- and post-PD were compared. Between May 2007 and November 2011, 259 patients underwent TAVR at our institution. PD was performed in 106 patients (41%). These patients had larger annulus, lower cover-index; more often had transfemoral access and implantation of a 26 mm valve. There was a nonsignificant greater rate of cerebrovascular events in PD patients. There was no significant difference in major aortic injury and permanent pacemaker implantation rates between groups. TTE studies were reviewed in 58 patients (35 with PD and 23 without PD). PD patients had larger PVR areas immediately after deployment (40.3±17.1 versus 15.4±14.2 mm(2); P<0.0001). There was significant reduction in PVR area attributable to PD (21.7±9.3 mm(2); P<0.0001). Spontaneous regression of PVR was seen in both groups. PD increased stent dimensions.

CONCLUSIONS:

This study demonstrates the efficacy of PD at reducing PVR in patients with greater than mild PVR after balloon-expandable TAVR.

PMID: 23339841

Efficacy and Safety of Postdilatation to Reduce Paravalvular Regurgitation During Balloon-Expandable Transcatheter Aortic Valve Replacement

Daneault R, Koss E, Hahn RT, Kodali S, Williams MR, et al.
Circ Cardiovasc Interv. 2013;6:85-91. http://dx.doi.org/10.1161/circinterventions.112.971614

Transcatheter aortic valve replacement (TAVR) has emerged as a new alternative treatment for patients with severe aortic stenosis, who are at high risk or deemed inadequate candidates for conventional surgical aortic valve replacement. Paravalvular regurgitation (PVR) is common after transcatheter aortic valve replacement (TAVR) reported in 80% to 96% of TAVR cases Moreover, moderate and severe degrees of regurgitation are associated with worse clinical outcomes While the risk factors are known and include: smaller cover index, annulus eccentricity, and the degree and distribution of leaflet calcifications, postdilatation (PD) of balloon expandable valves after implantation, including transcatheter heart valve (THV) traumatic aorta injury, cerebrovascular embolus, and conduction block may outweigh the potential benefits from reduction in aortic regurgitation. Therefore, these investigators performed a study to evaluate the safety and efficacy of PD after balloon expandable TAVR.

What Is Known

• Significant paravalvular regurgitation after transcatheter aortic valve replacement is associatedwith increased mortality.
• Calcifications, undersized prosthesis, and malposition are causes of paravalvular regurgitation.

Study Design

Procedural and in-hospital outcomes for all consecutive patients treated between May 2007 and November 2011 with Edwards SAPIEN THV (Edwards Lifescience, Irvine, CA) as part of the PARTNER and PARTNER 2 trials were reviewed both prospectively and retrospectively. Information on PD was collected retrospectively from chart and imaging review for the period between 2007 and August 2010, and prospectively after August 2010. PD was performed in cases where PVR was qualitatively more than mild, by transesophageal echocardiography (TEE), immediately after THV implantation. There were 259 patients who underwent TAVR. PD was performed in 106 patients (41%). Procedural transesophageal echocardiography imaging was reviewed for a subgroup of consecutive patients. PVR areas seen on a short-axis view were measured immediately after deployment, after PD, and at the completion of the study. Stent dimensions measured using angiography and the Paieon’s C-THV system pre- and post-PD were compared, and TTE studies were reviewed in 58 patients (35 with PD and 23 without PD).

Endpoints

Neurological events were defined using valve academic research consortium definitions.14 Cover-index is defined as: 100×([THV diameter–TEE annulus diameter]/THV diameter).3 Clinical end points for the current analysis included 30-day mortality, in-hospital stroke or transient ischemic attack, procedural related major aortic injury (aortic dissection, aortic wall hematoma, or annulus/aortic rupture) and need for new permanent pacemaker during the index hospitalization. Echocardiographic end points included spontaneous reduction of PVR [difference between PVR1 and PVR3 in the non-PD group (PD−) and difference between PVR2 and PVR3 in the PD group (PD+)], and reduction of PVR attributable to PD
(PVR1−PVR2) in the PD+. Angiographic end points included additional expansion of IF, OF, and minimal diameters of stents after PD.

Results and Clinical Outcomes

No valve embolization occurred during PD. No patient required implantation of a second THV after PD. Multiple PD was performed in 4 cases. There was no statistically significant
difference between the 2 groups in the incidence of neurological events, although they were more frequent in patients with PD. Permanent pacemaker implantation during the index hospitalization was not significantly different between the 2 groups. Major aortic injuries were rare and occurred at a similar rate between both groups with no aortic annulus rupture in either group.

These (PD) patients had larger annulus, lower cover-index; more often had transfemoral access and implantation of a 26 mm valve. There was a nonsignificant greater rate of cerebrovascular events in PD patients. There was no significant difference in major aortic injury and permanent pacemaker implantation rates between groups.
PD patients had larger PVR areas immediately after deployment (40.3±17.1 versus 15.4±14.2 mm2; P<0.0001). There was significant reduction in PVR area attributable to PD (21.7±9.3 mm2; P<0.0001). Spontaneous regression of PVR was seen in both groups.
PD increased stent dimensions. There was a significant increase in the OF, IF, and minimal diameters after PD of 26 mm valves. The changes were not statistically significant for the 23 mm valves. There was a greater expansion in the IF and OF diameters compared with the minimal diameter.

Discussion

This study is the second that demonstrates the efficacy of PD at reducing postdeployment PVR in patients with greater than mild PVR after balloon-expandable TAVR. Moreover, judicious use of PD for greater than mild PVR is not associated with excess morbidity or mortality, although some concerns regarding cerebral embolism deserve comment. When it occurs, PVR is a significant cause of nonstructural prosthetic valve dysfunction. The anatomic positioning and resultant physiology of THV, however, are different from surgical valves. After surgical aortic valve replacement, most commonly PVR is attributable to infection, suture dehiscence, or fibrosis and calcification of the native annulus, resulting in inadequate contact or gaps between the sewing ring and annulus. Because THVs do not have a sewing ring traditional dehiscence cannot occur. For balloon-expandable THV, significant PVR most commonly results from incomplete prosthesis apposition to the native annulus.

What the Study Adds

• Additional postdilatation can reduce the magnitude of paravalvular regurgitation.
• Spontaneous regression of paravalvular regurgitation occurs within minutes after transcatheter aortic valve replacement.
• Postdilatation may be associated with increased risk of cerebrovascular events.

Other TAVR related articles published on this Open Access Online Scientific Journal include the following:

Lev-Ari, A. 2/12/2013 Clinical Trials on transcatheter aortic valve replacement (TAVR) to be conducted by American College of Cardiology and the Society of Thoracic Surgeons

http://pharmaceuticalintelligence.com/2013/02/12/american-college-of-cardiologys-and-the-society-of-thoracic-surgeons-entrance-into-clinical-trials-is-noteworthy-read-more-two-medical-societies-jump-into-clinical-trial-effort-for-tavr-tech-f/

  

Lev-Ari, A. 8/13/2012 Coronary Artery Disease – Medical Devices Solutions: From First-In-Man Stent Implantation, via Medical Ethical Dilemmas to Drug Eluting Stents http://pharmaceuticalintelligence.com/2012/08/13/coronary-artery-disease-medical-devices-solutions-from-first-in-man-stent-implantation-via-medical-ethical-dilemmas-to-drug-eluting-stents/

 

Lev-Ari, A. 7/18/2012 Percutaneous Endocardial Ablation of Scar-Related Ventricular Tachycardia

http://pharmaceuticalintelligence.com/2012/07/18/percutaneous-endocardial-ablation-of-scar-related-ventricular-tachycardia/

 

Lev-Ari, A. 6/22/2012 Competition in the Ecosystem of Medical Devices in Cardiac and Vascular Repair: Heart Valves, Stents, Catheterization Tools and Kits for Open Heart and Minimally Invasive Surgery (MIS)

http://pharmaceuticalintelligence.com/2012/06/22/competition-in-the-ecosystem-of-medical-devices-in-cardiac-and-vascular-repair-heart-valves-stents-catheterization-tools-and-kits-for-open-heart-and-minimally-invasive-surgery-mis/

Lev-Ari, A. 6/19/2012 Executive Compensation and Comparator Group Definition in the Cardiac and Vascular Medical Devices Sector: A Bright Future for Edwards Lifesciences Corporation in the Transcatheter Heart Valve Replacement Market

http://pharmaceuticalintelligence.com/2012/06/19/executive-compensation-and-comparator-group-definition-in-the-cardiac-and-vascular-medical-devices-sector-a-bright-future-for-edwards-lifesciences-corporation-in-the-transcatheter-heart-valve-replace/

 

Lev-Ari, A. 6/22/2012 Global Supplier Strategy for Market Penetration & Partnership Options (Niche Suppliers vs. National Leaders) in the Massachusetts Cardiology & Vascular Surgery Tools and Devices Market for Cardiac Operating Rooms and Angioplasty Suites

http://pharmaceuticalintelligence.com/2012/06/22/global-supplier-strategy-for-market-penetration-partnership-options-niche-suppliers-vs-national-leaders-in-the-massachusetts-cardiology-vascular-surgery-tools-and-devices-market-for-car/

 We reported on the following Medical Devices News:

Cardiac Surgery Theatre in China vs. in the US: Cardiac Repair Procedures, Medical Devices in Use, Technology in Hospitals, Surgeons’ Training and Cardiac Disease Severity”    http://pharmaceuticalintelligence.com/2013/01/08/cardiac-surgery-theatre-in-china-vs-in-the-us-cardiac-repair-procedures-medical-devices-in-use-technology-in-hospitals-surgeons-training-and-cardiac-disease-severity/

Acute Chest Pain/ER Admission: Three Emerging Alternatives to Angiography and PCI    http://pharmaceuticalintelligence.com/2013/03/10/acute-chest-painer-admission-three-emerging-alternatives-to-angiography-and-pci/

FDA Pending 510(k) for The Latest Cardiovascular Imaging Technology
http://pharmaceuticalintelligence.com/2013/01/28/fda-pending-510k-for-the-latest-cardiovascular-imaging-technology/

PCI Outcomes, Increased Ischemic Risk associated with Elevated Plasma Fibrinogen not Platelet Reactivity
http://pharmaceuticalintelligence.com/2013/01/10/pci-outcomes-increased-ischemic-risk-associated-with-elevated-plasma-fibrinogen-not-platelet-reactivity/

The ACUITY-PCI score: Will it Replace Four Established Risk Scores — TIMI, GRACE, SYNTAX, and Clinical SYNTAX
http://pharmaceuticalintelligence.com/2013/01/03/the-acuity-pci-score-will-it-replace-four-established-risk-scores-timi-grace-syntax-and-clinical-syntax/

Coronary artery disease in symptomatic patients referred for coronary angiography: Predicted by Serum Protein Profiles
http://pharmaceuticalintelligence.com/2012/12/29/coronary-artery-disease-in-symptomatic-patients-referred-for-coronary-angiography-predicted-by-serum-protein-profiles/

Ablation Devices Market to 2016 – Global Market Forecast and Trends Analysis by Technology, Devices & Applications
http://pharmaceuticalintelligence.com/2012/12/23/ablation-devices-market-to-2016-global-market-forecast-and-trends-analysis-by-technology-devices-applications/

Heart Renewal by pre-existing Cardiomyocytes: Source of New Heart Cell Growth Discovered
http://pharmaceuticalintelligence.com/2012/12/23/heart-renewal-by-pre-existing-cardiomyocytes-source-of-new-heart-cell-growth-discovered/

To Stent or Not? A Critical Decision
http://pharmaceuticalintelligence.com/2012/10/23/to-stent-or-not-a-critical-decision/

Transcatheter Aortic-Valve Replacement for Inoperable Severe Aortic Stenosis

http://pharmaceuticalintelligence.com/2012/09/03/transcatheter-aortic-valve-replacement-for-inoperable-severe-aortic-stenosis/

New Definition of MI Unveiled, Fractional Flow Reserve (FFR)CT for Tagging Ischemia

http://pharmaceuticalintelligence.com/2012/08/27/new-definition-of-mi-unveiled-fractional-flow-reserve-ffrct-for-tagging-ischemia/

New Drug-Eluting Stent Works Well in STEMI
http://pharmaceuticalintelligence.com/2012/08/22/new-drug-eluting-stent-works-well-in-stemi/

Expected New Trends in Cardiology and Cardiovascular Medical Devices
http://pharmaceuticalintelligence.com/2012/08/17/expected-new-trends-in-cardiology-and-cardiovascular-medical-devices/

English: This is a video clip from a living, b...

