his majesty king abdullah ii bin al-hussein - jordan · pdf filehis majesty king abdullah ii...

1Ninth International Conference of the Jordan Cardiac Society

His MajestyKing Abdullah II Bin Al-Hussein


Wellcome Note :

On behalf of the executive committee, it is my pleasure to welcome you to the Ninth International Conference of the Jordan Cardiac Society.The scientific program will include plenary sessions and lectures conducted by prominent experts from Europe, North America and the Arab World, will endeavor to review recent advances in various fields of adult and pediatric cardiology, cardiac surgery, and cardiac anesthesia.Embedded in the program is the opportunity to shed light on the history of Jordan, the privileged home of some of the greatest monuments of human civilization. The breath-taking rose-red city of the Nabataeans, Petra, as one of the seven wonders of the world, the deepest gorge of the Dead Sea and the hot springs will be a memorable experience, in addition to the unique Byzantine Churches with their wonderful mosaics; and Jerash as a Roman Polity, all will make your stay in Jordan an overwhelming experience.I welcome you and your companions in Jordan and hope to make your stay of great benefit and joy.

Sincerely,

Mohammed Krayyem, MD President of the conference President of the Jordan Cardiac Society

4 Ninth International Conference of the Jordan Cardiac Society

Executive Committee:Mohammed Krayyem, MD (President of the Congress)Fakhri Al-Hakim, MD (Vice Preident )Mohammad Abu Shaikh, MD (Secretary General)Adnan Allaham, MDAli Aburumman, MDAziz Al-Saket, MDHatem Al-Tarawneh, MD

Counselors:Aktham Hiari, MD Ali Hijazi, MDBassam Akasheh, MD Daoud Hanania, MDFaris Doghmi, MD Harran Zriqat, MDHussam Nesheiwat, MD Laith Abu Nowar, MDMo‘ayad Al-Naser, MD Narmeen Harbi, MDNuman Abu Aisheh, MD Sami Rababa, MDSuhail Saleh, MD Yousef Goussous, MD

Scientific Committee :Adnan Allaham, MD (Chairman ) Abdel Fattah Abu Hawileh, MDAbdalla Al-Zoobiy, MD Abdullah Omeish, MDAhmad Al-Harasees, MD Akram Saleh, MDAli Al-Halabi, MD Ayman Hamoudeh, MDEyas Al-Musa, MD Fakhri Al-Hakim, MDHatem Al-Tarawneh, MD Khaled Al-Salaymeh, MDMustafa Al-Jammal, MD Qasem Al-Shamayleh, MDWalid Tarawneh, MD Yahya Al-Badayneh, MDYahya Ismail, MD


Social Committee: Ali Aburumman, MD Ayman Odeh, MDBasel Harahsheh, MD Emad Khraisat, MDHussien Amarat, MD Ibrahim Jarad, MDNabeel Qaqish, MD Waleed Sawalha, MDYaqthan Obeidat, MD

Treasurers Committee: Ali Aburumman, MD Mr. Faris Theib


GUEST SPEAKERS

Ahmad Abu Halimah,MD USA

Charles Jazra,MD Lebanon

Clive Weston,MD UK

David Zhao,MD USA

Emile Bacha,MD USA

Gebreen Elkhury,MD Belgium

John Davies,MD UK

Joseph Arrowsmith,MD UK

Marius Turcan,MD Romania

Mark Robbins,MD USA

Michael Norell,MD UK

Michael Petracek,MD USA

Mohamed Sobhy,MD Egypt

Sami Kabbani,MD Syria

Samir Alam,MD Lebanon

Stuart Graham,MD UK

Omar Lattouf,MD USA

Philippe Noirhomme,MD Belgium Zohair Al-Halees,MD Saudi Arabia


ACKNOWLEDGEMENTS:The organizing committee of the Ninth International Conference of the Jordan Cardiac Society wishes to acknowledge with gratitude the generous support given to the Meeting by the following organizations and person:


Al-Mutafawiqa For Medical Supplies ( Cordis J&J)

Novartis Pharma Services

م�ؤ�ش�شة اال�شراء لال�شت�شارات والتجارة

AstraZeneca Pharmaceutical Company

(JOSWE medical )

Servier

Advanced Medical equipments (AME) / Philips health care

Bayer Consumer Care

Fakhoury Medical Supplies co. / Sorin Group

Menarini International Co.

Merck Serono

Philips Medical Systems

Rawhi Drugstore- Biotronik

Terumo Corporation وكالء �شرق املت��شط لال�شترياد واال�شت�شارات مديكا

�شركة فايزر لالأدوية

�صركة اليمامة للم�صاريع ال�صحية والبيئية

الدولية للدواء

البنك التجاري الأردين


GENENRAL INFOMATION

Dates: Tuesday 22nd to Friday 25th April 2008

Venue: Le Meridien Hotel-Amman

Registration: at Le Meridien Hotel-RCC-Hall A & Hall B Tuesday 22 April 2008 13:00-18:00Wednesday 23 April 2008 8:30 – 18:00Registration fees : • Jordanian member of JCS : free

Non member Jordanian Doctors : 25 JD• • Students and trainees: free (scientific program only)• Others 100 $

Fees include access to the scientific sessions, professionalexhibits, opening ceremony, conference bag (including acertificate of attendance, final program and the abstract book), lunches, and coffee breaks.

Language: The official Language of the meeting is English.Lunch & refreshments: Coffee & tea will be available duringofficial meeting breaks.Lunch will take place at La Brasserie Restaurant on April 23, 24, 25.

Transportation: Shuttle Buses will be available for the guest speakers only.

Social events: social and Tourist activities will be announced during the meeting.

Scientific program information:Speaker- please report on arrival to the speaker desk.Please check-in your presentation before your session.

Discussion & Question:There will be hand held microphones in the meeting room,Delegates wishing to participate in discussion and questions periods should be make the themselves known and wait to beacknowledged by the chairman.


6 -7 م�شاءًا الثــالثاء 2008/4/22

“مــرا�شـــــم االفــتــــتــــاح“ 1- ال�سالم امللكي.

2- اآيات من الذكر احلكيم.

3 - كلمة رئ�س اللجنة العلمية( د.عدنان اللحام (.

4- كلمة رئي�س امل�ؤمتر ( د .حممد كرمي(.

5- كلمة عط�فة نقيب الأطباء ) د. زهري اأب� فار�س (.

6- راعي احلفل .

7- فرقة بلدية ال�سلط لحياء الرتاث

8- افتتاح املعر�س الطبي يليه حفل ال�ستقبال.

9- ندوة �سركة احلكمة :ارتفاع �سغط الدم ال�سرياين ( د.�سمري علم( .

عريف احلفل د. يحيى البداينة

Tuesday 22/4/2008 6 - 7 pm

Opening Ceremony

Royal1. Jordanian Anthem. Recital2. of Verses from the Holy Qura’n. Chairman3. of the Congress scientific Committee.

(Dr. Adnan Allaham)President4. of the conference

(Dr. Mohammed Krayyem)President5. of Jordan Medical Association.

( Dr. Zohir Abu- Faris) Patron of the Confer6. ence . Jordanian Folklore show 7. Opening8. the Exhibition followed by Cocktail Reception.Symposium9. sponsored by Hikma Jordan:

˝ The Patient with Hypertension: Issues beyond Lowering Blood Pressure˝ (Dr. Samir Alam, Lebanon)

Master of the ceremony. Dr. Yahya Al-Badayneh


Wednesday 23 April - 2008Session (1) ( 08:30 – 10:45 )

Chairman: Dr. Aktham Hiari, Dr. Faris Doghmi, Dr. Ali Hijazi

8:30 – 8:50

8:50 – 9:10

9:10 – 9:30

9:30 – 9:50

9:50 – 10:10

10:10– 10:30

10:30- 10:45

1) Interventional cardiology, 2007 and beyond 2) Statins And Atherosclerosis Prevention - So Far So Good

3) Controversies in Cardiology: the 15-20 most Asked Questions

4) Primary PCI for AMI; problems and pitfalls of establishing a “round the clock” service

5) Long-Term Follow-up of left main Ostial Stenosis Surgical Reconstruction

6) Minimally Invasive Mitral Surgery Without Crossclamping.

Discussion

Dr. David X. Zhao,

(USA)

Dr.Marius Turcan,

(Romania)

Dr. John Davies,

(UK)

Dr. Michael S.Norell,

(UK)

Dr. Mazen Khoury,

(Greece)

Dr. Michael Petracek

(USA)

10:45 – 11:10 Coffee Break


Wednesday 23 April - 2008Session 2 ( 11:10 – 1:05)

Chairman: Dr. Yousef Qoussous, Dr. Ahmad Al-Harasees, Dr. Moath Al-Smadi

11:10 – 11:30

11:30 – 11:50

11:50 – 12:10

12:10 – 12:30

12:30 – 12:50

12:50-01:05

7) Diabetes and Asymptomatic Vascular Disease

8) Hyperglycaemia in acute coronary syndrome - therapeutic target or risk marker?

9) Cardiac Resynchronization Therapy(CRT)Follow Up

10) Hypertension LVH and Sudden Death

11) Modern Management of heart failure in wales and the UK

Discussion

Dr. Mark A. Robbins,(USA)

Dr. Clive Weston,(UK)

Dr. Charles Jazra, (Lebanon)

Dr. Charles Jazra, (Lebanon)

Dr. John Davies, (UK)

01:05 – 02:30 Lunch Break


Wednesday 23 April - 2008Session 3 ( 02:30 – 04:05 )

Chairman: Dr. Ibrahim Abu Ata,Dr. Qasem Al-Shamayleh, Dr. Eyas Al Musa

2:30 – 2:50

2:50 – 3:10

3:10 – 3:30

3:30 – 3:50

3:50 – 4:05

12) ‘Half a million heart attacks - what have we learned? Lessons from the Myocardial Infarction National Audit Project’

13) Myocarditis versus myocardial infarction.

14) PCI activity in the UK; trends, traps and triumphs

15) PCI and multi slice CT ( from Egyptian ICC archives)

Discussion


Dr. Ahmad Abu Halimah,(USA)

Dr. Michael S. Norell,(UK)

Dr. Mohamed Sobhy, (Egypt)

04:05 - 04:30 Coffee Break


Wednesday 23 April - 2008Session 4 ( 04:30 – 06:15 )

Chairman: Dr. Assem Balawi, Dr. Ramzi Tabbalat Dr. Hatem Al-Tarawneh

4:30 – 4: 50

4:50 – 5:10

5:10 – 5:20

5:20-5:40

5:40-5:50

5:50-6:10

6:10-6:15

16) Off Pump Coronary Bypass vs On Pump Coronary Bypass and Evidence Based Medicine

17) Drug Eluting Stents and Late Thrombosis

18) Myocardial Protecton Against Ischemic/ Reperfusion Injury in Rabbit-heart comparison between Sildenafil and Ordonefil

19) PCI on diabetics with multivessel disease.. a new look.

20)Euro Heart Survey,Acute Coronary Syndrome(ACS) Rgistry

21) Aortic root surgery with the modified Bentall procedure. 12 year single unit>s results.