English: This is a video clip from a living, beating pig heart that was prepared in the laboratory as a working Langendorf preparation. The heart was arrested, connected to the perfusion system and restarted. The working fluid was oxygenated balanced saline solution. (Photo credit: Wikipedia)

English: Phonocardiograms from normal and abno...

English: Phonocardiograms from normal and abnormal heart sounds (Photo credit: Wikipedia)

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No Early Symptoms – An Aortic Aneurysm Before It Ruptures – Is There A Way To Know If I Have it?

Curator: Aviva Lev-Ari, PhD, RN

I shadowed Dr. Cambria in the Operating Room at MGH in January 2005 while he performed Carotid Endarterectomy following Aortic Valve Replacement performed by Dr. Jennifer D. Walker  in a sequence, first the Valve replacement, then the Endarterectomy.

Aneurysm

Published on Thursday, 15 November 2012 | Print | Email
This word has a Greek origin from the terms [aneurusma], composed of [ana] meaning “complete or throughout”, and [eurus] meaning “wide”, a “complete widening or dilation”. It is used to refer to the dilation of an artery. Aneurysms can be formed in any artery, although they have some preferred sites. The most common aneurysms are found in the aorta, arterial circle of Willis, the root of the cerebral arteries, and internal carotid arteries.Biomechanical studies suggest that once an aneurysm forms it will generally progress in its dilation until aneurysmal rupture. Because of turbulent flow within the aneurysm large clots are usually formed, which in turn can cause emboli.The image shows an excised infrarenal aortic abdominal aneurysm (AAA). The two common iliac arteries can be seen. If you click on the image you will be able to see the same aneurysm opened through its posterior wall and the clot that was contained inside.Photography by D.M.Klein  Abdominal Aortic Aneurysm

http://clinanat.com/mtd/153-aneurysm

On 6/11/2013, Efrain Miranda, Ph.D. commented on this article, as follows:

It is true that abdominal aortic aneurysms (AAA) are mostly asymptomatic, until they rupture. By luck, some are identified. An example was a AAA found in Albert Einstein by Dr. Nissen when Einstein went for abdominal surgery for something completely unrelated! In my experience, I have found many AAA’s in individuals who had a totally different cause of death.

Dr. Richard Cambria describes an Aortic Aneurysm and recalls the numerous risk factors associated with the condition.

VIEW VIDEO

http://www.empowher.com/aortic-aneurysm/content/there-are-no-early-symptoms-there-way-know-if-i-have-aortic-aneurysm-it-rupt

By Dr. Richard Cambria Expert April 12, 2011 – 10:08am

 

Dr. Cambria:
An aortic aneurysm can be most simply thoughts of as a weakening or ballooning of the aorta which is the body’s major and largest blood vessel. That’s important because this ballooning or weakening can eventually lead to the aneurysm bursting, which is usually a fatal event.

Aneurysms have been referred to as the ‘silent killer’ because in most cases these aortic aneurysms cause no symptoms or problems prior to bursting. Most aortic aneurysms occur in older patients, but there are a clearly defined set of risk factors which makes certain patients at higher risk of developing aortic aneurysms. These include, most importantly, a family history of aortic aneurysm disease, and by family history I mean, if your mother or father or a brother or sister had an aortic aneurysm, you are clearly at increased risk of developing an aneurysm.

20% of the patients that we treat for aortic aneurysms have a positive family history of aneurysm disease. You are also at higher risk for developing an aortic aneurysm if you are female, if you have a history of high blood pressure, if you have been a cigarette smoker, and if you have chronic obstructive pulmonary disease or emphysema, which is in turn related to long-term cigarette smoking.

If you are at risk for developing an aortic aneurysm there are simple diagnostic x-ray studies such as ultrasounds and CAT scans to accurately diagnose number one, whether or not an aneurysm is present, and more importantly, if it is present, to measure just how large it is because that’s the single most important factor in determining whether or not your aneurysm needs to be treated.

It’s important to detect and monitor aortic aneurysms before they reach the stage of bursting because treatment is then usually successful with an expected excellent recovery. Treatment of aortic aneurysms today is very effective and involves replacing the aneurysm with an artificial blood vessel.

There are a variety of different surgical treatments, some of them including minimally invasive operations known as stent grafts, which are applied today in many patients.

Mass General has been a leader in the northeast in the successful management of aortic aneurysms. More than a decade ago, we formed the Mass General Thoracic Aortic Center, which is a team-approach of vascular surgeons, cardiac or heart surgeons, and cardiologists to effectively manage thoracic aneurysms which are often the most challenging and clinically complex to treat.

About Dr. Richard Paul Cambria, M.D.:
Richard P. Cambria, M.D. is Professor of Surgery at Harvard Medical School and Chief, Division of Vascular/Endovascular Surgery at Massachusetts General Hospital. Dr. Cambria received his medical degree from the College of Physicians and Surgeons, Columbia University, in 1977. He trained in general and vascular surgery at Massachusetts General Hospital.

http://www.empowher.com/aortic-aneurysm/content/there-are-no-early-symptoms-there-way-know-if-i-have-aortic-aneurysm-it-rupt

Education & Awards

Dr. Cambria graduated from Columbia University, New York. He has 15 awards.

Awards
One of America’s Leading Experts on:
Abdominal Aortic Aneurysm
Aortic Aneurysm
Aortic Diseases
Aortic Rupture
Arterial Occlusive Diseases
Blood Vessel Prosthesis Implantation
Carotid Endarterectomy
Carotid Stenosis
Kidney Failure
Mesenteric Vascular Occlusion
Spinal Cord Ischemia
Thoracic Aortic Aneurysm
Vascular Surgical Procedures
Castle Connolly America’s Top Doctors® (2002 – 2012)
Top Ten Doctors (2012)
Vascular Surgery, Downtown, Boston, MA

http://www.vitals.com/doctors/Dr_Richard_Cambria.html#ixzz2VqxwIwMK

Publications & Research

Dr. Cambria has contributed to 164 publications.
Title Giant Cell Aortitis of the Ascending Aorta Without Signs or Symptoms of Systemic Vasculitis is Associated with Elevated Risk of Distal Aortic Events.
Date February 2012
Journal Arthritis and Rheumatism
Title Long-term Outcomes of Patients Undergoing Endovascular Infrainguinal Interventions with Single-vessel Peroneal Artery Runoff.
Date May 2011
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Management of Diseases of the Descending Thoracic Aorta in the Endovascular Era: a Medicare Population Study.
Date October 2010
Journal Annals of Surgery
Excerpt Read excerpt

Title The Effects of Systemic Hypothermia on a Murine Model of Thoracic Aortic Ischemia Reperfusion.
Date August 2010
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Long-term Outcomes of Diabetic Patients Undergoing Endovascular Infrainguinal Interventions.
Date August 2010
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Preoperative Variables Predict Persistent Type 2 Endoleak After Endovascular Aneurysm Repair.
Date August 2010
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Surgical Management of Descending Thoracic Aortic Disease: Open and Endovascular Approaches: a Scientific Statement from the American Heart Association.
Date August 2010
Journal Circulation
Title Balloon Expandable Stents Facilitate Right Renal Artery Reconstruction During Complex Open Aortic Aneurysm Repair.
Date March 2010
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Preoperative Functional Status Predicts Perioperative Outcomes After Infrainguinal Bypass Surgery.
Date March 2010
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Intermediate-term Outcomes of Endovascular Treatment for Symptomatic Chronic Mesenteric Ischemia.
Date February 2010
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title A Multicenter Clinical Trial of Endovascular Stent Graft Repair of Acute Catastrophes of the Descending Thoracic Aorta.
Date December 2009
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Effect of Pj34 on Spinal Cord Tissue Viability and Gene Expression in a Murine Model of Thoracic Aortic Reperfusion Injury.
Date December 2009
Journal Vascular and Endovascular Surgery
Excerpt Read excerpt

Title Secondary Intervention After Endovascular Abdominal Aortic Aneurysm Repair.
Date October 2009
Journal Annals of Surgery
Excerpt Read excerpt

Title Aortic Remodeling After Endovascular Repair of Acute Complicated Type B Aortic Dissection.
Date September 2009
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Significant Perioperative Morbidity Accompanies Contemporary Infrainguinal Bypass Surgery: an Nsqip Report.
Date September 2009
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Pj34, a Poly-adp-ribose Polymerase Inhibitor, Modulates Visceral Mitochondrial Activity and Cd14 Expression Following Thoracic Aortic Ischemia-reperfusion.
Date August 2009
Journal American Journal of Surgery
Excerpt Read excerpt

Title Thoracoabdominal Aneurysm Repair: Hybrid Versus Open Repair.
Date July 2009
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Successful Use of Bivalirudin for Combined Carotid Endarterectomy and Coronary Revascularization with the Use of Cardiopulmonary Bypass in a Patient with an Elevated Heparin-platelet Factor 4 Antibody Titer.
Date April 2009
Journal Anesthesia and Analgesia
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Title Atherosclerotic Peripheral Vascular Disease Symposium Ii: Controversies in Carotid Artery Revascularization.
Date January 2009
Journal Circulation
Title Functional Outcome After Thoracoabdominal Aneurysm Repair.
Date December 2008
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Outcomes Following Endovascular Abdominal Aortic Aneurysm Repair (evar): an Anatomic and Device-specific Analysis.
Date August 2008
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
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Title Zenith Abdominal Aortic Aneurysm Endovascular Graft.
Date August 2008
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Spinal Cord Complications After Thoracic Aortic Surgery: Long-term Survival and Functional Status Varies with Deficit Severity.
Date August 2008
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
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Title Five-year Results of Endovascular Treatment with the Gore Tag Device Compared with Open Repair of Thoracic Aortic Aneurysms.
Date June 2008
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
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Title Aortic Aneurysms.
Date May 2008
Journal Journal of the American College of Radiology : Jacr
Title International Controlled Clinical Trial of Thoracic Endovascular Aneurysm Repair with the Zenith Tx2 Endovascular Graft: 1-year Results.
Date March 2008
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
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Title Contemporary Management of Descending Thoracic and Thoracoabdominal Aortic Aneurysms: Endovascular Versus Open.
Date February 2008
Journal Circulation
Title Contemporary Management of Carotid Stenosis: Carotid Endarterectomy is Here to Stay.
Date January 2008
Journal Perspectives in Vascular Surgery and Endovascular Therapy
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Title Long-term Durability of Open Abdominal Aortic Aneurysm Repair.
Date November 2007
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Commentary On: Mas Jl, Chatellier G, Beyssen B, Et Al. Endarterectomy Versus Stenting in Patients with Symptomatic Severe Carotid Stenosis. N Engl J Med. 2006;355:1660-1671.
Date November 2007
Journal Perspectives in Vascular Surgery and Endovascular Therapy
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Title Defining the High-risk Patient for Carotid Endarterectomy: an Analysis of the Prospective National Surgical Quality Improvement Program Database.
Date October 2007
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
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Title Persistent Type 2 Endoleak After Endovascular Repair of Abdominal Aortic Aneurysm is Associated with Adverse Late Outcomes.
Date July 2007
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Restenosis After Eversion Vs Patch Closure Carotid Endarterectomy.
Date July 2007
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Surgical Revascularization Versus Endovascular Therapy for Chronic Mesenteric Ischemia: a Comparative Experience.
Date July 2007
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Comparison of Risk-adjusted 30-day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: Vascular Surgical Operations in Men.
Date July 2007
Journal Journal of the American College of Surgeons
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Title Thoracoabdominal Aneurysm Repair: a 20-year Perspective.
Date March 2007
Journal The Annals of Thoracic Surgery
Excerpt Read excerpt

Title Stent-graft Versus Open-surgical Repair of the Thoracic Aorta: Mid-term Results.
Date January 2007
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
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Title Intermediate Results of Percutaneous Endovascular Therapy of Femoropopliteal Occlusive Disease: a Contemporary Series.
Date October 2006
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
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Title Long-term Outcomes After Endovascular Abdominal Aortic Aneurysm Repair: the First Decade.
Date October 2006
Journal Annals of Surgery
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Title Poly Adenosine Diphosphate-ribose Polymerase Inhibitor Pj34 Abolishes Systemic Proinflammatory Responses to Thoracic Aortic Ischemia and Reperfusion.
Date August 2006
Journal Journal of the American College of Surgeons
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Title Contemporary Results of Open Surgical Repair of Descending Thoracic Aortic Aneurysms.
Date August 2006
Journal Seminars in Vascular Surgery
Excerpt Read excerpt

Title Commentary on “extra-anatomic Visceral Revascularization and Endovascular Stent-grafting for Complex Thoracoabdominal Aortic Lesions”.
Date May 2006
Journal Perspectives in Vascular Surgery and Endovascular Therapy
Title Multi-institutional Pivotal Trial of the Zenith Tx2 Thoracic Aortic Stent-graft for Treatment of Descending Thoracic Aortic Aneurysms: Clinical Study Design.
Date May 2006
Journal Perspectives in Vascular Surgery and Endovascular Therapy
Excerpt Read excerpt

Title Aortic Dissection: Perspectives in the Era of Stent-graft Repair.
Date March 2006
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Title Current Results of Open Surgical Repair of Descending Thoracic Aortic Aneurysms.
Date March 2006
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Title Late Results of Combined Carotid and Coronary Surgery Using Actual Versus Actuarial Methodology.
Date December 2005
Journal The Annals of Thoracic Surgery
Excerpt Read excerpt

Title Contemporary Results of Angioplasty-based Infrainguinal Percutaneous Interventions.
Date November 2005
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Pj34, a Poly-adp-ribose Polymerase Inhibitor, Modulates Renal Injury After Thoracic Aortic Ischemia/reperfusion.
Date October 2005
Journal Surgery
Excerpt Read excerpt

Title Safety and Efficacy of Reoperative Carotid Endarterectomy: a 14-year Experience.
Date July 2005
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Determinants of Carotid Endarterectomy Anatomic Durability: Effects of Serum Lipids and Lipid-lowering Drugs.
Date May 2005
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Early Outcomes of Endovascular Versus Open Abdominal Aortic Aneurysm Repair in the National Surgical Quality Improvement Program-private Sector (nsqip-ps).
Date May 2005
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Thoracoabdominal Aneurysm Repair: Anesthetic Management.
Date March 2005
Journal International Anesthesiology Clinics
Title Endovascular Treatment of Thoracic Aortic Aneurysms: Results of the Phase Ii Multicenter Trial of the Gore Tag Thoracic Endoprosthesis.
Date March 2005
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Poly(adenosine Diphosphate Ribose) Polymerase Inhibition Modulates Spinal Cord Dysfunction After Thoracoabdominal Aortic Ischemia-reperfusion.
Date March 2005
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Current Status of Thoracoabdominal Aneurysm Repair.
Date November 2004
Journal Advances in Surgery
Title Stenting for Carotid-artery Stenosis.
Date October 2004
Journal The New England Journal of Medicine
Title Carotid Endarterectomy at the Millennium: What Interventional Therapy Must Match.
Date September 2004
Journal Annals of Surgery
Excerpt Read excerpt

Title Surgical Management of Popliteal Artery Embolism at the Turn of the Millennium.
Date June 2004
Journal Annals of Vascular Surgery
Excerpt Read excerpt

Title Regional Hypothermia with Epidural Cooling for Prevention of Spinal Cord Ischemic Complications After Thoracoabdominal Aortic Surgery.
Date April 2004
Journal Seminars in Thoracic and Cardiovascular Surgery
Excerpt Read excerpt

Title Preservation of Renal Function with Surgical Revascularization in Patients with Atherosclerotic Renovascular Disease.
Date February 2004
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Durability of Aortouniiliac Endografting with Femorofemoral Crossover: 4-year Experience in the Evt/guidant Trials.
Date June 2003
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Late Aortic and Graft-related Events After Thoracoabdominal Aneurysm Repair.
Date February 2003
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Surgical Treatment of Complicated Distal Aortic Dissection.
Date October 2002
Journal Seminars in Vascular Surgery
Excerpt Read excerpt

Title Thoracoabdominal Aneurysm Repair: Results with 337 Operations Performed over a 15-year Interval.
Date October 2002
Journal Annals of Surgery
Excerpt Read excerpt

Title Clinical Outcome of Internal Iliac Artery Occlusions During Endovascular Treatment of Aortoiliac Aneurysmal Diseases.
Date October 2002
Journal Journal of Vascular and Interventional Radiology : Jvir
Excerpt Read excerpt

Title Evolving Experience with Thoracic Aortic Stent Graft Repair.
Date July 2002
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Clinical Failures of Endovascular Abdominal Aortic Aneurysm Repair: Incidence, Causes, and Management.
Date July 2002
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Regarding “analysis of Predictive Factors for Progression of Type B Aortic Intramural Hematoma with Computed Tomography”.
Date July 2002
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Title Contemporary Management of Aortic Branch Compromise Resulting from Acute Aortic Dissection.
Date July 2001
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Endovascular Stent-graft in Abdominal Aortic Aneurysms: the Relationship Between Patent Vessels That Arise from the Aneurysmal Sac and Early Endoleak.
Date June 2001
Journal Radiology
Excerpt Read excerpt

Title Regional Hypothermia with Epidural Cooling for Spinal Cord Protection During Thoracoabdominal Aneurysm Repair.
Date April 2001
Journal Seminars in Vascular Surgery
Excerpt Read excerpt

Title Endovascular Repair of Abdominal Aortic Aneurysms: Current Status and Future Directions.
Date August 2000
Journal Ajr. American Journal of Roentgenology
Title Epidural Cooling for Spinal Cord Protection During Thoracoabdominal Aneurysm Repair: A Five-year Experience.
Date July 2000
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Utility and Reliability of Endovascular Aortouniiliac with Femorofemoral Crossover Graft for Aortoiliac Aneurysmal Disease.
Date July 2000
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

Title Surgical Renal Artery Reconstruction Without Contrast Arteriography: the Role of Clinical Profiling and Magnetic Resonance Angiography.
Date January 2000
Journal Journal of Vascular Surgery : Official Publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
Excerpt Read excerpt

http://www.vitals.com/doctors/Dr_Richard_Cambria/credentials
http://www.vitals.com/doctors/Dr_Richard_Cambria/credentials#ixzz2VqyhFZVd

Cambria RP, Brewster DC, Lauterbach SR, Kaufman JA, Geller SC, Fan CM, Greenfield A, Hilgenberg A, Clouse WD. Evolving experience with thoracic aortic stent-graft repair. J Vasc Surg 2002:35:1129-36.

Cambria, RP, Clouse WD, Davison JK, Dunn PF, Corey M, Dorer D. Thoracoabdominal aneurysm repair: Results with 337 operations performed over a 15 year interval. Ann Surg 2002;236-471-79.

Cambria RP, Lauterbach SR, Brewster DC, Gertler JP, LaMuraglia GM, Isselbacher EM, Hilgenberg AD, Moncure AC. Contemporary management of aortic branch compromise secondary to acute aortic dissections. J Vasc Surg 2001;331185-92.

Cambria RP and Black JH. Aortic dissection perspectives for the vascular/endovascular surgeon. In Rutherford (ed) Comprehensive Vascular and Endovascular Surgery 6 th , W. B. Saunders, Inc. (in press, 2004).

Cambria RP, Marone LK, Cloud WD, Dorer, DJ, Brewster, DC, LaMuraglia, GM, Watkins, MT, Kwolek, CJ. Preservation of renal functions with surgical revascularization in patients with atherosclerotic renovascular disease. J Vasc Surg 2004; 10.023.

Abdominal Aortic Aneurysm – Case Study

by

Angela Rodriguez-Wong, MD, RVT, RPVI

Lois Eliassi, BS, RVT

http://www.navixdiagnostix.com/downloads/Navix%20-%20Q1%20’13%20Ultrasound%20Solutions.pdf

An aneurysm is defined as a focally dilated segment of an artery that is 1.5 times its normal diameter and involves all three arterial walls (intima, media and adventitia). Aneurysms can be found in the common femoral and popliteal arteries in the lower extremities, the splenic, mesenteric, and renal arteries in the abdomen, and also in the intracranial vessels. However, the most common is an abdominal aortic aneurysm (AAA) involving the aorta and iliac arteries.

Abdominal aortic aneurysms are generally asymptomatic and are discovered accidentally either by physician palpation or by a radiologic examination such as a chest or abdominal X-ray. The risk factors that increase the probability of developing a AAA are primarily smoking and family history. An abdominal aortic aneurysm can rupture and, according to the Centers for Disease Control and Prevention, ruptured AAA was the 10th leading cause of death in males between the ages of 65-74 in the United States in 2000.

The preferred method of screening for AAA is diagnostic ultrasound. According to the Journal of Vascular Surgery, diagnostic ultrasound performed by a registered vascular technologist has a sensitivity of 100 percent and a specificity of 96 percent for the detection of an infrarenal AAA. The abdominal aorta is considered aneurysmal when it measures >3.0 cm.

Because of its accuracy, diagnostic ultrasound not only has become an integral part in diagnosing AAA but is also an integral part in the evaluation of disease progression, the preoperative AAA evaluation, and the follow-up of AAA surgical repair. It is important to note that a rupture of an AAA is a surgical emergency and is difficult to evaluate with ultrasound due to the inability to easily demonstrate abdominal free fluid. If a rupture is suspected, it is recommended that other imaging modalities such as CT be employed to better demonstrate the ruptured aneurysm and any intra-abdominal free fluid.

Case Study – 

Abdominal Aortic Aneurysm – A 77 year-old male

Angela Rodriguez-Wong, MD, RVT, RPVI

Lois Eliassi, BS, RVT

Figure 1 Distal abdominal aortic aneurysm with mural thrombus.

pic1

Figure 2 Bifurcation of the aorta.

pic2

Case Study: A 77 year-old male with a past medical history of diabetes, hypertension, arthritis, aortic valve disease and heavy smoking was referred to Eastern Vascular Diagnostic Center with a 4.2 centimeter aneurysm. The patient denied any family history of aneurysm and is allergic to intravenous contrast. A physical exam found the patient alert with a blood pressure of 100/60 mmHg, a pulse of 58 and respiration of 16. Auscultation found a bruit in the left carotid artery, clear lungs, and a regular heart rhythm with an aortic systolic murmur. The patient had a well healed sub-costal incision on his abdomen. The physician was unable to palpate the aneurysms. The patient had an aortic valve replacement in 2007 and also a cholecystectomy. On May 12, 2012, a magnetic resonance imaging (MRI) scan without contrast was performed on the patient’s abdomen. The MRI found an AAA measuring greater than 3 cm with extensive plaque near the bifurcation. The aneurysm extended into the right common iliac artery (CIA) measuring 4.2 cm and into the left CIA measuring 3.1 cm. The MRI exam did not include the pelvis, so the extent of the iliac aneurysms was not clear. On July 31, 2012, the ultrasound was performed, demonstrating normal ankle brachial index (right-1.2, left-1.1) and a AAA measuring 3.9 cm which extended into the right and left CIA. The maximum diameter of the right CIA measures 4.1 cm with mural thrombus creating a residual lumen of 2.0 cm. The maximum diameter of the left CIA measures 4.3 cm, there is also mural thrombus noted but without significant appreciable diameter reduction within the vessel. A computed tomography (CT) scan of the abdomen and pelvis without contrast was performed on July 18th confirming the infrarenal AAA with extension into the iliac arteries bilaterally.