Discussion

Dr. Omar M.Lattouf, (USA)

Dr. Samir Alam, (Lebanon)

Dr. Said Al-Khateeb, (Jordan)

Dr. Mohamed Sobhy,(Egypt)

Dr Ahmad Hassonah(Jordan)

Dr. Mazen Khoury(Greece)


Thursday 24 April-2008Session 5 (08:30 – 10:45)

Chairman: Dr. Daoud Hanania, Dr. Moh’d Al-Azzam, Dr. Nabeel Qaqish

8:30 – 8:50

8:50 – 9:10

9:10 – 9:30

9:30 – 9:50

9:50 – 10:05

10:05-10:20

10:20-10:30

22) Coronary surgery: Can we improve our results? What are the best techniques?

23) Drug eluting stents: efficacy and safety...

24) Stem Cell Therapy and Ischemic Heart Disease; Has the Time Come for Clinical Application?

25) Pulmonary endarterectomy - surgical treatment for chronic thromboembolic pulmonary hypertension (CTEPH). 26) Surgical treatment for rupture of left ventricular free wall after acute myocardial infarction.

27)Apical Balloon Syndrome.

Discussion

Dr. Noirhomme, (Belgium)

Dr. David X.Zhao,(USA)

Dr. Omar M. Lattouf,(USA)

Dr. Joseph Arrowsmith,(UK)

Dr. Sulieman Haddadin,(Jordan)

Dr. Ahmad Abu Halimah(USA)

10:30 – 11:00 Coffee Break



Chairman: Dr. Suhail Saleh, Dr. Adnan Allaham , Dr. Walid Tarawneh

11:00 – 11:20

11:20 – 11:35

11:35 – 11:55

11:55 – 12:10

28) Hybrid cardiovascular intervention: New standard of care.

29) Hybrid coronary revascularization- the surgical view.

30) Hybrid procedures in congenital heart surgery

Discussion.

Dr. David X. Zhao, (USA)

Dr. Bahi Hiyasat,(Jordan)

Dr. Emile Bacha, (USA)

12:15 – 1:00 Symposia sponsored by PROMEDZ JORDAN Drug Eluting Stents: Optimizing the Outcome Mechanically Dr Waqar Habib Ahmed (Saudi Arabia)

Lunch Break 01:00 – 02:30



Chairman: Dr. Sami Rababa, Dr. Mohamad Al Fayez, Dr Yahya Al Badayneh

2:30 – 2:50

2:50 – 3:10

3:10 – 3:50

3:50 – 4:05

31) Mitral valve repair and replacement

32) The Choice of Valve Prosthesis in our area

33) Heart Rate Control In The Modern Treatment Of Heart Failure Discussion

Dr. Michael Petracek, (USA)

Dr. Zohair Al-Haless, (Saudi Arabia)

Dr. Marius Turcan, (Romania)

Coffee Break 04:05 – 04:30



Chairman: Dr. Mo’ayad Al-Naser , Dr. Ali Obeidat, Dr. Akram Al Saleh

4:30 – 4:50

4:50 – 5:10

5:10 – 5:30

5:30-5:50

5:50-6:05

34) Mitral Valve Repair

35) Aortic Valve Repair

36) Repair of Ebstein’s Anomaly.

37) Mechanical support, new developments and specific strategies

Discussion

Dr. Gebreen Elkhury, (Belgium)

Dr. Gebreen Elkhury, (Belgium)

Dr. Emile Bacha,(USA)

Dr. Noirhomme, (Belgium)


Friday 25 April - 2008Session 9 (09:00 – 10:15)

Chairman: Dr. Hussam Nesheiwat, Dr. Khaled Al-Salaymeh Dr. Emad Khraisat,

9:00 – 9:20

9:20 – 9:40

9:40 – 10:00

10:00 – 10:15

38) Cardiac aspects of Marfan Syndrome.

39) The cardiac patient undergoing non-cardiac surgery. Current guidelines and emerging evidence from prospective studies

40) Beating-heart aortic arch reconstruction

Discussion

Dr. Stuart Graham,(UK)

Dr. Joseph Arrowsmith,(Uk)


Coffee Break 10:15 – 10:40



Chairman: Dr. Narmeen Harbi , Dr Awni Al Madani, Dr. Ali Al-Halabi

10:40 – 11:00

11:00 – 11:20

11:20 – 11:45

41) Single ventricle palliation: 2008 update.

42) Total Cavopulmonary correction: Staged or one stage, fenestrated or not?

Discussion


Dr. Zohair Al-Haless,(Saudi Arabia)

Prayer & Lunch Break 11:45 – 02:00



Chairman: Dr. Numan Abu Aisheh, Dr. Munir Al-Zaqqa, Dr.Ayman Hamoudeh

2:00 – 2:20

2:20 – 2:40

2:40 – 2:50

2:50 – 3:00

3:00-3:20

3:20-3:40

3:40- 3:55

43) King Faisal Heart Institute Experience in the Management of Hypoplastic Left Heart Syndrome.

44) Management of Maternal Cardiac Disease in Pregnancy

45) A single dose of Dexamethasone preoperatively reduces postoperative nausia and vomiting in patients undergoing open heart surgery.

46) Results of Coronary Artery Bypass Surgery at Queen Alia Heart Institute

47) Carotid stenting

48) Surgical Aspects of Carotid Artery Disease

Discussion

Dr. Zohair Al-Haless, (Saudi Arabia)

Dr. Julie Damp,(USA)

Dr Yaser Alghoul(Jordan)

Dr Ali Abu Rumman(Jordan)

Dr. Mark A. Robbins, (USA)

Dr. Saber Al Rawashdeh(Jordan)

3:55-4:20 Coffee Break



Chairman: Dr. Saad Jaber, Dr. Abdullah Omesh, Dr. Mustafa Al-Jammal

4:20 – 4:40

4:40 – 4:50

4:50 – 5:05

5:05 – 5:15

5:15-5:25

5:25– 5:30

49) Neurological complications of cardiac surgery

50) Preoperative Carotid Duplex Screening

51) The biatrial approach for atrialmyxoma

52) Surgery on hydatid cyst of the heart, the outcome

53) Justified Drive-By Renal Angiography

Discussion

Dr. Joseph Arrowsmith,(UK)

Dr. Zeyad Shawabkah, (Jordan)

Dr. Sami Kabbani,(Syria)

Dr. Mutaz Al-Kateeb,(Iraq)

Dr. Issa Ghanma, (Jordan)


ABSTRACT


1) Interventional cardiology, 2007 and beyondDr. David X.Zhao

ABSTRACT Not Available

2) Statins And Atherosclerosis Prevention - So Far So GoodDr.Marius Turcan, (Romania)

“Statins And Atherosclerosis Prevention - So Far So Good”Statins are, arguably, the most important medication introduced in cardiovascular prevention and treatment in the last decade of the twentieth century. With their introduction, the cardiovascular risk represented by the high levels of LDL for the atherosclerosis onset and progression was, for the first time, efficiently reduced.Since then, evidence is continuously accumulating, concerning their value in various circumstances, even if there are some setbacks - like the failure of the recent CORONA trial to show any clear benefit on survival in patients with heart failure. So much so, that low doses of statins are now approved as OTC in some countries.The survival improvement provided by these drugs is backed by overwhelming evidence: in patients with high cardiovascular risk (4S) in primary prevention (WOSCOPS) in moderate risk hypertensive subjects (ASCOT-LLA), in acute coronary syndrome (MIRACL), after revascularization for AMI (RIKS-HIA).The benefit is maintained over a very large spectrum of baseline cholesterol (HPS), in elderly patients (PROSPER), in diabetics (CARDS). “The lower, the better theory” has been amply proven (TNT, IDEAL, PREVENT) and with the ASTEROID IVUS trial we have some exciting insight into the possibility of reducing the atherosclerotic burden – even if more confirmation is needed.But, all this impressive amount of data must not make us abandon the search for better therapeutic solutions, because statin treatment, good as it may be, cannot solve all the problems. One limiting factor is the clinical fact that the target levels for LDL recommended by both US and European guidelines for the high risk patients are not easily obtained, at least in Caucasian subjects.


The dose effect relation on LDL is far from linear and changing to another statin is not a universal solution. Another problem is that important side effects, which are usually very rare, may still become important when we speak about lifelong treatment, high doses, millions of potential users and combinations with other medication.To what extent is combination therapy with other lipid lowering drugs a valid alternative in real life practice? Which drugs to employ in which patients? Can ezetimibe, the uncertainties of ENHANCE notwithstanding, represent the way to get the best results with the minimum of trouble? What about the HDL? Is rimonabant a solution in patients with metabolic syndrome? Are fibrates doomed? Could the analogues of torcetrapib overcome its disappointing shortcomings? These are some challenging questions to be answered during a period I like to characterize as the adulthood of statin treatment. The statins are now firmly established as a landmark medication for cardiovascular patients, but there are still refinements to be made in the way we employ them and in the thinking process behind the optimal management of our patients.

3) Controversies in Cardiology: the 15-20 most Asked Questions

Dr. John Davies,(UK)Abstract Not Available


4) Primary PCI for AMI; problems and pitfalls ofestablishing a “round the clock” service

Dr. Michael S.Norell, (UK)

In 2006, 74000 PCI’s were undertaken in 91 UK centres. Of these 5900 (8%) were performed in the setting of AMI, with 3900 of these being so called primary procedures.

The heart and Lunge Centre in Wolverhampton UK, opened in 2004 and serves a population of 1.1 million. 3 cath labs and 3 operating theatres undertake 1600 angioplasty and 900 CABG procedures annually. In 2005 plans were made to offer primary PCI during “office hours” to our local population (3000,000), with a view to expanding this across our referral base on a 24/7 basis, from April 2007.

Accepting the advantages of angioplasty over thrombolysis in AMI, what elements of a cardiac service have to be put in place in order to construct a robust and affective primary PCI programme?

The financial case to support our program rested on saving in thrombolysis costs, reduced bed stays and the use of bare metal stents. However, any profit is tempered by the use of Reopro, and the need to staff the cardiac catheterization laboratories around the clock. Initially the programme was run with 4 consultant operators;Currently there are 7 on our rota with plans to increase to 9 later this year.

The public need education regarding possible cardiac symptoms and to call for immediate medical assistance. Ambulance personnel require training and confidence in ECG interpretation, and the confidence bypass local hospitals in order to take patients to the nearest “Heart Attack Centre”. The construction of “isochrones” helps to inform ambulances as to the shortest journey depending on the time of day and the day of the week.

The hospital emergency department has to amend thrombolysis protocols and transfer patients to their cardiac unit with equal speed. Communication to, and within, the cardiac unit, had to be clear and involve one phone number that was constantly monitored. Similarly a protocol defining suitable cases, and the referral pathway to be followed, had to be made concise and unambiguous. Out of hours, the PCI team is alerted at the same time as the centre accepts the patient, thus minimising” door-to-balloon” time. Rather than being taken directly into the cath lab, patients are initially assessed on the cardiac ward; this ensures that appropriate patients are treated.