Surgery is recommended when an AAA reaches 5.0-5.5 cm in a male and 4.5-5.0 cm in females. Surgery, depending on the aneurysm, can be an open repair or an endovascular repair. In this patient, despite the size of the AAA being 4.1 cm, the disease also involved the bilateral common iliacs prompting the need for surgical intervention. The patient was cleared by cardiology and on July 31st had an AAA and bilateral Iliac aneurysm resection with a re-implantation of the inferior mesenteric artery and an Aorta to right Hypogastric bypass to maintain pelvic perfusion.

The U.S. Preventive Services Task Force has released a statement summarizing recommendations for screening for AAA. It states that screening benefits patients who have a relatively high risk for dying from an aneurysm; major risk factors are age 65 years or older, male sex, and smoking at least 100 cigarettes in a lifetime. The guideline recommends one-time screening with ultrasound for AAA in men 65 to 75 years of age who have ever smoked. No recommendation was made for or against screening in men 65 to 75 years of age who have never smoked, and it recommended against screening women. Men with a strong family history of AAA should be counseled about the risks and benefits of screening as they approach 65 years of age.

Angela Rodriguez-Wong, MD, RVT, RPVI 

awong@navixdiagnostix.com

Lois Eliassi, BS, RVT

leliassi@navixdiagnostix.com

Figure 3 Sagittal image of the right common iliac artery demonstrating the measurement of the aneurysm and the true lumen.

pic3

Figure 4 Coronal view of the left common iliac artery.

pic4

REFERENCES 

1. Anderson RN. Deaths: Leading causes for 2000. Natl Vital Stat Rep. 2002;50:1–85.

2. Kent KC, Zwolak RM, Jaff MR, et al. Screening for abdominal aortic aneurysm. J Vasc Surg. 2004;39:267–9.

3. Upchurch G Jr, Schaub T. Abdominal aortic aneurysm. American Family Physician. 2006;73(7), 1198-1204. http://www.aafp.org/afp/2006/0401/p1198.html

http://www.navixdiagnostix.com/downloads/Navix%20-%20Q1%20’13%20Ultrasound%20Solutions.pdf

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Reporter: Aviva Lev-Ari, PhD, RN

 

PCR is an organisation dedicated to education and information in the field of cardiovascular therapies, most notably for cardiolovascular intervention and interventional medicine.
Its activities cover a large spectrum, from the organisation of annual courses in Europe, Asia and the Middle East to editing a scientific journal, publishing textbooks as well as providing training seminars on thematic subjects.

[92] TUESDAY 21 MAY

Abstract & Case Corner
Complex and unusual interventions for structural heart disease 12:30 – 13:30
Congenital disease treatment in children and adults 13:30 – 15:00
Challenges during percutaneous balloon mitral valvuloplasty 15:00 – 16:30
Percutaneous treatment of mitral regurgitation 16:45 – 18:15
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2013 Great Debate: The burning issues – Bioresorbable scaffolds and dual antiplatelet therapy 
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13:00 – 14:30
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In vascular disease, think global! 15:30 – 16:30
Room 241
Embolic stroke and cardiovascular interventions 13:30 – 15:00
RSICA@EuroPCR – Combined structural heart disease interventions 
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15:00 – 16:30
Percutanous haemodynamic support in high-risk PCI and cardiogenic shock: your safety net in the cathlab 
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16:45 – 18:15
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How to decide between antegrade versus retrograde recanalisation of coronary chronic total occlusions? 12:30 – 13:30
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Coronary chronic total occlusion: set up your strategy to achieve success while keeping it simple 
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A decade of experience with DES: insights from large registries and randomised clinical trials 12:30 – 14:00
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Emerging technologies for transcatheter aortic valve therapies – Part I 
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Catheter-based renal sympathetic denervation: long-term Symplicity clinical evidence, new data and future perspectives 
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Outcome in contemporary coronary intervention 12:30 – 14:00
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Patients in whom PCI is preferred over CABG 
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Risk scores to aid decision making between CABG and PCI – Role of SYNTAX Score II 12:30 – 14:00
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Various imaging techniques for TAVI procedures 12:30 – 14:00
TAVI nightmares 
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Left main PCI using transradial approach 
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Expanding the indication for TAVI: who, why and when? 14:30 – 16:30
Tips and tricks on the four key steps of left atrial appendage closure: selection, planning, imaging, and guidance 
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16:45 – 18:45
Theatre Havane
Learning bifurcations – How to successfully perform PCI in your patient presenting complex bifurcation lesions requiring two stents 14:00 – 15:30
Interactive case-based discussion on complex bifurcations 15:40 – 16:30
Incorporating bioresorbable vascular scaffolds in daily clinical practice: the time has come 
With an unrestricted educational grant from ABBOTT VASCULAR

 

[173] WEDNESDAY 22 MAY

Abstract & Case Corner
Left main treatment: dedicated stents, complex strategies and post-CABG situation 08:00 – 09:30
Left main PCI for left main disease intervention: outcome in 2013 09:45 – 10:45
Treatment of left main stem stenosis in high-risk patients 10:45 – 11:45
Fistula and haematoma during PCI 12:00 – 13:00
PCI challenges: just another day in the cathlab? 13:00 – 14:00
Retrieval techniques of lost ‘bits and pieces’ during PCI 14:10 – 15:40
Unusual causes of ACS 15:40 – 16:40
Stent deformation during PCI 16:45 – 18:15
Interactive Case Corner
Interactive case corner #4 08:00 – 09:30
Interactive case corner #5 09:45 – 11:15
Interactive case corner #6 12:00 – 13:30
Interactive case corner #7 14:10 – 15:40
Interactive case corner #8 16:45 – 18:15
Main arena
Complex cardiovascular interventions and new techniques – Master LIVE demonstrations by Jean Fajadet & Talib Majwal and expert panel discussion 08:00 – 11:45
Complex cardiovascular interventions and new techniques – Master LIVE demonstrations by Karl Heinz Kuck & Talib Majwal and expert panel discussion 14:10 – 16:45
Moderated Poster Area
Moderated posters 2 12:00 – 14:00
Moderated posters 3 16:45 – 18:15
Nurses and Technicians Corner
Moderated posters 12:00 – 13:00
PCR Sharing Centre
Do you want to become comfortable with pathophysiology? Practical example: hypertensive patients 08:00 – 09:00
Understand what you see with the iPad Atlas of OCT – Interactive OCT image interpretation 09:45 – 11:15
Do you want to become comfortable with health economics? Practical example: is renal denervation cost effective? 14:10 – 15:10
Do you want to become comfortable with data analysis? 15:40 – 16:40
Peripheral Abstract & Case Corner
Thoraco-abdominal aneurysm treatment 08:00 – 09:30
Endovascular aortic aneurysm repair: an evergrowing story 09:45 – 10:45
Aortic aneurysms: fundamentals to innovation 10:45 – 11:45
Renal artery stenting: challenging but rewarding cases 12:00 – 13:00
How to manage aorto-renal rupture and dissection 13:00 – 14:00
Aneurysm and false aneurysm management for superficial femoral artery and popliteal artery 14:10 – 15:40
Multilevel vascular interventions 15:40 – 16:40
Complications and great saves on carotid interventions 16:45 – 17:45
Room 241
Percutaneous mitral valve repair with the MitraClip system: determinants of outcome 08:00 – 09:30
Technical and approach issues in renal artery stenting 
Under the auspices of the Working Group on Interventional Cardiology of the Bulgarian Society of Cardiology, the Working Group on Interventional Cardiology of the Macedonian Society of Cardiology and the Working Group on Interventional Cardiology of the Romanian Society of Cardiology
09:45 – 11:45
Chronic total occlusion and multivessel disease: can novel imaging help to reduce risks? 
With an unrestricted educational grant from PHILIPS and INFRAREDX
12:00 – 13:00
Cardioprotective strategies to reduce ischaemic injury during PCI 
With an unrestricted educational grant from MENARINI
13:05 – 14:05
How to avoid patient-prosthesis mismatch and aortic regurgitation after aortic valve interventions 14:10 – 15:40
Hot Line – First-in-man in valvular heart disease 15:40 – 16:40
New frontiers – Exploring reduced contrast volume and fluoroscopy time with the GPSCath balloon dilatation catheter for complex percutaneous transluminal angioplasty procedures 
With an unrestricted educational grant from TELEFLEX
16:45 – 18:15
Room 242AB
Innovative stents and scaffolds 08:00 – 09:40
Emerging technologies for transcatheter aortic valve therapies – Part II 09:45 – 11:45
Real-world considerations for selecting antiplatelet therapy in high-risk ACS patients: putting evidence into clinical practice 
This educational programme is accredited by EBAC for one hour of External CME credit – Programme supported by an unrestricted educational grant from ASTRAZENECA
12:00 – 13:30
Hot Line – Trial updates and registries 14:10 – 15:10
Managing patients with unprotected left main coronary artery disease 
With the collaboration of China Interventional Therapeutics (CIT)
15:10 – 16:40
Catheter-based renal sympathetic denervation – Building momentum with the next generation Vessix system 
With an unrestricted educational grant from BOSTON SCIENTIFIC
16:45 – 18:15
Room 243
Challenging coronary artery intervention in ACS 
Under the auspices of the Iranian Society of Interventional Cardiology (ISOIC) and the Russian Society of Interventional Cardioangiology (RSICA)
08:00 – 09:30
Hot Line – First-in-man & novel DES and scaffolds 09:45 – 11:45
Management of complex coronary disease in Asia Pacific 
With an unrestricted educational grant from MEDTRONIC
12:00 – 13:30
Complex cardiovascular intervention in patients primarily reported as ACS 
Under the auspices of the Working Group on Interventional Cardiology of the Czech Society of Cardiology and the Working Group on Interventional Cardiology of the Slovak Society of Cardiology
14:10 – 15:40
How to improve the STEMI treatment in large territories like Russia? 15:40 – 16:40
Impact of thrombus aspiration device on the results of primary PCI 16:45 – 18:15
Room 251
Primary PCI in complex STEMI with cardiogenic shock 08:00 – 09:30
Learning FFR – Assisting for FFR measurement in the cathlab 09:45 – 11:15
Synchronising polymer absorption and drug elution with the Synergy stent. Implications for healing and dual antiplatelet therapy duration 
With an unrestricted educational grant from BOSTON SCIENTIFIC
12:00 – 13:00
The Direct Flow valve: innovation for improving outcomes in TAVI 
With an unrestricted educational grant from DIRECT FLOW MEDICAL
13:05 – 14:05
Assisting for PCI through radial approach 14:10 – 15:40
Pre-procedure risk assessment to prevent complications after/during PCI 15:40 – 16:40
Clinical value of anti-restenosis and pro-healing Combo stent 
With an unrestricted educational grant from ORBUSNEICH
16:45 – 18:15
Room 252AB
How to treat a patient with complex multivessel disease and/or left main disease 
Under the auspices of the Argentine College of Interventional Cardioangiologist (CACI) and the Atheroma Coronary and Interventional Cardiology Group (GACI)
08:00 – 09:30
GRCI@EuroPCR – Challenging cases in the catheterisation laboratory: international viewpoint Gestion de cas complexes en salle de cathétérisme: approche internationale 
Bilingual session in collaboration with the GRCI (Groupe de Réflexion sur la Cardiologie Interventionnelle) Session bilingue en collaboration avec le GRCI (Groupe de Réflexion sur la Cardiologie Interventionnelle)
09:45 – 11:15
Advancing innovations in catheter-based renal sympathetic denervation 
CORDIS, JOHNSON & JOHNSON
12:00 – 13:30
Device-based interventions in heart failure: targeting deleterious mechanisms of heart failure progression 14:10 – 15:40
Novel devices for acute or chronic heart failure 15:40 – 16:40
DES and dual antiplatelet therapy: customising treatment duration to your patient 
With an unrestricted educational grant from ABBOTT VASCULAR
16:45 – 18:15
Room 253
Transradial approach for complex coronary interventions in patients with ACS 
Under the auspices of the Working Group on Interventional Cardiology of the Hungarian Society of Cardiology and the Working Group on Interventional Cardiology of the Macedonian Society of Cardiology
08:00 – 09:30
How to write a scientific manuscript and get it published! 09:45 – 10:45
From bench to cathlab: clinical implication of stent design 10:45 – 11:45
Conduction disturbances after TAVI 12:00 – 13:00
Overcoming TAVI challenges 13:00 – 14:00
Planning is the key to avoiding TAVI complications 
Under the auspices of the Association of Cardiovascular Interventions (ACVI) of the Polish Cardiac Society and the South African Society of Cardiovascular Intervention (SASCI)
14:10 – 15:40
How to write a scientific abstract and get it accepted! 15:40 – 16:40
Use of DES in specific subsets of patients/lesions 16:45 – 18:15
Room 341
Tough calls in primary PCI: STEMI and multivessel disease 
Under the auspices of the Working Group on Interventional Cardiology of the Israeli Heart Society and the Working Group on Interventional Cardiology of the Slovenian Society of Cardiology
08:00 – 09:30
Antegrade or retrograde strategy for coronary chronic total occlusion recanalisation? 09:45 – 10:45
Complicated coronary chronic total occlusion recanalisation 10:45 – 11:45
Resistant hypertension and its treatment across the world 
With an unrestricted educational grant from TERUMO
12:00 – 13:00
Coronary intervention in the elderly population 13:00 – 14:00
PCI in the elderly: when to stop, when to intervene 
Under the auspices of the Working Group on Interventional Cardiology of the Dutch Society of Cardiology and the Working Group on Interventional Cardiology (GTCI) of the Tunisian Society of Cardiology and Cardiovascular Surgery
14:10 – 15:40
Percutaneous revascularisation from coronary chronic total occlusion: results from registries 15:40 – 16:40
Single-guide catheter techniques for retrograde recanalisations for coronary chronic total occlusions 16:45 – 18:15
Room 342A
Intravascular diagnostics – Does it really change our treatment strategy? 
Under the auspices of the Working Group on Interventional Cardiology of the Danish Society of Cardiology and the Working Group on Interventional Cardiology of the Norwegian Society of Cardiology
08:00 – 09:30
Multivessel disease: “a tale of two cities” 
Under the auspices of the British Cardiovascular Intervention Society (BCIS) and the Working Group on Interventional Cardiology of the Cyprus Society of Cardiology
09:45 – 11:15
Self-expanding stents: a NEW solution for patients presenting with atypical coronary anatomy 
With an unrestricted educational grant from STENTYS
12:00 – 13:30
Complex primary PCI in high-risk STEMI patients 14:10 – 15:40
Non-left main bifurcation stenting: tips and tricks 15:40 – 16:40
Ischaemia-driven revascularisation: the evolution of FFR in daily practice 
With an unrestricted educational grant from ST. JUDE MEDICAL
16:45 – 18:15
Room 342B
Unusual causes of STEMI in young women 08:00 – 09:30
Different approaches for thrombus removal during primary PCI 09:45 – 10:45
Primary PCI for STEMI when stent is not the solution 10:45 – 11:45
Revascularisation strategies for multivessel disease patients: stents, bypasses or both? 12:00 – 13:00
Complex PCI in patients with multivessel disease 13:00 – 14:00
Challenging cases from Turkey 