5) Long-Term Follow-up of left main OstialStenosis Surgical Reconstruction

Dr. Mazen Khoury, (Greece)

M KHOURY, S A DIMITRIOU , K G PERREAS, A S MICHALIS, B’ Dept Onassis Cardiac Surgery Center, Athens, Greece OBJECTIVES: Left main stenosis, including ostial lesions, is conventionally treated by coronary bypass surgery, However, this approach restores a less physiologic, retrograde perfusion of the ostial LMCA avoids these potential drawbacks. METHODS: From May 1995 until December 1997, 11 surgical angioplasties have been perormed in our unit, 8 pts in CCS class 2 and 3 pts in CCS . One patient had undergone coronary bypass prior to angioplasty of the LMCA. Patients were all followed up clinically and with echocardiography. RESULTS: Mean age of patients 53 years (range 33-79). Male to female ratio was 1.75. The left main coronary stem was approached anteriorly in all patients. The onlay patch concisted of saphenous vein in all our cases. There were no early deaths or perioperative myocardial infractions. During mean follow up of 8 years, there were 2 deaths ( one non cardiac and one due to unknown cause), making an 8 year all causes survival of 81% . None of those patients had any cardiac events or received repeated coronary intervention. The post operative course was uneventful in all patiens. All patients underwent follow up transesophageal echocardiography ( at mean post op time 7.5 months) This demonstrated a wideopen left main coronary artery normal flow pattern by pulsed wave Doppler, and no aneurismal dilatation or calcification of the onlay patch in 10 patients. In one case the left ventricular function was compromised compared to its preoperative status and the echo failed to demonstrate flow on the anterior descending artery which had rreceived a LIMA graft.

CONCLUSION: Surgical reconstruction of the LMCA is safe and effective for the treatment of ostial left main stenosis. Re institution of normal blood flow through the left main coronary artery possibly confers advantages over multiple sequential bypass surgery to more distal branches.


6) Minimally Invasive Mitral Surgery WithoutCrossclamping.

Dr. Michael Petracek (USA)Abstract Not Available

7) Diabetes and Asymptomatic Vascular DiseaseDr. Mark A. Robbins,(USA)

Abstract Not Available

8) Hyperglycaemia in acute coronary syndrome -therapeutic target or risk marker?


Patients with acute coronary syndrome (ACS) often have an elevated blood glucose concentration when admitted to hospital; a marker for poorer prognosis. Interventions that rapidly normalise blood glucose are inconsistently applied and their utility remains unclear. In my presentation I will review the association of hyperglycaemia with outcome, present evidence that hyperglycaemia on admission reflects more than a pre-existing diabetic state and discuss mechanisms by which glucose may directly and adversely affect the course of acute myocardial infarction (AMI). Finally, I will briefly review the evidence that intensive insulin treatment aimed at achieving ‘euglycaemia’ improves outcome.


9) PCI on diabetics with multivessel disease.. a new lookDr. Mohamed Sobhy,(Egypt)


10) Aortic root surgery with the modifiedBentall procedure. 12 year single unit’s results.

Dr. Mazen Khoury(Greece)

M Khoury MD, E Ntalarizou MD, N Michalopoulos MD, K Perreas P Kalogris MD, G Amanatidis MD, AS Michalis MD, FACS. Background: Replacement of the aortic valve and aortic root in a variety of pathological conditions. is commonly performed by the modified Bentall procedure. Methods. From September 1993 to December 2005, 216 consecutive patients were operated on in our unit with the modified Bentall procedure that entails aortic root and valve replacement with composite valved graft and re-implantation of the coronary ostia as “buttons”. The aortic pathology requiring aortic root replacement was chronic aneuryms in 162 patients, chronic dissection in 8 patients, acute aortic dissection in 23 patients while the remaining 23 underwent the procedure as an emergency due to intraoperative adverse events during other procedures. There were 46 emergency cases and 170 had elective surgery. In 54 cases combined procedures were performed (CABG - 44, MVR - 6 patients and left main arterioplasty - 4). 33 patients had undergone previous cardiac surgery. Results: Male to female ratio was (174/42). The mean age was 58,46 months at the time of the operation. Deep hypothermic circulatory arrest was utilised in 28 patients for replacement of the distal ascending aorta and aortic arch.

30 day survival was 93.5% (97,4% for elective cases and 87% for emergencies). Perioperative bleeding occurred in 10 of our patients (4,3%). Myocardial dysfunction led to insertion of an IABP in 15 patients. 16 patients required a permanent pacemaker. Major event free actuarial survival was 90,3% at mean follow-up of 82 months and 86% at 100 months. Conclusion: The Modified Bentall operation with the button technique is a safe, reproducible technique with good peri-operative and long-term results


11) Modern Management of heart failure inwales and the UK

Dr. John Davies, (UK)Abstract Not Available

12) ‘Half a million heart attacks - what havewe learned? Lessons from the Myocardial

Infarction National Audit Project’Dr. Clive Weston,(UK)


13) Myocarditis versus myocardial infarctionDr. Ahmad Abu Halimah,(USA)



14) PCI activity in the UK; trends, traps and triumphsDr. Michael S. Norell,(UK)

Since 1987, the British Cardiovascular Intervention Society has collected information on all angioplasty procedures undertaken in the UK. The number of centres performing PCI has grown from 52 in 1991, to 91 in 2006, the last year for which there is complete data. Over the same time period there has been an average annual growth of 14% in the number of procedures from 9900 to 74000, currently representing a rate of 1216 per million population. This growth in PCI contrasts with the trend in surgical activity which has seen a plateau of approximately 23,000 cases per year for the last decade. Nevertheless, UK PCI activity lies well below that in other European countries.

63% of cases involve the drug eluting stents but new technology such as this is appraised by a government body, the M\National Institute for health and clinical Excellence (NICE), before it is recommended for use.

The use of glycoprotein 2b 3a blockers during PCI (31% of all cases) has fallen over the last few years perhaps reflecting the increasing trend to pre-treatment with Clopidogrel. The majority of cases (74%) incorporate single vessel intervention while 21% of cases are undertaken from the radial approach. 5700(7.8 %) patients were treated as day cases whilst half of all cases were undertaken in the setting of an acute coronary syndrome, 11 % for AMI.

Outcome for all PCI procedures include a Q wave MI rate of 0.15%, emergency CABG of 0.09% and overall mortality of 0.74%. Mortality for elective, non-elective, primary PCI for STEMI and shock was 0.2%, 0.62%, 4.6% and 30.2% respectively. Other interventional procedures are also documented showing increases in the use of rotational atherectomy, thrombus extraction, IVUS and pressure wire and a decline in the use of DCA and septal ablation for HCM. Whilst the number of balloonValvuloplasty procedures has fallen ASD and PFO closure rates are increasing.

The BCIS audit collection has provided valuable information to UK interventionists for the last 20 years. Information is now being collated into a national repository, the Central Cardiac Audit Database (UKCCAD) which incorporates surgical information as well as pacemaker and ICD implantation, and is able to track long term outcomes.


15) PCI and multi slice CT ( from Egyptian ICC archives)Dr. Mohamed Sobhy, (Egypt)


16) Off Pump Coronary Bypass vs On Pump CoronaryBypass and Evidence Based Medicine

Dr. Omar M.Lattou, (USA)

Omar M. Lattouf MD, PhD1, Vinod H. Thourani, MD1, Patrick D. Kilgo, Msc2, Michael E. Halkos1 MD, Richard Myung1 MD, William A. Cooper1 MD, Robert

A. Guyton1 MD, John D. Puskas1 MD

Background: Technological advancements with improved monitoring, hemodynamic support and the utilization of newly introduced positioning and stabilizing devices have significantly facilitated the performance of beating-heart surgery. In this study we report the influence of surgery type, number of grafts, and the Index of Completeness of Revascularization (number of grafts/number diseased vessel system, ICOR) on 30 day morbidity and mortality long-term survival. Methods: From 1997-2006, 12,812 consecutive patients underwent isolated coronary artery bypass surgery patients at a single academic center. Retrospective analysis of prospectively collected institutional Society of Thoracic Surgery Data Base was interrogated for 30 day peri-operative morbidity and mortality.Additionally, ten year survival data were obtained by cross-referencing patients with the national Social Security Death Index. A propensity score (PS) analysis of 46 preoperative characteristics balanced risk factors between surgical groups. A proportional hazards regression (PHREG) modeled the hazard of death as a function of surgery type (on vs. off ), distal group (1-3 vs. 4-7 vessels), ICOR and PS. Results: Patients treated with OPCAB techniques, in the few vessels as well as in the many-vessel bypass groups, had reduction in the risk of post-operative Death, Stroke, Renal Failure and MACE (Major Adverse Composite Outcome).Long-term survival within the four groups: OPCAB 1-3 grafts (n=3946; ICOR 1.11), OPCAB 4-7 grafts (n= 1721; ICOR 1.56), ONCAB 1-3 grafts (n=3380; ICOR 1.21) and ONCAB 4-7 grafts (n= 3765; ICOR 1.64) was not significantly influenced


by surgery type or number of grafts. However, irrespective of technique of revascularization, there was a survival advantage for patients with higher ICOR. Conclusion: OPCAB techniques provide a greater short-term safety margin in the few vessels as well as in the many-vessel bypass groups.Long-term survival was similar for patients receiving 1-3 or 4-7 grafts by either on-pump or off-pump techniques. A higher ICOR was associated with improved long- term survival within all groups.

17) Drug Eluting Stents and Late ThrombosisDr. Samir Alam, (Lebanon)



18) Myocardial Protecton Against Ischemic/ Reperfusion Injury in Rabbit-heart comparison between

Sildenafil and Ordonefil Dr. Said Al-Khateeb, (Jordan)

MYOCARDIAL PROTECTON AGAINST ISCHEMIC/REPERFUSION INJURY IN RABBITHEART: COMPARISON BETWEEN EFFECTS OF SILDENAFIL AND ORDONAFIL Said Khatib and Tariq Tamimi, Dept of Physiology, Facultyof Medicine, Jordan University of Scienc and Technology, irbid-Jordan

Phosphodiesterase type-5 (PDE-5) inhibitors, Sildenafil (SILD) and Ordonafil (ORD), have been developed for erectile dysfunction. Recently SILD was shown to have myocardial protective effect by reducing the infarct size in ischemia/ reperfusion injury. To test the hypothesis that this effect is a generalized “class” effect we decided to test the protective effect of ORD in comparison to that of SILD. Isolated rabbit hearts, perfused using Langendorff system, were subjected to 30 min of global ischemia followed by 2 hrs of reperfusion. At the end of reperfusion, the area of infarction wasdetermined using triphenyl tetrazolium chloride staining technique. Area of

infarction and the whole left ventricle (LV) were measured by computer morphometry using image tool software. The infarct size was expressed as % of the LV size. Creatine Kinase (CK) enzyme activity, as a marker of cellular death, was determined in the perfusate pre- and post-ischemia by enzyme bioassay. SILD or ORD at 400nM, perfused the heart for 5 min before induction of ischemia. The results of both drugs showed significant myocardial protective effect. The infarct size was reduced from 25.6± 4.2 % in control to 4.4± 0.8 % and

10.9± 2.3%, (mean± SEM, n=5-8, p<0.05) for ORD and SILD,respectively. 5-HD (a blocker of mitochondrial KATP channels)

partially blocked the protective effect of ORD as demonstrated by an infarctsize of (19± 2.3%) suggesting a pivotal role of mitoKATP channels in ORD- induced protection. Additionally, the increase in CK activity was decreased from 30 times increase post ischemia in control to 15 times and 18 times in ORD and SILD, respectively. These results support the notation that PDE-5inhibitors have “class” protective effect on the ischemic heart


19) A single dose of Dexamethasone preoperatively reducespostoperative nausia and vomiting in patients

undergoing open heart surgery.Dr. Yaser Alghoul(Jordan)

Dr. Yaser Al-Ghoul, M.D, Senior specialist of cardiac anaesthesia.RMS

Despite improvements in anaesthesia, 50-60 % of patients still experience nausea and vomiting after surgery.Known predictors of postoperative nausea and vomiting include female gender, non-smoking, history of motion sickness and the use of opioids postoperatively.اA large clinical trial of postoperative nausea and vomiting (PONV) showed that metchlorpromide, ondansetrone, dexamethazone and droperidol were effective antiemetics.dexamethazone was recommended as the first line drug as it is safe and cheap drug.In our study we reviewed efficacy of a single dose of dexamethazone (4-8 mg) for prevention of PONV in adult patients undergoing open heart surgery.A total of 100 patients were studied and divided in to two groups; group A (50 patients) received 4-8 mg of Dexamethazone immediately after induction of anaesthesia, and group B (50 patients) received normal saline injection (placebo group).Results: 6 patients were excluded from the study because either they died (2 patients) or they needed rescue treatment of severe PONV (4 patients).The incidence of PONV in group A (Dexamethazone) was 24% compared with 50% in placebo group in the first 24 hours after surgery.Conclusion: a single dose of Dexamethazone preoperatively is a safe, cheap and effective method of reducing PONV in patients undergoing open heart surgery.