With the collaboration of the Turkish Society of Cardiology’s Association of Percutaneous Cardiovascular Interventions
14:10 – 15:10
Individualised antiplatelet therapy based on testing or genotyping: idea from the past or solution for the future 15:40 – 16:40
Real life use of bioabsorbable vascular scaffold in coronary disease 16:45 – 18:15
Room 343
Patent foramen ovale closure in patients with cryptogenic stroke – Timed out or role respected? 
Under the auspices of the British Cardiovascular Intervention Society (BCIS) and the Working Group on Interventional Cardiology of the Danish Society of Cardiology
08:00 – 09:30
Multislice computed tomography: emerging indication in interventional cardiology 09:45 – 10:45
The role of non-invasive imaging to guide percutaneous coronary revascularisation procedures 10:45 – 11:45
FFR in the real world 12:00 – 13:00
FFR are we working with the best threshold? 13:00 – 14:00
STEMI and multivessel disease 
Under the auspices of the Working Group on Interventional Cardiology of the Georgian Society of Cardiology and the Working Group on Interventional Cardiology of the Kazakhstanese Society of Cardiology
14:10 – 15:40
Coronary aneurysms and ACS 15:40 – 16:40
Left ventricular assistance devices in acute ischaemic heart failure 16:45 – 18:15
Room 351
All you need to know about TAVI 08:00 – 09:30
New devices for TAVI 09:45 – 10:45
Percutaneous valve implantation: new valves and new indications 10:45 – 11:45
Complex patients today and tomorrow: Medtronic DES solutions from Resolute Integrity to bioresorbable stents 
With an unrestricted educational grant from MEDTRONIC
12:00 – 13:30
All you need to know about OCT 14:10 – 15:40
Use of OCT during PCI 15:40 – 16:40
The Medtronic transcatheter valve programmes – Recapturability, transapical technology and mitral solutions 
With an unrestricted educational grant from MEDTRONIC
16:45 – 18:15
Room 352A
You are facing an elderly patient presenting with high risk NSTE-ACS: how do you successfully perform PCI? 08:00 – 09:30
Radial approach – Fundamental rules 09:45 – 10:40
Radial approach – Navigation from radial to brachial 10:50 – 11:45
Radial access: anything new? 12:00 – 13:00
When there is no access site, remember that the arteries lead to the heart 13:00 – 14:00
You are facing a patient presenting with an acute STEMI: how do you successfully perform PCI? 14:10 – 15:40
Radial approach – Navigation from brachial artery to ascending aorta 15:45 – 16:40
Radial access: a gold standard worldwide? 16:45 – 18:15
Room 352B
TAVI: typical and atypical complications 
Under the auspices of the Association of Cardiovascular Interventions (ACVI) of Polish Cardiac Society and the Saudi Arabia Cardiology Interventional Group (SACIG) of the Saudia Heart Association
08:00 – 09:30
AICT@EuroPCR – How Asia performs PCI of coronary chronic total occlusion 
With the collaboration of the Asian Interventional Cardiovascular Therapeutics (AICT)
09:45 – 11:15
Titanium-nitride-oxide bioactive stent: the evidence-based choice in STEMI and NSTEMI patients 
With an unrestricted educational grant from HEXACATH
12:00 – 13:30
TAVI and coronary artery disease: what is the best treatment strategy? 
Under the auspices of the Working Group on Interventional Cardiology of the Latvian Society of Cardiology and the Russian Society of Interventional Cardioangiology
14:10 – 15:40
TAVI and coronary artery disease 15:40 – 16:40
A new combination of factor Xa inhibition and standard antiplatelet therapy to prevent more recurrent cardiovascular events in ACS 
With an unrestricted educational grant from BAYER HEALTHCARE PHARMACEUTICALS
16:45 – 18:15
Room 353
Czech Republic shares its most educational cases 
Under the auspices of the Working Group on Interventional Cardiology of the Czech Society of Cardiology
08:00 – 08:45
India shares its most educational cases 
Under the auspices of the Cardiovascular Society of India
08:45 – 09:30
Hungary shares its most educational cases 
Under the auspices of the Working Group on Interventional Cardiology of the Hungarian Society of Cardiology
09:45 – 10:30
Saudi Arabia shares its most educational cases 
Under the auspices of the Saudi Arabia Cardiology Interventional Society (SACIS) of the Saudia Heart Association
10:30 – 11:15
South Africa shares its most educational cases 
Under the auspices of the South African Society of Cardiovascular Intervention (SASCI)
11:15 – 12:00
Diabetes and coronary artery disease: a bad association! 12:00 – 13:00
Renal function and clinical outcome after PCI 13:00 – 14:00
Switzerland shares its most educational cases 
Under the auspices of the Working Goup on Interventional Cardiology and ACS of the Swiss Society of Cardiology
14:10 – 14:55
United Kingdom shares its most educational cases 
Under the auspices of the British Cardiovascular Intervention Society (BCIS)
14:55 – 15:40
Serbia shares its most educational cases 
Under the auspices of the Working Group on Interventional Cardiology of the Serbian Society of Cardiology
15:40 – 16:25
Iran shares its most educational cases 
Under the auspices of the Iranian Society of Interventional Cardiology (ISOIC)
16:45 – 17:30
Germany shares its most educational cases 
Under the auspices of the Working Group on Interventional Cardiology (AGIK) of the German Society of Cardiology (DGK)
17:30 – 18:15
Room Cordis
Training Village: Radial approach for coronary diagnostic and interventions – hands-on with the experts 
With an unrestricted educational grant from CORDIS CARDIAC & VASCULAR INSTITUTE
09:00 – 11:00
Training Village: Catheter-based renal sympathetic denervation: introduction to an irrigated technology 
With an unrestricted educational grant from CORDIS CARDIAC & VASCULAR INSTITUTE
14:00 – 15:00
Training Village: Advanced tips and tricks: vessel preparation and post dilation 
With an unrestricted educational grant from CORDIS CARDIAC & VASCULAR INSTITUTE
15:30 – 16:30
Room Maillot
Carotid LIVE session: the “state-of-the-art” of stroke prevention 08:00 – 09:55
Access is key for carotid artery stenting in complex aortic arches 10:00 – 10:50
Embolic protection devices for carotid artery stenting 10:50 – 11:45
Access is critical 
With an unrestricted educational grant from COOK MEDICAL
12:00 – 13:30
Visceral and renal artery interventions 14:10 – 15:40
Guest lectures: how I survived the peripheral endovascular battle? 15:40 – 16:40
The evolving evidence of IN.PACT drug-eluting balloon in claudication and critical limb ischaemia 
With an unrestricted educational grant from MEDTRONIC
16:45 – 18:15
Room Medtronic Academia
Training Village: Hands-on introduction to the new Symplicity Spyral catheter-based renal sympathetic denervation system 
With an unrestricted educational grant from MEDTRONIC ACADEMIA
09:00 – 10:30
Training Village: Hands-on introduction to the new Symplicity Spyral catheter-based renal sympathetic denervation system 
With an unrestricted educational grant from MEDTRONIC ACADEMIA
10:30 – 12:00
Training Village: Hands-on introduction to the new Symplicity Spyral catheter-based renal sympathetic denervation system 
With an unrestricted educational grant from MEDTRONIC ACADEMIA
12:30 – 14:00
Training Village: Hands-on introduction to the new Symplicity Spyral catheter-based renal sympathetic denervation system 
With an unrestricted educational grant from MEDTRONIC ACADEMIA
14:15 – 15:45
Training Village: Hands-on introduction to the new Symplicity Spyral catheter-based renal sympathetic denervation system 
With an unrestricted educational grant from MEDTRONIC ACADEMIA
16:00 – 17:30
Room St Jude Medical
Training Village: Left atrial appendage 
With an unrestricted educational grant from ST. JUDE MEDICAL
09:00 – 10:30
Training Village: TAVI 
With an unrestricted educational grant from ST. JUDE MEDICAL
10:15 – 11:15
Training Village: Left atrial appendage 
With an unrestricted educational grant from ST. JUDE MEDICAL
10:45 – 12:15
Training Village: TAVI 
With an unrestricted educational grant from ST. JUDE MEDICAL
11:30 – 12:30
Training Village: TAVI 
With an unrestricted educational grant from ST. JUDE MEDICAL
14:00 – 15:00
Training Village: TAVI 
With an unrestricted educational grant from ST. JUDE MEDICAL
15:15 – 16:15
Training Village: Left atrial appendage 
With an unrestricted educational grant from ST. JUDE MEDICAL
15:45 – 17:15
Training Village: TAVI 
With an unrestricted educational grant from ST. JUDE MEDICAL
16:30 – 17:30
Talk ‘LIVE’ Corner
Talk ‘LIVE’ 17:00 – 18:30
Theatre Bleu
Structured care pathways for NSTE-ACS: best practice examples 08:00 – 09:30
Complex bifurcation stenting: LIVE demonstration of emerging techniques 09:45 – 11:45
Do we really need dedicated stents to treat bifurcation lesions? 
With an unrestricted educational grant from BIOSENSORS INTERNATIONAL
12:00 – 14:00
Bioresorbable coronary scaffolds in practice 14:10 – 16:10
Acurate positioning of transapical and transfemoral aortic valves with self-seating and self-sealing design 
With an unrestricted educational grant from SYMETIS S.A.
16:45 – 18:45
Theatre Bordeaux
The best way to diagnose ischaemia in my patient? Convince me! Personal views from interventional cardiologists 08:00 – 09:30
Can left atrial appendage or patent foramen ovale closure prevent embolic stroke? 09:45 – 11:45
Optimising PCI outcomes using OCT and FFR in patients with stable and acute coronary artery disease 
With an unrestricted educational grant from ST. JUDE MEDICAL
12:00 – 14:00
What to do with coronary artery disease in TAVI candidates? 14:10 – 16:10
The next frontier for catheter-based renal sympathetic denervation for patients with resistant hypertension 
With an unrestricted educational grant from COVIDIEN
16:45 – 18:45
Theatre Havane
Learning access for TAVI – Access options for TAVI 08:00 – 09:30
Learning transseptal puncture and mitral balloon valvuloplasty – Transseptal puncture and mitral balloon valvuloplasty made easy 10:15 – 11:45
An in-depth look into the BIOFLOW trials: a modern limus-eluting stent with bioabsorbable polymer 
With an unrestricted educational grant from BIOTRONIK
12:00 – 13:30
Learning atrial closure procedures – Patent foramen ovale and left atrial appendage closure made easy 14:10 – 15:40
Interactive case-based discussion – complications on atrial closure procedures 15:45 – 16:40
Interventional management of high-risk ACS and STEMI: don’t just do it… do it right! 
With an unrestricted educational grant from TERUMO and THE MEDICINES COMPANY
16:45 – 18:15

[172] THURSDAY 23 MAY

Abstract & Case Corner
FFR or IVUS to guide coronary revascularisation? Do you believe in morphology or function? 08:00 – 09:30
Role of imaging in in-stent restenosis 09:45 – 10:45
Diagnostics and management of stent fracture 10:45 – 11:45
PCI of totally occluded saphenous vein graft 12:00 – 13:00
Interventional management of unusual causes of angina 13:00 – 14:00
The role of drug-eluting balloons in contemporary coronary intervention 14:10 – 15:40
Management of late in-stent restenosis 15:40 – 16:40
Coronary perforation management 16:45 – 17:45
Interactive Case Corner
Interactive case corner #9 08:00 – 09:30
Interactive case corner #10 09:45 – 11:15
Interactive case corner #11 12:00 – 13:30
Interactive case corner #12 14:10 – 15:40
Interactive case corner #13 16:45 – 18:15
Main arena
Complex cardiovascular interventions and new techniques – Master LIVE demonstrations by Corrado Tamburino, Martyn Thomas & Simon Redwood and expert panel discussion 08:00 – 11:45
Complex cardiovascular interventions and new techniques – Master LIVE demonstrations by Christian Hamm & Corrado Tamburino and expert panel discussion 14:10 – 16:45
Moderated Poster Area
Moderated posters 4 12:00 – 14:00
Moderated posters 5 16:45 – 18:15
PCR Sharing Centre
Understand what you see with the iPad Atlas of OCT – Interactive OCT image interpretation 08:00 – 09:30
Do you want to be more confident when developing and delivering PowerPoint presentations? 14:10 – 15:10
Do you want to become comfortable with data analysis? 15:40 – 16:40
Peripheral Abstract & Case Corner
Tips and tricks in carotid artery stenting 08:00 – 09:30
Carotid artery stenting: clinical outcome 09:45 – 10:45
Acute procedural events in carotid artery stenting 10:45 – 11:45
Carotid artery stenting: novelties in risk assessment 12:00 – 13:00
Carotid artery stenting: challenging scenarios 13:00 – 14:00
Aorto-iliac angioplasty: what is new in 2013 14:10 – 15:40
Iliac angioplasty 15:40 – 16:40
Complex aortic interventions 
With the collaboration of the International Society of Endovascular Specialists
16:45 – 18:15
Room 241
How I treat complications after peripheral endovascular intervention 
Under the auspices of the Italian Society for Vascular and Endovascular Surgery (SICVE) and the Vascular Surgery Society of Southern Africa (VASSA)
08:00 – 09:30
Cardiovascular Innovation Pipeline – New valves and devices 09:45 – 10:45
Radiation safety during PCI 10:45 – 11:45
Innovating vascular restoration: paving the way for the DESolve scaffold platform 
With an unrestricted educational grant from ELIXIR MEDICAL
12:00 – 13:30
How to prevent and treat ilio-femoral complications of TAVI? 14:10 – 15:40
Emerging technologies for transcatheter mitral valve therapies 2013 – Part I: transcatheter mitral valve repair devices 15:40 – 16:40
Tryton growing clinical experience and data displacing provisional stenting? 
With an unrestricted educational grant from TRYTON MEDICAL
16:45 – 18:15
Room 242AB
Challenges in complex percutaneous valve treatment: the combination of aortic stenosis and significant functional mitral regurgitation 08:00 – 09:30
Preclinical studies of upcoming bioresorbable scaffolds 09:45 – 11:45
The Embolic Protection Stent – Beyond current techniques: a more effective solution in STEMI primary PCI 
With an unrestricted educational grant from INSPIRE MD
12:00 – 13:30
Effect of catheter-based renal sympathetic denervation: is there a role beyond resistant hypertension? 14:10 – 15:40
Contribution of renal denervation to the treatment of resistant hypertension: a health technology assessment perspective 15:40 – 16:40
Edwards TAVI: a predictable procedure with sustained clinical results 
With an unrestricted educational grant from EDWARDS LIFESCIENCES
16:45 – 18:15
Room 243
PCI of bifurcation lesions: results from registries and new dedicated stents 08:00 – 09:30
Non-left main bifurcation stenting: tips and tricks 09:45 – 10:45
Non-left main bifurcation lesions: tips and tricks 10:45 – 11:45
Stent thrombosis: management challenges 12:00 – 13:00
Very late stent thrombosis 13:00 – 14:00
Innovations in Cardiovascular Interventions@EuroPCR 2013 
With the collaboration of Innovations in Cardiovascular Interventions (ICI)
14:10 – 15:40
Intervention for prevention of stroke 15:40 – 16:40
Stent thrombosis: new evidence from clinical trials and registries 16:45 – 18:15
Room 251
Best clinical abstract presentations 08:00 – 09:30
Best nurse research abstract session 09:45 – 11:15
Nurses and Technicians best presentation award and closing ceremony 11:15 – 11:45
The Portico TAVI system – How new design translates into clinical results 
With an unrestricted educational grant from ST. JUDE MEDICAL
12:00 – 13:00
Emerging clinical use of drug-eluting balloons in challenging atherosclerotic lesions 
With an unrestricted educational grant from BIOTRONIK
13:05 – 14:05
Challenging cases from Taiwan 
With the collaboration of the Taiwan Society of Cardiovascular Interventions
14:10 – 15:40
Left main dissection during PCI 15:40 – 16:40
Cre8: welcome back confidence in short dual antiplatelet therapy with effective DES 
With an unrestricted educational grant from CID
16:45 – 18:15
Room 252AB
All you need to know about catheter-based renal sympathetic denervation 08:00 – 09:30
Antiplatelet and antithrombotic therapy in PCI: a balancing act 09:45 – 11:15
Clinical update on EnligHTN, the original multi-electrode catheter-based renal sympathetic denervation system 
With an unrestricted educational grant from ST. JUDE MEDICAL
12:00 – 13:30
Up-to-date primary PCI technique 14:10 – 15:40
GPIIbIII inhibitors : still useful in 2013? 15:40 – 16:40
What do YOU think? A case-based discussion on biodegradable versus durable polymer DES in complex patients 
With an unrestricted educational grant from BIOSENSORS INTERNATIONAL
16:45 – 18:15
Room 253
Restenosis after failure of CABG and PCI 
Under the auspices of the Working Group on Interventional Cardiology of the Danish Society of Cardiology and the Working Group on Interventional Cardiology of the Finnish Society of Cardiology
08:00 – 09:30
How to write a scientific manuscript and get it published! 09:45 – 10:45
ABC for biotechnology innovators@EuroPCR 
With the collaboration of Innovations in Cardiovascular Interventions (ICI)
10:45 – 11:45
Tools and techniques for PCI of coronary chronic total occlusion 12:00 – 13:00
How to treat coronary chronic total occlusion with limited resources and material? 13:00 – 14:00
New challenges for high-risk primary PCI in 2013 
Under the auspices of the Association of Cardiovascular Interventions (ACVI) of the Polish Cardiac Society and the Working Group of Acute Cardiology of the Slovenian Society of Cardiology
14:10 – 15:40
The unusual coronary chronic total occlusion: recanalisation in bypass patients, acute myocardial infarction and anomalous coronaries 15:40 – 16:40
New generation DES: comparison with older DES 16:45 – 18:15
Room 341
Prevention and management of complications after TAVI 
Under the auspices of the Portuguese Association for Interventional Cardiology (APIC) and the Working Group on Interventional Cardiology of the Spanish Society of Cardiology
08:00 – 09:30
Incidence and prevention of cerebrovascular events after TAVI 09:45 – 10:45
Challenges before, during and after TAVI 10:45 – 11:45
TAVI and bleeding complication 12:00 – 13:00
TAVI and kidney injury 13:00 – 14:00
TAVI with coronary artery disease 
Under the auspices of the Working Goup on Interventional Cardiology (EWGIC) of the Egyptian Society of Cardiology and the Working Group on Interventional Cardiology of the Lebanese Society of Cardiology
14:10 – 15:40
TAVI in unique clinical scenarios 15:40 – 16:40
TAVI technical issues 16:45 – 18:15
Room 342A
How to treat a patient with significant paravalvular leak after TAVI 
Under the auspices of the British Cardiovascular Intervention Society (BCIS) and the Atheroma Coronary and Interventional Cardiology Group (GACI)
08:00 – 09:30
Interventional treatment of acute ischaemic stroke: which role for STEMI networks? 09:45 – 11:45
Self-expanding stents: a NEW solution to optimise primary PCI beyond the open artery 
With an unrestricted educational grant from STENTYS
12:00 – 13:30
Cardiovascular Innovation Pipeline – Treatment of resistant hypertension 14:10 – 15:40
Hot Line – Registries and first-in-man for structural heart disease 15:40 – 16:40
Patient with STEMI: learn the best from East and West 
With an unrestricted educational grant from TERUMO
16:45 – 18:15
Room 342B
Determinants of outcome in STEMI patients 08:00 – 09:30
Resuscitated cardiac arrest – Burning interventional questions 09:45 – 11:45
Updates on contrast-induced nephropathy 12:00 – 13:00
Updates on myocardial revascularisation in patients with chronic kidney disease and haemodialysis 13:00 – 14:00
Unusual causes of STEMI 14:10 – 15:40
You cannot miss this great session on Rotablator! 15:40 – 16:40
Rotational atherectomy in complex coronary cases 16:45 – 18:15
Room 343
Challenges in acute myocardial infarction 
Under the auspices of the Working Group on Interventional Cardiology of the Austrian Society of Cardiology and the Working Goup on Interventional Cardiology and ACS of the Swiss Society of Cardiology
08:00 – 09:30
New methods for physiological assessment of coronary stenosis? 09:45 – 10:45
Complex PCI: which role for self-expanding stents? 10:45 – 11:45
Clinical value of IVUS during ACS: when you lose your way 12:00 – 13:00
Clinical value of IVUS: what others don’t tell 13:00 – 14:00
Challenging prosthetic mitral valve malfunction 
Under the auspices of the Working Group on Interventional Cardiology (AGIK) of the German Cardiac Society (DGK) and the Working Group on Invasive Cardiology of the Italian Society of Invasive Cardiology (SICI-GISE)
14:10 – 15:40
Clinical value of IVUS during coronary chronic total occlusion PCI: with a little help from your friend 15:40 – 16:40
Room 351
All you need to know about bioresorbable scaffolds 08:00 – 09:30
Hot Line – Evolving procedural strategies 09:45 – 11:45
Treating complex lesions and patients with bioresorbable vascular scaffolds 
With an unrestricted educational grant from ABBOTT VASCULAR
12:00 – 13:30
Bioresorbable vascular scaffolds in chronic total occlusions and calcified lesions 14:10 – 15:40
Bioresorbable scaffolds: clinical results 15:40 – 16:40
Complex cases of mitral regurgitation: how far can you go with MitraClip? 
With an unrestricted educational grant from ABBOTT VASCULAR
16:45 – 18:15
Room 352A
You are a practitioner who wishes to successfully start a peripheral percutaneous transluminal angioplasty (PTA) programme 08:00 – 09:30
Radial approach – Cannulation of the targeted vessels ostia 09:45 – 10:40
Forum on radial approach 10:50 – 11:45
Difficult diagnosis and management of ACS 12:00 – 13:00
Acute heart failure due to ACS 13:00 – 14:00
Cardiovascular Innovation Pipeline – Novel interventional approaches for heart failure 15:40 – 16:40
Radial access: problem or solution? 16:45 – 18:15
Room 352B
All you need to know about treatment of coronary chronic total occlusion 08:00 – 09:30
Renal denervation: novel approaches and first-in-man results 09:45 – 10:45
Management of intra-coronary thrombus during primary PCI 10:45 – 11:45
Provisional treatment approach of a distal left main and true bifurcation lesion: combination of a dedicated stent in the main branch and drug-eluting balloon in the side branch 
With an unrestricted educational grant from MINVASYS
12:00 – 13:30
EuroIntervention / European Heart Journal@EuroPCR 14:10 – 15:40
Unusual presentation of coronary aneurysms 15:40 – 16:40
How to treat aorto-ostial coronary dissection 16:45 – 18:15
Room 353
Tunisia shares its most educational cases 
Under the auspices of the Working Group on Interventional Cardiology (GTCI) of the Tunisian Society of Cardiology and Cardiovascular Surgery
08:00 – 08:45
Italy shares its most educational cases 
Under the auspices of the Working Group on Invasive Cardiology of the Italian Society of Invasive Cardiology (SICI-GISE)
08:45 – 09:30
Egypt shares its most educational cases 
Under the auspices of the Working Group on Interventional Cardiology (EWGIC) of the Egyptian Society of Cardiology
09:45 – 10:30
Kazakhstan shares its most educational cases 
Under the auspices of the Working Group on Interventional Cardiology of the Association of Cardiologists of Kazakhstan
11:15 – 12:00
Stent dislodgement during PCI 12:00 – 13:00
Aortic damage during percutaneous intervention 13:00 – 14:00
Spain shares its most educational cases 
Under the auspices of the Working Group on Interventional Cardiology of the Spanish Society of Cardiology
14:10 – 14:55
Sweden shares its most educational cases 
Under the auspices of the Working Group on Interventional Cardiology of the Swedish Society of Cardiology
14:55 – 15:40
Argentina shares its most educational cases 
Under the auspices of the Argentine College of Interventional Cardioangiologist (CACI)
15:40 – 16:25
Portugal shares its most educational cases 
Under the auspices of the Portuguese Association for Interventional Cardiology (APIC)
16:45 – 17:30
Greece shares its most educational cases 
Under the auspices of the Working Group on Interventional Cardiology of the Hellenic Cardiological Society
17:30 – 18:15
Room Cordis
Training Village: Endovascular complication management: renal access 
With an unrestricted educational grant from CORDIS CARDIAC & VASCULAR INSTITUTE
09:00 – 10:00
Training Village: Catheter-based renal sympathetic denervation: introduction to an irrigated technology 
With an unrestricted educational grant from CORDIS CARDIAC & VASCULAR INSTITUTE
10:30 – 11:30
Training Village: Radial approach for coronary diagnostic and interventions – hands-on with the experts 
With an unrestricted educational grant from CORDIS CARDIAC & VASCULAR INSTITUTE
13:00 – 15:00
Training Village: Advanced Exoseal: achieving haemostasis and managing access site complications 
With an unrestricted educational grant from CORDIS CARDIAC & VASCULAR INSTITUTE
15:30 – 16:30
Training Village: Importance of vessel pre- and post- dilatation for better patient outcomes 
With an unrestricted educational grant from CORDIS CARDIAC & VASCULAR INSTITUTE
16:45 – 18:00
Room Maillot
Solutions for complex abdominal aortic aneurysm 08:00 – 09:55
Therapeutic embolisation – Part I: tools and techniques for coronary and peripheral arteries 10:00 – 11:45
Left atrial appendage closure for stroke prevention: what every interventional cardiologist should know 
With an unrestricted educational grant from BOSTON SCIENTIFIC
12:00 – 13:00
New hopes for critical limb ischaemia 
With an unrestricted educational grant from TERUMO
13:05 – 14:05
Solutions for complex thoracic aortic disease 14:10 – 15:40
Therapeutic embolisation – Part II: clinical applications for coronary and peripheral arteries 15:40 – 16:40
Titanium-nitride-oxide active stent in ACS patients with or without bleeding risks 
With an unrestricted educational grant from HEXACATH
16:45 – 18:15
Room Medtronic Academia
Training Village: Hands-on introduction to the new Symplicity Spyral catheter-based renal sympathetic denervation system 
With an unrestricted educational grant from MEDTRONIC ACADEMIA
09:00 – 10:30
Training Village: Hands-on introduction to the new Symplicity Spyral catheter-based renal sympathetic denervation system 
With an unrestricted educational grant from MEDTRONIC ACADEMIA
10:30 – 12:00
Training Village: Hands-on introduction to the new Symplicity Spyral catheter-based renal sympathetic denervation system 
With an unrestricted educational grant from MEDTRONIC ACADEMIA
12:30 – 14:00
Training Village: Hands-on introduction to the new Symplicity Spyral catheter-based renal sympathetic denervation system 
With an unrestricted educational grant from MEDTRONIC ACADEMIA
14:15 – 15:45
Training Village: Hands-on introduction to the new Symplicity Spyral catheter-based renal sympathetic denervation system 
With an unrestricted educational grant from MEDTRONIC ACADEMIA
16:00 – 17:30
Room St Jude Medical
Training Village: PCI optimisation – Focus on OCT 
With an unrestricted educational grant from ST. JUDE MEDICAL
09:00 – 10:00
Training Village: PCI optimisation – Focus on OCT 
With an unrestricted educational grant from ST. JUDE MEDICAL
10:15 – 11:15
Training Village: Left atrial appendage 
With an unrestricted educational grant from ST. JUDE MEDICAL
10:45 – 12:15
Training Village: TAVI 
With an unrestricted educational grant from ST. JUDE MEDICAL
11:30 – 12:30
Training Village: TAVI 
With an unrestricted educational grant from ST. JUDE MEDICAL
14:00 – 15:00
Training Village: TAVI 
With an unrestricted educational grant from ST. JUDE MEDICAL
15:15 – 16:15
Training Village: Left atrial appendage 
With an unrestricted educational grant from ST. JUDE MEDICAL
15:45 – 17:15
Training Village: TAVI 
With an unrestricted educational grant from ST. JUDE MEDICAL
16:30 – 17:30
Talk ‘LIVE’ Corner
Talk ‘LIVE’ 17:00 – 18:30
Theatre Bleu
Revascularisation in a patient with ischaemic heart failure and reduced left ventricular function 08:00 – 09:30
Treatment of coronary chronic total occlusion: Japan meets Europe 
With the collaboration of Complex Cardiovascular Therapeutics (CCT)
09:45 – 11:45
Left main and complex bifurcation stenting 
With an unrestricted educational grant from TERUMO
12:00 – 14:00
Am I treating the right lesion? Angiography versus ischaemia-based coronary revascularisation in stable coronary artery disease patients 14:10 – 16:10
Catheter-based renal sympathetic denervation: introducing the new Symplicity Spyral and Flex systems 
With an unrestricted educational grant from MEDTRONIC
16:45 – 18:45
Theatre Bordeaux
Enabling technologies for TAVI 08:00 – 09:30
Percutaneous treatment options for functional mitral regurgitation 09:45 – 11:45
Optimising TAVI procedures and patients outcomes: Medtronic’s new technologies and valve-in-valve procedure with Evolut 
With an unrestricted educational grant from MEDTRONIC
12:00 – 14:00
Valve-in-valve 14:10 – 16:10
Physiological stenosis assessment with FFR and instant wave-free ratio: we need both! 
With an unrestricted educational grant from VOLCANO
16:45 – 18:45
Theatre Havane
Optimal management of your NSTE-ACS patient with complex multivessel disease 08:00 – 09:30
Learning renal denervation – Critical appraisal on device-based therapies targeting the sympathetic system 09:45 – 11:45
Contemporary ACS antithrombotic therapy 
With an unrestricted educational grant from THE MEDICINES COMPANY
12:00 – 13:30
Learning ostial PCI – How to successfully perform PCI in a patient presenting ostial left main and ostial right coronary artery 14:10 – 15:40
Interactive case-based discussion – complications on ostial PCI 15:45 – 16:40
Contemporary coronary chronic total occlusion PCI: integrating the hybrid approach to your practice 
With an unrestricted educational grant from BOSTON SCIENTIFIC
16:45 – 18:15