20)Euro Heart Survey,Acute Coronary Syndrome(ACS) Rgistry

Dr Ahmad Hassonah(Jordan)Ahmad Hassonah *, Riyad Mosa, Natalia Shawabkeh, Dina Oran, Suhail Suleiman, Atif Bishtawi

Objectives: The Euro Heart Survey ACS-Registry is the first continuous registration of consecutive patients presenting with ACS in Europe providing benchmark reports for quality assurance with the intention to improve the implementation of ESC guidelines into clinical practice. The main objectives of our participation in this registry are to determine the adherence to current ESC guidelines for the management of the different kinds of ACS with respect to acute reperfusion treatment (STEMI), invasive vs conservative treatment (NSTEMI / UA) , adjunctive medical treatment (all ACS), to document current presentation of ACS in Jordan, and to assess the immediate, in-hospital and 1-year outcome of patients with ACS.Methods: Consecutive patients with any of the acute coronary syndromes should be enrolled into the registry on first admittance to hospital.Data were collected using online internet data entry. The electronic case report form (CRF) was provided by the Euro Heart Survey Team . The CRF includes four main data sections; Patient Characteristics, Investigations and Treatment, Hospital Outcome, and One Year follow-up. A central database is set up with the data of the ACS-Registry, from which data analysis is performed.The Euro Heart Survey Team at the European Heart House provides reports of all collected data including patient characteristics, treatment and clinical outcome of the enrolled patients to every participating centre. This benchmarking system offers the participating centre a tool for internal quality control to checkfor adherence to the ESC practice guidelines for the management of ACS. Results: In the baseline characteristics of our overall population, the results showed the following main differences with the rest of the world; a median age of 58.69 years compared to (64.28) , median BMI 27.73 (26.78), Current smoker (%) 68.00 (32.95) , Diabetes All (%)40.80 (27.39), Hypertension (%)36.29 (62.04), and Hypercholesterolaemia (%)26.19 (47.73 ), respectively.


In STEMI the main differences were in regard to primary PCI which was nil in our hospital compared to 43.34% in the rest of the world. Thrombolysis as the main reperfusion treatment was almost always provided in the CCU settings compared to 31.40% being done in the emergency room in the rest of the world. In-Hospital treatment differences include clopidogrel (%)5.32 (85.01), and LMWHs (%)15.91 (59.07). Complications mainly Heart failure (%)40.43 (26.91).In regard to NSTE-ACS, the main differences of all characteristics of our population compared to the rest of the world were as follows; Age over 65 years (%)22.58 (53.85) , Current smoker (%)58.06 (25.39) , Urgent < 72h (%) reperfusion for NSTE-ACS 3.45 (29.92). In-Hospital treatment, Clopidogrel (%)12.90 (71.72), LMWHs (%)27.59 (70.09), Unfractionated Heparin (%)72.41 (33.57), and GPIIbIIIa antagonists (%)3.23 (22.09).

Conclusion: We need to address issues like providing PCI and interventional facilities to our services as well as providing medications considered to be essential in the management of ACS like antiplatelet clopedogril and anticoagulants like IIbIIIa inhibitors, beside some other facilities and quality control to become more adherent to the ESC and international guidelines. The study would be more useful if other centres in Jordan which provide the above services participate in this registry to reflect the shortcomings of our centre compared to overall practice in Jordan


21)Results of Coronary Artery Bypass Surgeryat Queen Alia Heart InstituteDr Ali Abu Rumman(Jordan)

Outcome of coronary artery bypass surgery at Queen Alia Heart Institute.Dr Ali Abu Rumman*1, Dr Walid Sawalha**, Objective;

Our objective was to assess the demographic characteristics, assess the prevalence of the various risk factors, and outcome in patients undergoing coronary artery bypass graft at Queen Alia Heart Institute.Methods;

All patients who had coronary artery bypass graft at Queen Alia Heart Institute between April 2005 and September 2006 were included in our study. The data collected included the patients’ demographic characteristics, risk factors for coronary artery disease, history of myocardial infarction, renal dysfunction, history of prior cardiac surgery and the nature of coronary artery disease. We assessed operative mortality, rate of stroke, atrial or ventricular arrhythmias, duration of ventilatory support and Intensive Care Unit stay.Results;We had a total of 1018 patients. The mean age was 61.1 ± 11 years, with 24% females. The mean age was 59.6 ± 11.6 years for males and 63.6 ± 9.6 years for females (P = 0.001). 31% had previous MI, 41.1% had diabetes mellitus and 40.8% were hypertensive. Females had a prevalence of 59.4% of diabetes and 58% hypertension compared to 33% & 32.6% in males (P <0.001). Almost two thirds (61%) were smokers. Only 18% of females were smokers compared to 73.8% of males (P<0.001). Hypercholesterolemia was present in 29.2% of patients (36.4 % in females compared to 27 % in males (P<0.001). Family history of coronary artery disease was present in 24% {22% in females and 25% in males (statistically a non significant difference)}. The prevalence of risk factors was 95% for at least one risk for CAD to be present. Two risk factors were present in 28% and three risk factors were present in 20%. Three percent had renal dysfunction. More than 85% had three vessel disease and 12.5% had significant left main disease. 3.8% had prior CABG surgery. The mean ICU stay was 1.9 ± 0.5 days (1.6 ± 0.4 days for males versus 2.3 ± 0.7 days for females (P<0.001).


The mean post-operative hospital stay was 7.6 ± 3.1 days (6.4 ± 2.6 days for males versus 8.6 ± 3.0 days for females (P<0.001). In-hospital mortality was 4.8% (4.2% for males versus 6.6% for males (P<0.001). Stroke was seen in 2.8% (2.7% for males versus 2.85% in females (P = NS). Ventilatory support for more than 24 hours was seen in 7.0% (6.2% in males versus 8.4% in females (P 0.01). Intra-Aortic Balloon Pump (IABP) support was used in 5.1% (4.9% in males versus 5.4% in females (P 0.01).Conclusion;Our data showed high prevalence of smoking, diabetes, hypertension with the later two being more prevalent in females, who tended to be older. Males had significantly higher in-hospital complications than females. The mean hospital stay and overall hospital mortality are comparable to international results.

22) Coronary surgery: Can we improve our results?

What are the best techniques?Dr. Noirhomme, (Belgium)


23) Drug eluting stents: efficacy and safety...Dr. David X.Zhao,(USA)Abstract Not Available


24) Stem Cell Therapy and Ischemic Heart Disease;Has the Time Come for Clinical Application?

Dr. Omar M. Lattouf,(USA)

New techniques involving genetic engineering and cell therapy offer many possibilities in the surgical treatment of ischemic myocardium. Currently surgical coronary artery bypass (CABG) and percutaneous coronary intervention (PCI) are the two procedural options that are most commonly available to treat patients suffering from ischemic heart disease. Revascularization in these patients results in symptomatic and survival benefit. However, many subjects with advanced coronary artery disease remain symptomatic because their ischemic and viable areas of the myocardium are under-perfused, accentuating the resulting LV dysfunction. For patients with coronary anatomy not suitable for such procedural intervention, trans-myocardial revascularization with laser (TMR) has become an accepted standard of care. TMR is an often used therapy for treatment of refractory angina in patients with ungraftable vessels. With TMR, a laser apparatus creates trans-myocardial channels in a viable ischemic area of myocardium. The channels eventually heal, producing remarkably little scarring, and encouraging new blood capillaries to grow in the area. A 1999 study by Frazier and colleagues documents improvement in myocardial perfusion by 20% (documented by Thallium scan) in a group of patients treated with TMR. A series of patients followed jointly by Drs. Lattouf and Sigman, at Emory, have shown improved myocardial perfusion on PET scans several weeks after TMR therapy.

A new and promising advancement in the treatment of end-stage coronary artery disease is the use of stem cells. Stem cell research has revealed a vast potential for the use of cell therapy in treatment of ischemic tissue. It has also brought with it serious ethical dilemmas, with attention centering on stem cells derived fromabortedfetuses.

This embryonic tissue is rich in the most primitive of all stem cell populations with the highest degree of developmental plasticity. Remarkably, these embryonic stem cells can undergo an undetermined number of cell doublings while retaining the capacity to differentiate into multiple specific cell types, including heart cells. The use of human embryonic stem cells has not been approved and is not the subject of this document


Current research using stem cells derived from other sources, such as umbilical tissue, peripheral blood and bone marrow examines the role of stem cells in cardiac muscle repair. This research has shown that mononuclear cells and progenitor cells in the bone marrow and peripheral blood have great potential for treating ischemic areas by effecting the generation of new blood vessels and possibly aid in heart cell recovery. Experimental work by various authorities in this field have demonstrated that peripheral blood and bone marrow based mononuclear cells and platelets supply angiogenic factors (mainly vascular endothelial growth factor or VEGF) and cytokines and induce collateral vessel formation in ischemic tissue.

Studies have shown that the direct application of vascular growth factors, stem cells, mononuclear cells, and platelets are effective in promoting angiogenesis in myocardium after acute MI. TMR has been shown to improve symptoms of angina by stimulating vascular growth and improving perfusion to ischemic myocardium. This evidence warrants investigation into a therapy involving the use of TMR to induce angiogenesis and healing in poorly supplied areas of the heart, and the surgical application of stem cells to the area to promote and sustain the healing process. A combination of these techniques, with stem cell injection immediately following TMR, could prove to be an effective method with more than additive effect for the healing of ischemic regions of the heart.