 

 

 

[59] FRIDAY 24 MAY

Abstract & Case Corner
How to close paravalvular leak 09:00 – 10:30
Cases you have never seen 10:45 – 11:45
Unusual cases in the cathlab: diagnostic challenges 11:45 – 12:45
Interactive Case Corner
Interactive case corner #14 09:00 – 10:30
Interactive case corner #15 10:45 – 12:15
Main arena
Complex cardiovascular interventions and new techniques – Master LIVE demonstrations by Farrel Hellig, Martyn Thomas & Simon Redwood and expert panel discussion 09:00 – 13:00
PCR Sharing Centre
Do you want to be more confident when developing and delivering PowerPoint presentations? 09:00 – 10:00
Peripheral Abstract & Case Corner
Femoro-popliteal angioplasty : could new devices improve mid-term follow-up? 09:00 – 10:30
Chronic total occlusion revascularisation for superficial femoral artery 10:45 – 12:15
Room 241
Bioresorbable versus durable polymer coatings for DES 09:00 – 10:30
All you need to know about drug-coated balloons in coronary and peripheral vascular disease 10:45 – 12:15
Room 242A
Fully-absorbable jacket, in-stent restenosis and bypasses: new avenues for bioabsorbable vascular scaffolds? 09:00 – 10:30
Bioresorbable scaffolds: lessons learned from intracoronary imaging 10:45 – 11:45
Managing difficult stent cases 11:45 – 12:45
Room 242B
Challenging cases of saphenous vein graft interventions 09:00 – 10:30
Overcoming challenges during PCI 10:45 – 11:45
Helpful techniques during “extreme” PCI 11:45 – 12:45
Room 243
Predictors of in-stent restenosis and stent thrombosis after DES implantation 09:00 – 10:30
Stent thrombosis: overcoming challenging scenarios 10:45 – 12:15
Room 251
Emerging technologies for transcatheter mitral valve therapies 2013 – Part II: transcatheter replacement technologies 09:00 – 11:00
Novel catheter-based therapies of mitral regurgitation 11:00 – 12:00
Room 252A
Developments in percutaneous closure of the left atrial appendage 09:00 – 10:30
Percutaneous treatment of complex coronary aneurysms 10:45 – 11:45
Percutaneous management of complex coronary aneurysms 11:45 – 12:45
Room 252B
Primary PCI when the left main is the culprit 09:00 – 10:30
Primary PCI when the left main is the culprit 10:45 – 11:45
Left main dissection during PCI 11:45 – 12:45
Room 253
Below-the-knee angioplasty: risk stratification and DES benefits 09:00 – 10:00
Severe aortic stenosis combined with coronary artery disease in high-risk patient 
Under the auspices of the Working Group on Interventional Cardiology of the Hellenic Cardiological Society and the Working Group on Interventional Cardiology of the Israeli Heart Society
10:45 – 12:15
Room 341
Slow flow and no flow in PCI, not only in ACS: how to prevent and how to treat it? 
Under the auspices of the Working Group on Interventional Cardiology of the Danish Society of Cardiology and the Working Group on Interventional Cardiology of the Swedish Society of Cardiology
09:00 – 10:30
Renal denervation for resistant hypertension 10:45 – 12:15
Room 342A
Cardiogenic shock and intra-aortic balloon pump 
Under the auspices of the Luxembourg Society of Cardiology and the Working Group on Interventional Cardiology of the Norwegian Society of Cardiology
09:00 – 10:30
PCI of bifurcation lesions: impact of procedural techniques on clinical outcome 10:45 – 11:45
Bifurcation lesion: problems and solutions 11:45 – 12:45
Room 342B
TAVI or not TAVI: that is the question 
Under the auspices of the British Cardiovascular Intervention Society (BCIS) and the Working Group on Interventional Cardiology of the Spanish Society of Cardiology
09:00 – 10:30
Unfrequent indications for TAVI 10:45 – 11:45
TAVI in patients with previous cardiac valve operations 11:45 – 12:45
Room 343
Insights from OCT 09:00 – 10:30
Importance of OCT during PCI today 10:45 – 12:15
Room 351
Primary PCI for STEMI 
Under the auspices of the Working Group on Interventional Cardiology (BWGIC) of the Belgium Society of Cardiology and the Working Group on Interventional Cardiology of the Scottish Cardiac Society
09:00 – 10:30
All you need to know about radial approach for PCI 10:45 – 12:15
Room 352A
Learning rotablator – How to easily and successfully use rotational atherectomy 09:00 – 10:30
Novel techniques using rotational atherectomy 10:45 – 12:15
Room 352B
All you need to know about antiplatelet and antithrombotic pharmacology for PCI: NSTEMI and STEMI 09:00 – 10:30
Management of acute coronary artery occlusion during PCI 10:45 – 11:45
Retrieval of ‘things’ left behind during PCI 11:45 – 12:45
Room 353
Israel shares its most educational cases 
Under the auspices of the Working Group on Interventional Cardiology of the Israeli Heart Society
09:00 – 09:45
Macedonia shares its most educational cases 
Under the auspices of the Working Group on Interventional Cardiology of the Macedonian Society of Cardiology
09:45 – 10:30
Cyprus shares its most educational cases 
Under the auspices of the Working Group on Interventional Cardiology of the Cyprus Society of Cardiology
10:45 – 11:30
Austria shares its most educational cases 
Under the auspices of the Working Group on Interventional Cardiology of the Austrian Society of Cardiology
11:30 – 12:15
Room Maillot
Hybrid angio suite 09:00 – 10:30
Large size percutaneous access for endoaortic procedures 10:45 – 12:45
Theatre Bleu
Coronary perforation: management and implications 09:00 – 10:30
Device-based left ventricular cavity reduction in heart failure 10:45 – 12:15
Theatre Bordeaux
SOLACI@EuroPCR 
With the collaboration of the Sociedad Latino Americana de Cardiologia Intervencionista (SOLACI)
09:00 – 10:30
Tips and tricks for a successful catheter-based renal sympathetic denervation in difficult anatomies 10:45 – 12:45
Theatre Havane
Optimal management of your patient with coronary chronic total occlusion 09:00 – 10:30
The ‘undefeatable’ coronary chronic total occlusion: warriors at work 10:45 – 11:45
Challenging retrograde recanalisations of coronary chronic total occlusion 11:45 – 12:45
 SOURCE:

 

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Texas Heart Institute: 50 Years of Accomplishments

Reporter: Aviva Lev-Ari, PhD, RN

 

Texas Heart Institute’s Overachieving President and Medical Director Dr. James T Willerson Profiles THI’s 50 Years Of Accomplishments


Posted Thursday , April 25,2013

The Texas Heart Institute is a not-for-profit cardiology and heart surgery center located at the Texas Medical Center in Houston. Founded in 1962 by Dr. Denton A. Cooley, the mission of the Texas Heart Institute has been to reduce the devastating toll of cardiovascular disease through innovative programs in research, education and improved patient care. Over the past 51 years the Institute has been involved in training cardiologists, heart surgeons, imaging specialists in cardiovascular medicine and cardiac electrophysiology, and pathologists, and educated hundreds of cardiovascular specialists.

texasheart

A nonprofit organization in the truest sense, and unlike most institutions that have a source of operating revenue, the Texas Heart Institute relies solely on government grants, research contracts and, above all, philanthropy, with donations from grateful patients, foundations, corporations, physicians, and the general public account for more than half of the Institute’s annual operating budget. The Institute’s location in and affiliations with St. Luke’s Episcopal Hospital and Texas Children’s Hospital have assured that all age groups will be treated, and has freed the Institute of the burden of financing a health care facility.

The Texas Heart Institute (THI) and its clinical partner, St. Luke’s Episcopal Hospital, have become one of America’s largest cardiovascular centers, whose 160-member professional staff have reportedly performed more than 100,000 open heart operations, 200,000 cardiac catheterizations, and 1,000 heart transplants.

In its 2010 annual survey of “America’s Best Hospitals,” U.S. News & World Report ranked the Texas Heart Institute at St. Luke’s Episcopal Hospital number four in the United States for heart care, marking this its 20th consecutive year of inclusion as one of the top 10 heart centers in the country.

willersonIn an interview with the European science news journal Research Media, THI President and Medical Director, Dr. James T Willerson, says that when he originally came to the Institute in 2004, then still President Dr Cooley wanted him to be Medical Director of Cardiovascular Research, and upon Dr. Cooley’s resignation in 2008, he asked Dr. Willerston to succeed him in that position.

In the interview, Dr. Willerston, a native Texan, profiles the THI’s achievements and shares his thoughts on reducing the heavy burdens of Cardiovascular disease, which is estimated to cost the economy $449 billion annually.

Accounting for over a quarter of all deaths in the U.S. each year, cardiovascular disease is obviously a major health concern, but mortality from coronary heart disease (CHD) has substantially decreased in recent decades. Dr. Willerston attributes the decrease to research discoveries that have provided insights into mechanisms responsible for thrombosis in injured coronary and cerebral arteries, and led to improved treatment.

He cites as an example that increased understanding of ‘bad’ low-density lipoprotein (LDL) cholesterol in patients to values well below 100 mg/dl has been a very important contribution, as has the development of statins to lower LDL has also been crucial, the use of low-dose aspirin and other medications to control blood pressure, avoidance of smoking and use of recreational drugs, control of blood sugar in patients who are diabetic, emphasis on diet and exercise, and improved imaging techniques for blood vessels and the cardiovascular system, as factors that have played a role in protecting CHD patients and decreasing mortality risk.

However, he notes that the greatest GHD risk factor is a genetic one, and a remaining priority must be to identify genes that contribute to this risk; ultimately silencing the most dangerous ones using microRNA methodology. Dr. Willerston says numerous clinical studies in patients with cardiovascular disease using a variety of stem cell types, including mesenchymal stem cells taken from the bone marrow or adipose tissue have been conducted, and that through the pioneering work of Dr Doris Taylor, scientists are now able to deplete human hearts of their cellular structure and then restore that same heart to normal function by the infusion of stem cells. With continued success, these efforts could fill a great unmet need and pave the way to a new area of transplant medicine.

Dr. Willerston maintains that prevention would be the single most effective means of reducing healthcare costs, and should be the main concern initiated at very young ages and continue throughout adulthood.

Dr. James T. Willerson, born in Lampasas, Texas, is President of The University of Texas Health Science Center at Houston where he is the Alkek-Williams Distinguished Professor and holds the Edward Randall III Chair in Internal Medicine. In October 2004, Dr. Willerson was named President-Elect of the Texas Heart Institute in Houston, Texas. He holds the Dunn Chair in Cardiology Research and the John O’Quinn Chair named the “James T. Willerson Distinguished Chair in Cardiovascular Research,” both at the Texas Heart Institute, Houston, Texas. From 1989 through 2000, he was the Chairman of the Department of Internal Medicine at The University of Texas Medical School at Houston where an Annual Lectureship has been established in his name. During this same period, he served as the Chief of Medical Services at Memorial Hermann Hospital. He is also the Medical Director, Director of Cardiovascular Research, and Co-Director of the Cullen Cardiovascular Research Laboratories at the Texas Heart Institute. He is an Adjunct Professor of Medicine at Baylor College of Medicine and at The University of Texas M.D. Anderson Cancer Center in Houston.

Dr. Willerson also founded TexGen Research, a collaboration which brings together all of the institutions in the Texas Medical Center to collect blood samples necessary for the discovery of those genes and proteins that play a key role in causing major diseases. With TexGen, each Texas Medical Center institution obtains blood samples from patients who have a personal or family history of cardiovascular disease, stroke, dementia, or selected cancers and who are admitted to their hospitals. Great progress is being made by this collaborative biomedical research effort.

A graduate of the Texas Military Institute in San Antonio, Texas, where he was the Battalion Commander, President of the Senior Class, Editor of the school newspaper, and a state swimming champion, Dr. Willerston attended The University of Texas at Austin, graduating as a Phi Beta Kappa, member of the Texas Cowboys, and where he lettered for three years in varsity swimming. Upon graduating as a member of Alpha Omega Alpha from Baylor College of Medicine in Houston, Texas, he completed his medical and cardiology training as an intern, resident, and research and clinical fellow at the Massachusetts General Hospital in Boston, Massachusetts, and as a Clinical Associate at the National Institutes of Health in Bethesda, Maryland.

He is the former Chairman of the National American Heart Association Research Committee and of the Cardiovascular and Renal Study Section of the National Institutes of Health. He has received the Award of Merit from the American Heart Association and has served as a member of the Board of Directors and Steering Committee of the National American Heart Association. Before coming to The University of Texas Medical School at Houston, Dr. Willerson was Professor of Medicine and Director of the Cardiology Division at The University of Texas Southwestern Medical School in Dallas, Texas, and Director and Principal Investigator of the National Heart, Lung, and Blood Institute’s Specialized Center of Research under a major grant from the NIH. Upon his departure, the “James T. Willerson, M.D. Distinguished Chair in Cardiovascular Diseases” was established at The University of Texas Southwestern Medical School.

Dr. Willerson has served as visiting professor and invited lecturer at more than 220 institutions worldwide, and has received numerous national and international awards, as well as having served on editorial boards for many professional publications including: The New England Journal of Medicine, Journal of Clinical Investigation, Circulation, Circulation Research, Arteriosclerosis and Thrombosis, American Journal of Medicine, Journal of the American College of Cardiology, American Journal of Cardiology, American Heart Journal, and Cardiovascular Medicine. From 1993 to 2004, he was the longest-serving Editor of Circulation, the major publication of the American Heart Association. In 1998, the monthly journal was converted to a weekly publication and attained the highest Impact Factor of any cardiology journal in the world. He has edited or co-edited twenty-four textbooks, including the Third Edition of Cardiovascular Medicine which was released in February of 2007. Additionally, he has published more than 850 scientific articles.

Dr. Willerson has been elected to membership in numerous professional societies, including the American Society of Clinical Investigation, the Association of American Physicians, the Association of Professors of Medicine, and the Institute of Medicine of the National Academy of Sciences. He was named a Distinguished Alumnus by the Baylor College of Medicine in 1998 and a Distinguished Alumnus of The University of Texas at Austin in 1999.

SOURCE:

http://bionews-tx.com/news/2013/04/25/texas-heart-institutes-overachieving-president-and-medical-director-dr-james-t-willerson-profiles-this-50-years-of-accomplishments/

Comment of Note

Dr. Lev-Ari, was a visitor at Texas Heart Institute, Perfusion Program, and shadowed Open Heart Surgery in 8/2005.

The museum on the First floor of the building represents a Historical exhibit of Images of Cardiac Procedures. On display is a complete array of surgical tools used in Cardiac Repair during the last 50 years of unprecedented development in Cardiac Medical Devices and Procedures. A duplicate of the exhibit is available at the Smithsonian Museum at WashDC.

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