25) Pulmonary endarterectomy - surgicaltreatment for chronic thromboembolic

pulmonary hypertension (CTEPH).Dr. Joseph Arrowsmith,(UK)

J E Arrowsmith, MD FRCP FRCA. Papworth Hospital, Cambridge, UK

Following an acute pulmonary embolism, some 3-4% of patients will develop chronic thromboembolic pulmonary hypertension (CTEPH) [1]. Organization – rather than dissolution – of thromboembolic material, followed by further episodes of embolism and in situ thrombosis, produces an obstructive pulmonary vasculopathy [2]. Progression to CTEPH is more likely in splenectomized patients and those with elevated levels of factor VIII or the anticardiolipin antibody syndrome. Curiously, an association between CTEPH and other thrombophilic (i.e. procoagulant) states has not been demonstrated.The combination of progressive right ventricular pressure overload and ventilation-perfusion mismatch is associated with the insidious onset of exertional dyspnoea, reduced effort tolerance, atypical chest pain and palpitations. In more than 50% of cases, however, there is no history of deep vein thrombosis or pulmonary embolism. This, combined with a general lack of awareness of CTEPH and the misdiagnosis of symptoms as ‘asthma’ or ‘left ventricular failure’, means that the interval between the onset of symptoms and diagnosis of may be two or more years. Prognosis is directly related mean pulmonary artery pressure (PAP) at presentation. Fewer than 20% of patients with a mean PAP >50 mmHg will survive more than 2 years [3].Medical therapy in CTEPH, other than anticoagulation to prevent further embolism, is largely symptomatic and, until recently, the only surgical option for this group of patients has been lung

or heart-lung transplantation. In 1973, Moser and Braunwald reported the first successful surgical intervention for CTEPH [4]. The modern era of pulmonary endarterectomy (PEA) began in 1990 at the University of California in San Diego. Under the leadership of Stuart Jamieson more than 2000 patients have now undergone the procedure [5]. Despite encouraging symptomatic and prognostic benefits, and global dissemination of the technique, fewer than 10 centres worldwide currently offer a PEA service – Papworth Hospital, which began its PEA programme in 1997, now has the third largest experience.


The management of patients with CTEPH requires a multidisciplinary team approach. At present there is to system by which to risk-stratify patients. Patient selection and suitability for surgery is based on extensive preoperative investigation, the presence and severity of co-morbidities and, most importantly, the anatomical distribution of pulmonary vascular disease. In many case, preoperative optimization with selective pulmonary vasodilators is required [6]. PEA is both complex and time consuming; requiring deep hypothermia with circulatory arrest or selective cerebral perfusion [7]. Morbidity is primarily related to incomplete clearance and pulmonary reperfusion injury. Lessons learned from transplantation and use of ventricular assist devices has greatly improved our management of right ventricular dysfunction, and encouraged the early use of extracorporeal membrane oxygenation in compromised PEA patients. Initially perioperative mortality in our series was high (30-40%), however with gradual expansion of the programme and the persistence of an ‘institutional learning’ effect mortality over the last 18 months is <5%.The lecture presentation will include discussion of the aetiology and pathophysiology of pulmonary hypertension and CTEPH, preoperative investigation and perioperative management.

Pengo V, Lensing AW, Prins MH, Marchiori A, Davidson BL, Tiozzo F, et al. 1. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med 2004; 350(22): 2257-64.

Hoeper MM, Mayer E, Simonneau G, Rubin LJ. Chronic thromboembolic 2. pulmonary hypertension. Circulation 2006; 113(16): 2011-20.

Riedel M, Stanek V, Widimsky J, Prerovsky I. Longterm follow-up of 3. patients with pulmonary thromboembolism. Late prognosis and evolution of hemodynamic and respiratory data. Chest 1982; 81(2): 151-8.

Jamieson SW, Kapelanski DP, Sakakibara N, Manecke GR, Thistlethwaite 4. PA, Kerr KM, et al. Pulmonary endarterectomy: experience and lessons learned in 1,500 cases. Ann Thorac Surg 2003; 76(5): 1457-62.

Moser KM, Braunwald NS. Successful surgical intervention in severe 5. chronic thromboembolic pulmonary hypertension. Chest 1973; 64(1): 29-35.

Fischer LG, Van Aken H, Burkle H. Management of pulmonary 6. hypertension: physiological and pharmacological considerations for anesthesiologists. Anesth Analg 2003; 96(6): 1603-16.

Webb ST, Jenkins DP, Latimer RD. Recent advances in anaesthesia for 7. pulmonary endarterectomy. Kardiochir Torakochir Polska 2006; 3(4): 356-60.


26) Surgical treatment for rupture of left ventricularfree wall after acute myocardial infarction.

Dr. Sulieman Haddadin,(Jordan)

OBJECTIVES:Left ventricular free wall rupture (LVFWR) is still one of the fatal complications after myocardial infarction. Surgical repair is mandatory even with high operative mortality. The aim of the study is to analyze the results according to the status of the left ventricular tear and type of surgical repair. MATERIALS AND METHODS: From January 1997 to December 2007, 19 patients with LVFWR were treated at our Institution. According to type of ventricular rupture patients were divided into two categories: blow-out type in 11 cases (group 1) and oozing type in 8 cases (group 2). Mean interval time between first diagnosis of LVFWR and surgery was 21±9 hours for group1 and 9+7 h for group2 (p<0.05). Patch cover and glue technique was applied for oozing type patients, while for blow-out type patients direct closure using buttress sutures or a sutured patch technique was used. RESULTS: There were four hospital deaths in group 1 (36%) and 1 (12%) in group 2 (p<0.05). Fourteen patients were discharged with a mean follow-up of 3.8±3.7 years. During follow-up one further death occurred (after 7.5 yrs) in patient of group 2. No recurrence of free wall rupture or aneurysm was demonstrated in all cases. At last follow-up all survivors showed excellent clinical results with a preserved left ventricular function. Patients with oozing type LVFWR and patch covering technique repair showed absence of left ventricular restricted motion at the echocardiographic study. CONCLUSION: In patients with LVFWR early diagnosis of starting left ventricular tear is crucial for successful treatment when excellent results can be achieved with glued patch covering technique.


27) LV RestorationDr. Majed Othman,(Syria)


28) Hybrid cardiovascular intervention:New standard of care.

Dr. David X. Zhao,(USA)Abstract Not Available

29) Hybrid coronary revascularizationthe surgical view.

Dr. Bahi Hiyasat,(Jordan)

Authors: Bahi Hiyasat MD, Friedrich Wilhelm Mohr, MD PhD

Hybrid coronary artery revascularization combines grafting the Left Internal Thoracic Artery (LITA) to the left anterior descending artery (LAD) with percutaneous coronary intervention (PCI) of the remaining diseased coronary arteries.The setup is the Hybrid OR = Surgery + PCI(very complex logistical setup).Surgeon,Cardiologist,Anesthesist ,Nurses and Radiology assistent are all in one team.If there is adequate equipment ,a good team ,good cooperation with your interventional cardilogists ,ability to perform high end“ MIDCAB/ TECAB and PCI,vast experience,and sophisticated patient selection; then the hybrid revascularization may be performed,but If we do it ,we better do it right,If not it is better to go for complete arterial revascularization.


30) Hybrid procedures in congenital heart surgeryDr. Emile Bacha,(USA)

Hybrid pediatric cardiac surgery is an emerging field that combines skills and techniques traditionally used by congenital heart surgeons and interventional pediatric cardiologists. A key paradigm shift for surgeons is the extensive use of indirect imaging techniques (as opposed to direct visualization in the field), such as fluoroscopy or transesophageal echocardiography (TEE), used on the beating heart while performing a given task, as opposed to working on an arrested flaccid heart. Hybrid techniques are especially useful when surgery alone or catheter-based interventions alone are not achieving a satisfactory result for a given problem, or when the combination of the two fields results in less invasiveness and less trauma to the patient. Hybrid procedures can be performed in an OR, cath lab, or hybrid room. The key conditions for any location is to have enough space and outlets available to use a CPB machine or ECMO, an echo machine, good lighting for surgery, stocked equipment nearby, and a fluoroscopy-friendly table that can move side to side. A biplane cath lab is not typically required. Most hybrid procedures can be performed with a high-quality C-arm that can store images and provide road maps. Fluoroscopy is not always essential, but echocardiography nearly always is. Hybrid procedures are now employed in several areas of congenital heart surgery:

1.The hybrid stage I procedure: In the most common version, the procedure is performed in the catheterization lab or a specially designed “hybrid room”. Via median sternotomy, bilateral branch PA bands are placed using 1.5-2 mm wide rings cut from the usual 3.5mm Goretex shunt. A clip should be applied to each band, so that it can be seen on fluoroscopy. Next, a 5-0 prolene purse-string is placed at the sinotubular junction of the main PA and a wire is passed into the descending aorta under fluoroscopy.

A 6 or 7 Fr introducer is positioned with a few mm’s of the tip inside the vessel (if too far in, difficult to shoot PA angiogram and deploy stent in proximal duct). An angiogram is shot to delineate the aortic arch and exclude any possible narrow areas at the isthmus, transverse arch or ascending aorta-arch junction that would preclude a hybrid approach (risk of retrograde CoA). The band position and tightness is verified by selective branch PA angiograms, using a Judkins-Right catheter if necessary. If all the above conditions are met, a ductal stent (either self-inflatable or balloon dilated) is placed under fluoroscopic guidance. Creating a non-restrictive atrial septum remains difficult. If the atrial septum is non restrictive, it is left alone. If it is restrictive, balloon dilation or stenting can be performed. This can be done peratrially (via purse-string on right atrial free wall), or via a umbilical venous line, or percutaneously in a delayed fashion. Some centers prefer to band the PA’s in the OR first, and follow by ductal stent placement (with or without atrial stent) in the cath lab. If the bands have to be revised, the patient has to undergo a second operation.


The 2d stage consists of aortic arch reconstruction, removal of ductal stent, atrial septectomy, cavopulmonary shunt and PA plasty if necessary. Advantages of this strategy include complete avoidance of neonatal CPB, avoidance of sensitization to homograft tissue in case transplantation is planned, less use of hospital resources and the possibility of stabilizing sick neonates with little intervention. Disadvantages include the possibility of retrograde aortic coarctation with subsequent cerebral or coronary malperfusion (mostly in aortic atresia patients), ductal stent embolization, branch PA distortion and the difficulty of achieving a truly non-restrictive atrial septum. A retrograde shunt from main PA to innominate artery has been described to bypass any isthmus obstruction, but this does not bypass an obstruction between ascending aorta and aortic arch.

Hybrid palliation is very likely to be beneficial in the following single ventricle patients:

Major non-cardiac defects– Cerebral hemorrhage– Late presentation– Non-resolving end-organ damage from shock at – presentationSepsis–

Hybrid palliation is possibly beneficial in the following patients with single ventricle:

Intact or highly restrictive atrial septum – Additional cardiac defects– Poor ventricular function +/- TR–

The role of hybrid palliation is still questionable in: “Straightforward” HLHS or other SV anomalies such as single – LV’s (because of improved outcomes in this category)Aortic atresia (because of the strong likelihood of retrograde – aortic coarctation)

Further developments will depend on new technologies such as therapeutic ultrasound for percutaneous ASD creation, bioabsorbable stents, injectable gene therapy to keep the ductus open, percutaneous flow occluders for all-percutaneous approach, miniaturized adjustable PA bands, or stable oral version of PGE.

2. Perventricular closure of muscular VSDs:Current indications for the perventricular closure of muscular VSD’s include any infant weighing less than 5 kg, or any child with associated muscular VSD’s and other cardiac defects requiring simultaneous repair, such as PA debanding, DORV, or TGA. Technique: The heart is exposed via median sternotomy or minimally-invasive incision. Under continuous TEE guidance, a purse-string suture is placed on the RV free wall. The RV is punctured and a guide wire is passed through the VSD.

An introducer sheath with a dilator is fed over the wire and advanced into the LV cavity. Care is exercised not to advance the sheath with the dilator too far into the LV cavity because of risk of perforation. We have found that real-time 3D echo (epicardial echo) is very helpful in determining the position of the tip and the VSD anatomy. An Amplatzer MVSD device or


Amplatzer Ductal Occluder (AGA Medical Corporation, Golden Valley, MN) is then advanced inside the delivery sheath until the LV disk opens up in the LV cavity by retraction of the sheath over the cable. Further retraction of the sheath over the cable deploys the waist and then the RV disk. As long as the device is still attached to the cable, it can still be re-captured. If the position is satisfactory, the device is released. The advantage of this technique over standard surgery is first and foremost the real-time feedback obtained by continuous TEE monitoring during perventricular device closure. Lesser advantages include avoidance of cardiopulmonary bypass (CPB) in patients with isolated muscular VSDs, or, if associated cardiac lesions are present, marked reduction in CPB times. There are no weight and no vascular access limitations. Some VSD’s may not be easy to cross. A percutaneous femoral arterial access to cross the VSD with a wire from the left side under fluoroscopic guidance can be used. An arteriovenous loop is established by snaring the wire via a perventricular approach and the procedure can be performed as explained above. Complications include difficulties with the RV disk expansion in patients with RV hypertrophy. An alternative is to use an Amplazter duct occluder device which has no right-sided disk. AV valve subvalvar apparatus may get entangled in the device. This should be recognized immediately on the TEE and dealt with by recapturing the disk and re-deploying it. Intermediate term results have been excellent.

3. Intraoperative ballooning and stenting of pulmonary arteries:Intraoperative ballooning and stenting of pulmonary arteries can be helpful in selected circumstances, such as a distal branch

PA stenosis, PA stenosis due to compression, or for re-ballooning of a previously implanted stent. This can be done on the arrested heart, or on the beating heart via a puncture of the main PA or RVOT under fluoroscopic guidance. Key technical elements include precise positioning of the balloon or stent. The lobar bifurcation can be injured if the stent abuts it, and oversizing can result in tears.

4. Intraoperative ballooning of pulmonary veins:Intraoperative ballooning with or without stenting of stenotic pulmonary veins has been tried before with poor results. In cases of extensive congenital or recurrent pulmonary veins stenoses, we have found that initial ballooning of the pulmonary veins will often guide the surgeon down the correct luminal pathway. This is because a wire is introduced in the pulmonary vein lumen (which can be as narrow as 1-2mm). Following wire passage, a balloon is introduced and dilated. This will “crack” the hypertrophic intimal layer and show the surgeon which layer to excise. Cutting balloons are helpful. A extensive pulmonary venous “endarterectomy” extending into the extramediastinal intraparenchymal pulmonary veins is then performed. Trying to perform this internal layer resection without having dilated the stenotic passage is very difficult and likely to result in extravasation. Intraoperative stenting of pulmonary veins has no role given the poor long-term results of stents in this position.


5. Perventricular pulmonary valve implantation:Percutaneous pulmonary valve implantation is currently under study. It typically requires advanced catheterization skills. Significant complications can result from the large sheath sizes required, or from negotiating a large bulky and stiff device (the valve is implanted and crimped on a stent) across the tricuspid valve. Most interventional cardiologist agree that getting to the RVOT is the most difficult portion of the procedure, and carries the risk of tricuspid valve injury. Perventricular pulmonary valve

placement provides direct access to the RVOT. Direct puncture of the RV apex or free wall is very simple. In some patients, including redo’s, a xyphoid incision (cut-down onto anterior RV surface) may suffice. Percutaneous pulmonary valve implantation is currently limited to calcified RV-PA conduits with a size < 22mm. With the perventricular approach, a large RVOT (older TOF patient after transannular patch) can be downsized to the desired diameter with sutures. The valved stent can also be anchored with external sutures. Selected References:-Akintuerk H, Michael-Behnke I, Valeske K, et al. Stenting of the arterial duct and banding of the pulmonary arteries. Basis for combined Norwood stage 1 and 2 repair in hypoplastic left heart. Circulation 105:1099-1103, 2002 -Bacha EA, Cao QL, Starr JP, et al. Perventricular device closure of muscular ventricular septal defects on the beating heart: Technique and results. JTCVS 126;1718-23, 2003


31) Mitral valve repair and replacementDr. Michael Petracek, (USA)


32) THE CHOICE OF VALVE PROSTHESISIN OUR AREA

Zohair Al Halees, MD

It is true that many valvular problems can be dealt with in the catheterization laboratory by cardiologists; nevertheless, surgery remains the main therapy at present. Many surgical options are available. The most appropriate procedure depends on multiple factors. There is no doubt that valve repair is superior if it can be accomplished successfully. The tricuspid valve is the most frequently repaired valve; the mitral valve is often repaired, whereas the aortic valve is repaired occasionally. When it comes to replacement, the dilemma starts. We have two basic entities: biological and mechanical valves. In balance is the problem of durability with biological valves and the need for anticoagulation with mechanical prostheses. There are published guidelines to help in decision-making.1 However, these guidelines are based on studies and observations mainly from the Western hemisphere where facilities are good, education is widespread, and the culture is fairly homogenous. So are the guidelines applicable for us where the facilities in many parts are scarce, education is lacking, and the culture is so diversified?

Anticoagulation control is extremely problematic in our society. Other major drawbacks of permanent anticoagulation relate to exercise limitation in the young and to females who wish to become pregnant. Keeping that in mind and knowing that mechanical valves are not truly life long replacement as patients are not guaranteed reoperation free survival, we opt in these situations to use biological valves. Use of bioprosthesis in the young is controversial but our data support their use in the young in certain circumstances accepting the need for reoperation. Reoperations are now safe and in many hands operative mortality in the first redo operation is the same as in the initial operation.


33) Heart Rate Control In The Modern TreatmentOf Heart Failure

Dr. Marius Turcan, (Romania)

«Heart Rate Control In The Modern Treatment Of Heart Failure»

Clinical evidence has been accumulating for many years to suggest a link between heart rate and mortality in coronary diseased patients and those with heart failure.

Epidemiologic data have also indicated a strong link between sudden cardiac death and sustained elevated heart rate, as an independent risk factor, raising the issue that slow heart rate might exert a protective effect. Nowadays is widely accepted that lowering heart rate reduces cardiovascular risk and prolongs life expectancy.

Inappropriate tachycardia generally seen in patients with sever heart failure is a marker of depressed LV function and reflects abnormal activation of sympathetic nervous system. Thus, heart rate lowering appear useful for reducing myocardial oxygen demand and prolonging diastolic filling and coronary perfusion time.

Beta-blockers as heart rate lowering agents reduce \total mortality, cardiovascular mortality, sudden cardiac death in post myocardial infarction and heart failure patients. A large amount of evidence supports the use of beta-blockers in heart failure (CIBIS I, II, III, MERRIT-HF, COPERNICUS, COMET, etc). Is there a relationship between the extent of the beta-blockade and the magnitude of the benefit as trials like COMET and BEST might suggest?

The beneficial effect is related to both reduction in heart rate and partial inhibition of the neurohormonal cascade caused by sympathetic stimulation. However, the use of full therapeutic doses of beta-blockers is often limited in clinical practice by the concomitant adverse effects.

Ivabradine selectively inhibits hyperpolarization- activated If channel in the sinus node with minimal effects on other channels. By doing so, it reduces heart rate, decreasing the diastolic depolarization gradients, and it maintains myocardial contractility, atrio ventricular conduction and ventricular repolarization, all of these being documented by experimental studies.


The cardioprotective effects achieved by prolonging diastolic perfusion time, improved subendocardial perfusion, decreased myocardial oxygen demand and translate in experimental reduction of stunned myocardial areas (on animal models).Potential benefits of ivabradine in patients with LV disfunction were documented in randomized double blind placebo controlled studies, in coronary patients in which the decrease in LV volumes could be seen especially in those with low LVEF < 35%.

Two undergoing studies BEAUTIFUL in postmyocardial infarction patients with systolic disfunction and SHIFT enrolling heart failure patients with severe systolic disfunction irrespective of ethiology will bring relevant data on this issue.

It is thus conceivable that in the near future the treatment of heart failure will suffer significant changes with the use of heart rate lowering agents like ivabradine alone or in combination with the already established beta-blockers.

34) Mitral Valve RepairDr. Gebreen Elkhury, (Belgium)



35) Aortic Valve RepairDr. Gebreen Elkhury, (Belgium)

Aortic Valve Repair: Results of Ten Years Experience.

Laurent de Kerchove, David Glineur, Michel van Dyck, Jean-Louis Vanoverschelde, Philippe Noirhomme, Gebrine El KhouryDepartment of Cardiovascular Surgery, Cardiology and Anesthesiology, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium PurposeIn patients with aortic valve insufficiency (AI), valve repair requires a tailored surgery determined by the leaflets and proximal aorta anatomy which prompt us to develop a functional classification of AI. This classification has implication on the surgical strategy and outcome. In this study, we analyze one decade experience with aortic valve (AV) repair.MethodBetween January 1996 and december 2006, 298 patients underwent elective aortic valve repair. Aortic annulus, root or ascending aorta dilatations were managed by following techniques: subcommissural annuloplasty, sinotubular junction plication, ascending aorta replacement, root remodelling or valve reimplantation. Cusp prolapses were corrected by plication, triangular resection or free margin shortening with PTFE (Goretex 7/0). Cusps perforation were closed with autologous pericardial patches. ResultsHospital mortality was 1.5% (4 patients). Five (2%) patients needed early aortic valve reoperation, 2 of them were re-repaired. Follow-up is 94% complete and reach a mean of 45±32 months. During this period, 14 late deaths occurred, 10 cardiac related. Eleven patients needed late aortic valve reoperation, 2 of them were re-repaired. At 3 and 6 year, overall survival, freedom from aortic valve reoperation and freedom from aortic valve

regurgitation >2 were 96±2% and 91±6%, 95±3% and 94±4%, 93±4% and 86±7% respectively. Thromboembolic events occurred in 6 (2.3%) patients during the follow-up and no aortic valve endocarditis were recorded. ConclusionThe functional classification allows a systematic approach of AI and may enhance the reparability rate. Moreover, it facilitates anticipation of the surgical technique and the prediction of the durability. Cusp restrictive motion (type III), due to fibrosis or calcification, is an important limitation for conservative surgery.


36) Repair of Ebstein’s Anomaly.Dr. Emile Bacha,(USA)

Ebstein’s anomaly is a congenital malformation of the right ventricle and tricuspid valve that is characterized by multiple features that can exhibit an infinite spectrum of malformation [1]. Abnormalities of the tricuspid valve and right ventricle include: 1) adherence of the tricuspid leaflets to the underlying myocardium (failure of delamination), 2) anterior and apical rotational displacement of the functional annulus (septal > posterior > anterior leaflet), 3) dilatation of the “atrialized” portion of the right ventricle with variable degrees of hypertrophy and thinning of the wall, 4) redundancy, fenestrations, and tethering of the anterior leaflet, 5) dilatation of the right atrioventricular junction (the true tricuspid annulus) and 6) variable ventricular myocardial dysfunction. These anatomical and functional abnormalities cause important tricuspid regurgitation which results in right atrial and right ventricular dilatation and atrial and ventricular arrhythmias.Numerous techniques of repair have been described since the first report of Hunter and Lillehei [2]. This is not surprising, since each heart with Ebstein’s anomaly is different, and there is infinite variability that can occur with all of the above mentioned characteristics. The cone reconstruction as described by Dr. da Silva [3] is different than previous valvuloplasty techniques in that it is closest to an “anatomic repair.” The end result of the cone reconstruction includes 360 degrees of tricuspid leaflet tissue surrounding the right atrioventricular junction. This allows leaflet tissue to coapt with leaflet tissue, similar to what occurs with normal tricuspid valve anatomy. In addition, the reconstructed tricuspid valve is reattached at the true tricuspid valve annulus (atrioventricular junction) so the hinge point of the valve is now in a normal anatomical location.

Thinned, transparent atrialized right ventricle is plicated so any areas of right ventricular dyskinesis are eliminated. Redundant right atrium is excised so the size of the right atrium is closer

to normal. With the exception of some persistent right ventricular dilatation in the early postoperative period, the cone reconstruction restores the appearance of normal tricuspid valve anatomy and function more than any previously described technique. Since this technique can be applied to the wide variety of anatomical variations encountered with Ebstein’s anomaly, we have adopted this repair technique when approaching patients with this malformation.Indications for operation have included symptoms, deteriorating exercise capacity, NYHA functional class III, IV heart failure, cyanosis (oxygen saturation < 90%), paradoxical embolism, progressive cardiomegaly on chest x-ray (CT ratio > 0.6), progressive right ventricular enlargement on echocardiography, and onset or progression of atrial of ventricular arrhythmias.


Observation has been recommended for asymptomatic patients with low normal exercise tolerance, no right-to-left shunting and only mild cardiomegaly. With the introduction of the cone repair and its excellent early to mid-term results [3], consideration to earlier operative intervention may be given since this procedure can be performed with low risk and provides a near anatomic repair. The operation will be detailed.

References

Dearani JA, O’Leary PW, Danielson GK. Surgical treatment of Ebstein’s 1. malformation: state of the art in 2006. Cardiol Young 2006;16(Suppl. 3):12-20.Hunter SW, Lillehei W. Ebstein’s malformation of the tricuspid valve: 2. study of a case together with suggestion of a new form of surgical therapy. Dis Chest 1958;33:297-304.da Silva JP, Baumgratz JF, da Fonseca L, et al. The cone reconstruction 3. of the tricuspid valve in Ebstein’s anomaly. The operation: early and midterm results. J Thorac Cardiovasc Surg 2007;133:215-23.Leung MP, Baker EJ, Anderson RH, Zuberbuhler JR. Cineangiographic 4. spectrum of Ebstein’s malformation: its relevance to clinical presentation and outcome. J Am Coll Cardiol 1988;11:154-61.

37) Mechanical support, new developmentsand specific strategies

Dr. Noirhomme, (Belgium)Abstract Not Available

38) Cardiac aspects of Marfan Syndrome.Dr. Stuart Graham,(UK)Abstract Not Available


39) The cardiac patient undergoing non-cardiac surgery. Current guidelines and emerging evidence from

prospective studiesDr. Joseph ArrowSmith,(Uk)

Cardiovascular complications are a significant cause of morbidity and mortality after both cardiac and non-cardiac surgery. It is increasingly accepted that the ‘window’ of cardiac risk persists long into the postoperative period and that non-fatal perioperative cardiac events are predictive of long-term (>18 months) morbidity and mortality [1]. The human and financial implications are enormous; as many as 10% of all patients undergoing non-cardiac surgery have – or are at risk of having – cardiovascular disease (CVD); a third of patients over 65 years of age have CVD and two-thirds of patients undergoing vascular surgery have clinically relevant CVD. Despite significant advances in risk assessment, diagnostic techniques and therapeutic interventions, myocardial ischaemia remains the most important potentially reversible risk factor for morbidity after non-cardiac surgery. An accumulating body of evidence suggests that perioperative cardioprotection may have significant short and long-term benefits. The aims of preoperative cardiac risk assessment are straightforward – evaluation of the patient with known CVD, identification of patients with symptoms or signs of CVD, and identification of patients who, by virtue of the type of surgery planned, are at high risk of perioperative cardiac complications. Guidelines produced jointly by the American College of Cardiology (ACC) and the American Heart Association (AHA) have sought to address the issue of perioperative cardiovascular evaluation

and risk assessment [2,3,4]. Despite the fact that many of the ACC/AHA guideline recommendations are based on level B (i.e. single randomized trials or non-randomized trials) or level C (i.e. expert opinion or case studies) evidence, they have been widely accepted into clinical practice. Prospective application of existing guidelines in the setting of randomized trials will undoubtedly be reflected in future versions of the guidelines [5].

Consideration of the patient’s functional status, the presence of cardiac risk factors and the type of surgery planned allows risk stratification, in terms of identification of low-risk patients who need no further investigation, and of high-risk patients who may benefit from further investigation (e.g. stress echocardiography or myocardial scintigraphy, coronary angiography) or risk modification (e.g. preoperative coronary revascularization, valve surgery). The management of intermediate-risk patients, however, presents the clinician with a dilemma. The 2002 ACC/AHA updated guidelines recommend that all intermediate-risk patients undergoing major vascular surgery should undergo preoperative non-invasive cardiac testing. This recommendation is based


on the assumption that non-invasive testing has high positive and negative predictive values – an assumption that may not hold true in certain groups [6,7]. Unfortunately, for the majority of patients in this group, this approach merely delays surgery without conferring any outcome benefit. Recent evidence suggests that, (i) non-invasive testing should be reserved only for high-risk patients, (ii) preoperative myocardial revascularisation does not reduce perioperative mortality in patients with significant but symptomatically stable coronary artery disease, and (iii) intermediate and high-risk patients should receive perioperative beta-blocker therapy [8]. The lecture presentation will focus on changes in the most recent ACC/AHA guidelines and examine some of the evidence supporting perioperative use of beta-blockers [9], antiplatelet drugs [10] and statins [11].

Bursi F, Babuin L, Barbieri A, Politi L, Zennaro M, Grimaldi T, et al. Vascular 1. surgery patients: perioperative and long-term

risk according to the ACC/AHA guidelines, the additive role of post-operative troponin elevation. Eur Heart J 2005; 26: 2448-56.

Eagle KA, Brundage BH, Chaitman BR, Ewy GA, Fleisher LA, Hertzer 2. NR, et al. Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the ACC/AHA Task Force on Practice Guidelines. Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery. Circulation 1996; 93: 1278-317.

Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann 3. KE, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery---executive summary a report of the ACC/AHA Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 2002; 105: 1257-67.

Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann 4. KE, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation 2007; 116(17): e418-99.

Auerbach A, Goldman L. Assessing and reducing the cardiac risk of 5. noncardiac surgery. Circulation 2006; 113: 1361-76.

Raux M, Godet G, Isnard R, Mergoni P, Goarin JP, Bertrand M, et al. Low 6. negative predictive value of dobutamine stress echocardiography before abdominal aortic surgery.


Br J Anaesth 2006; 97: 770-6.

Poldermans D, Bax JJ, Schouten O, Neskovic AN, Paelinck B, Rocci G, et 7. al. Should major vascular surgery be delayed because of preoperative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate control? J Am Coll Cardiol 2006; 48(5): 964-9.

Wesorick DH, Eagle KA. The preoperative cardiovascular evaluation of 8. the intermediate-risk patient: new data, changing strategies. Am J Med 2005; 118: 1413.

Wiesbauer F, Schlager O, Domanovits H, Wildner B, Maurer G, Muellner 9. M, et al. Perioperative beta-blockers for preventing surgery-related mortality and morbidity: a systematic review and meta-analysis. Anesth Analg 2007; 104(1): 27-41.

Burger W, Chemnitius JM, Kneissl GD, Rucker G. Low-dose aspirin for 10. secondary cardiovascular prevention - cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation - review and meta-analysis. J Intern Med 2005; 257: 399-414.

Kapoor AS, Kanji H, Buckingham J, Devereaux PJ, McAlister FA. Strength 11. of evidence for perioperative use of statins to reduce cardiovascular risk: systematic review of controlled studies. BMJ 2006; 333(7579): 1149.

40) Beating-heart aortic arch reconstructionDr. Emile Bacha,(USA)Abstract Not Available


41) Single ventricle palliation: 2008 updateDr. Emile Bacha,(USA)

Recent progress in Management of Hypoplastic Left Heart Syndrome and other single ventricles

Significant progress in the following areas has been made recently in the management of single ventricles:

Diagnostics:-prenatal diagnosis-non-invasive technique such as MRI or CT angio vs cath (pre-stage II)

Interventional Cardiology:-fetal therapy (aortic valvuloplasty, atrial septostomy)-stenting Blalock-Taussig shunts (BTS), RV-PA conduits (Sano)-restrictive or intact atrial septum

Surgery:-Regional Low Flow Perfusion (RLFP) vs Deep Hypothermic Circulatory Arrest (DHCA)-Aortopulmonary shunt (modified BTS) vs RV-PA conduit in stage I Norwood (NIH-funded Single Ventricle Restauration (SVR) trial)-Hybrid stage I vs Norwood-borderline hypoplastic LV with Endocardial Fibroelastosis (EFE): possibility for biventricular repair?

Intensive care:-mechanical support (ECMO, Berlin Heart, Abiomed, Thoratec)-Rx for pulmonary hypertension-Near Infrared Spectroscopy (NIRS) for assessment of cerebral blood flow

Long-term care:-afterload reduction-mechanical support, bridge to transplant or bridge to recovery, artificial heart

Transplantation:-results vs. transplantation for non-Congenital Heart Disease or non-Single Ventricle-“Thymoheart”-xenotransplant


42) TOTAL CAVOPULMONARY CONNECTIONSTAGED OR ONE STAGE FENESTRATED OR NOT?

Zohair Al Halees, MD (Saudi Arabia)

The Fontan principle is based on the fact that an elevated systemic venous pressure is an adequate driving force for pulmonary blood flow. A pumping right ventricle is not necessary [total right heart bypass is possible].

At KFHI, we developed a comprehensive management strategy for the functional single ventricle based on the presentation and anatomy. This enabled us to perform the Fontan operation at a relatively younger age. Currently our median age for the Fontan is 3 years.

The management of patients with FSV involves attempts to balance pulmonary and systemic resistances and blood flow so that adequate oxygenation is maintained along with adequate systemic blood flow.

40 consecutive Fontan operations were performed at KFHI. We prefer the lateral tunnel Fontan constructed in a “reverse Senning tissue flaps”. Extracardiac Fontan is used selectively and for specific indications (20%). A preparation to allow completion of the Fontan Operation in the Cath Lab is performed in some patients at the time of the Glenn Procedure. Our policy is selective use if the fenestration. Patients who are not fenestrated include those without outflow obstruction, with normal ventricular function, good size pulmonary arteries with low mean PA pressure (≤20 mm Hg), low PVR and with no significant AV valve regurgitation.


43) King Faisal Heart Institute Experience inthe Management of Hypoplastic Left Heart Syndrome

Zohair Al Halees, MD; Ahmed Sallehuddin, MD

The incidence is not known in Saudi Arabia, however the number of referrals is on the rise. The surgical management of HLHS is complex and expensive. It puts a lot of pressure on the health care system. Many centers in the world will opt for either abortion if diagnosis is made pre-natally or comfort care after birth. At KFHI, the Norwood procedure is the basis of our surgical palliation of HLHS or other cardiac malformation with hypoplasia or obstruction of the systemic outflow tracts, unobstructed pulmonary blood flow and a PDA dependent systemic circulation.

From 1996-2006, 90 patients underwent the Norwood procedure for either classic HLHS or for one of its variants. There were 55 males and 43 females with a mean age at operation of 30 days (range 2-150 days). The mean weight was 3.1 kg (range 2-4.3 kg). Excluded from surgery patients with significant pulmonary or tricuspid valve abnormality, impaired ventricular function and there with associated severe cardiac or non-cardiac malformation or with severe chromosomal abnormalities. Overall hospital mortality is 26% and 3 years to 10%. The average ICU stay was 15 days and average hospital stay was 22 days. Patients are followed up closely and plans are made for a pre-Glenn catheterization study aiming for the 2nd stage to be done between 4-6 months.

A Sano RV to PA conduit has been performed in the latter experience however we have had some reservation about using it in everybody.

In conclusion, patients with HLHS are challenging difficult subset of patients but the overall results are improving. The effects of learing curve are obvious. . Mortality seems to be related to the Norwood procedure itself – subsequent mortality is those who survive the procedure is low.


44) Management of Maternal Cardiac Disease inPregnancy

Dr. Julie Damp,(USA)

«Management of Maternal Cardiac Disease in PregnancyPregnancy involves unique hemodynamic changes which have implications for the outcome and management of patients with cardiac disease. This discussion will provide a review of these normal hemodynamic changes as well as a discussion of risk stratification of the pregnant patient with cardiac disease. Management of specific cardiac diseases during pregnancy will be discussed including valvular heart disease, peripartum cardiomyopathy, and hypertension. Congenital heart disease, coronary artery disease, aortic dissection, cardiac transplant, and arrhythmias will be briefly discussed as well.”

45) Cardiac ResynchronizationTherapy (CRT)Follow Up

Dr. Charles Jazra, (Lebanon)Abstract Not Available

46) Sudden Cardiac DeathDr. Charles Jazra, (Lebanon)


47) Carotid stentingDr. Mark A. Robbins, (USA)


48) Surgical Aspects of CarotidArtery Disease

Dr. Saber Al Rawashdeh(Jordan)Abstract Not Available


49) Neurological complications of cardiac surgeryDr. Joseph Arrowsmith,(UK)

The first reported coronary artery bypass resulted in a fatal neurological complication [1]. Alexis Carrel’s attempt to make an anastamosis between the ascending aorta and a coronary artery took longer than anticipated and the unfortunate subject of his experiment (a dog) died from cerebral ischaemia.

In the first half of the 20th century most cardiac surgical procedures were performed on the beating heart during brief periods of circulatory interruption using venous inflow occlusion [2]. From his report of the first successful closed mitral valvotomy, it is very clear that Sir Henry Souttar was well aware that prolonged intraoperative hypoperfusion placed the brain at extreme peril.

In the same year that John Gibbon published his account of the first successful clinical use of cardiopulmonary bypass (CPB) [3], a report appeared describing neurological and psychological dysfunction in a group of 32 patients following mitral valve surgery [4].

Since the introduction of CPB into modern cardiac surgical practice, innumerable reports describing neurological complications have been published [5,6]. In the latter half of the 1980s, the focus of investigation gradually shifted from determining the incidence and nature of neurological injury following cardiac surgery injury, to understanding the root causes and testing the impact of neuroprotective interventions.

A neurological complication following otherwise successful cardiac surgery is a devastating outcome. Despite advances in technology and perioperative care, neurological injury remains one of the leading causes of postoperative morbidity and is associated with significantly increased mortality and resource utilization.

The clinical spectrum of neurological injury following cardiac surgery is wide; ranging from the fortunately rare fatal cerebral ‘catastrophe’ to persistent, subtle changes in behaviour, intellectual function and cognitive function. Recent evidence suggests that even subtle changes in cerebral function have a significant impact on mortality [7] and lasting psychosocial implications [8,9,10].

Using a variety of investigative tools and a wide range of clinical settings, it is now clear that the aetiology of the neurological complications of cardiac surgery is multifactorial - the risk of sustaining a neurological injury being dependent on patient factors (i.e. age, gender, comorbidities), the type of surgery being undertaken, the conduct of surgery and CPB [11,12] (if used) and postoperative factors.

The lecture presentation will include a brief discussion of the nature, quantification, incidence and aetiology of neurological complications following cardiac surgery. The findings of two long-term followup studies will be compared and contrasted, and the evidence for some of the putative neuroprotective interventions (e.g. CPB management and off-pump surgery) will be presented.


50) Preoperative Carotid Duplex ScreeningDr. Zeyad Shawabkah, (Jordan)

Zeyad Shawabkak,MD*,Adnan Allaham,MD*,Hussein Al-Daboubi,MD*,Razi AbuAnzeh,MD*,Yanal Al-Naser,MD*,Sameeh Khleefat,MD**,Mohammad Ghatasheh,MD**.

Objective: To show the prevalence of significat carotid artery disease in a representative sample of adult Jordanian patients undergoing cardiac surgical procedures and delinate the importance of preoperative carotid duplex ultrasonography screening.Patients and Methods:This is a retrospective study of a consecutive series of 70 Jordanian patients who underwent cardiac surgical procedures at Queen Alia Heart Institute between January/2007 and April /2007,and were preoperatively screened for carotid artery disease. Mean age of this sample was 63(range:40-78)years,there was 56 males and 14 females,50/70 (71%) were hypertensives,42/70(60%)were diabetics,42/70(60%) had history of smoking,31/70(44%) had a body mass index ≤ 30,8/70(11%) had significant left main disease,the mean EuroSCORE of this sample was 3.3(range:0-11).Eleven patients (16%) had a preoperative history of transient ischemic attack or cerebrovascular accident.Results: 12/70(17%) found to have a 50% or greater stenosis of one or both carotid arteries,for a 75% or greater stenosis ,it was 10%.Prevalence of a 50% or greater stenosis of one or both carotid arteries was 17.6% in patients between age 60 and 69

years,increasing to 45% for patients age 70 year and older.Incremental risk factors for presence of≤50% stenosis in one or both carotid arteris in this group of patients were a previous history of transient ischemic attack or cerebrovascular accident,male gender,left main coronary disease,hypertension,history of smoking,peripheral vascular disease,and higher EuroSCORE.In 4/12 patients found to have concomittant significant carotid lesions and were hemodynamically stable with no critically stenotic coronary arteries, the procedures were staged, carotid stenting was done as a first stage in 2 patients and carotid endarterectomy was done as a first stage in another 2 patients, cardiac proceduers were done sucessfully as a second stage in these 4 patients.Conclusion:Incidence of concomittant significant carotid artery disease in elderly Jordanian patients undergoing cardiac procedures is quite high, selective preoperative carotid dupleax ultrasonography seems mandatory in some patients and might save lives.


51) The biatrial approach for atrial myxomaDr. Sami Kabbani,(Syria)


52) Surgery on hydatid cyst of the heart,the outcome

Dr. Mutaz Al-Kateeb,(Iraq)

Objectives: The purpose of this study is to determine the surgical outcome in patients with cardiac hydatid cysts.Background:

Hydatid cyst or echinococcus was known in ancient times and still endemic in many countries, Fifty to seventy percent may infest the liver, while twenty to fifty are pulmonary hydatid cyst, only ten to fifteen percent could be found in other tissues. However primary cardiac hydatid cysts are rare, including intra cavity lesions or those involving the pericardium. Surgical treatment is indicated as soon as diagnosis is achieved an operation is urgent in impending or actual rupture of the cyst.Methods:

Fifteen patients with hydatid cyst of the heart over the period of six years in Bin Al Bitar Hospital for cardiac surgery were studied regarding their age and sex distribution, the site of the hydatid cyst in the heart with other extra cardiac location, clinical presentation, modalities of diagnosis, surgical approach, post operative complication, the surgical outcome and their hospital stay.Results:

Fifteen patients with ages ranging between 14- 42 years having cardiac hydatid cyst underwent accurate diagnosis and urgent proceeding for surgery.Male to female ratio was 2:1 and the commonest blood group was A +ve in nine patients. The duration of diagnosis ranged between 2 months up to 13 years, of mean of 24 months. Hospital mortality was 0%, and no cardiac hydatid cyst recurrence with a follow up period between 3 months up to 3 years.

Conclusions:Diagnosis with careful and urgent removal of hydatid cyst of the

heart, cardiopulmonary bypass with hypothermic cardioplegia with gentle handling is the treatment of choice for cardiac hydatid cyst from morbidity and mortality of view, and avoidance of recurrence.


53) Justified Drive-By Renal AngiographyDr. Issa Ghanma, (Jordan)

Objective : To determine the prevalence of renal artery stenosis (RAS) in a cohort of jordanian patients suspected of having coronary artery disease (CAD) who underwent either selective or non-selective drive-by renal angiography at the time of coronary arteriography. We then examined the associations between the presence of angiographically demonstrated RAS and several baseline demographic, clinical, laboratory, and angiographic variables.

Methods:Consecutive 870 patients ( 586 males, 284 females) undergoing non-emergent cardiac catheterization at a single institution ( QAHI) during a 4 month period extending from 1/1/2006 till 1/4/2006 were evaluated regarding the presence and severity of RAS based on visual estimation of drive-by renal angiograms performed at time of coronary study. Univariate analysis was then performed to evaluate the prevalence of RAS according to several patient characteristics including demographic (age, weight, diabetes, gender, smoking status), clinical (Systolic blood pressure SBP, diastolic blood pressure DBP), laboratory (creatinine clearance in females, creatinine clearance in males) as well as angiographic variables (CAD severity, left ventricular ejection fraction). Multiple logistic regression was used for multivariate analysis.

Results: We found a very low prevalence of RAS in our unselected cohort in comparison to previously reported studies. Renal stenotic lesions were 19 distributed among 16 patients as three patients had bilateral RAS, yielding overall frequency of 1.65%. Moderate RAS ≤ 50%- 70% was found in 7 patients and severe stenosis ≤ 70% was found in 8 patients while one patient had bilateral right moderate and left severe RAS. Lesions were seen more in the left side (n=13) than the right side (n= 6) . In univariate analysis , significant association with RAS was found with age, male gender, CAD severity, SBP and creatinine clearance , while our series failed to show association with diabetes , smoking weight, DBP or Left ventricular ejection fraction. In mutivariate model, association did persist only with female gender ( p value 0.006, CI 1.73-25.31,OR 6.61) and creatinine clearance in males ( p value 0.009, CI 0.95-0.99, OR 0.97).

Coclusion:Taking the very low prevalence of RAS in our series and the lack of persistence of association between many recognizable risk factors and RAS in the multivariate model, we would strongly discourage performing drive-by renal angiography at time of conventional cardiac catheterization in Jordanians. Meanwhile we recommend adherence to the recently published American Heart Association guidelines in performing renal angiography only in an otherwise high risk group for RAS who are potential candidates for revascularization.

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