Global Cardiology Science and Practice - Volume 2013, Issue 4

The symposium “The Unstable Plaque: From Molecules to the Community” was sponsored by The Aswan Heart Centre in El Gouna, Egypt, on February 1–3, 2013, as the third installment of the Centre's Science and Practice series. This 3-day symposium delved into the pathophysiology, prevention, and treatment of acute coronary syndromes, bringing together leading international experts who bridged the spectrum of epidemiology, molecular mechanisms, clinical trials, and clinical practice.

Heart failure with preserved ejection fraction (HFpEF) continues to be a challenging form of heart failure – one in which no therapy has yet been proven to improve outcome. Aldosterone antagonists have previously been shown to improve survival in a wide spectrum of patients with heart failure with reduced ejection fraction (HFrEF), and more recently, small trials suggested that they might have role in HFpEF patients. The effect of spironolactone on clinical outcomes in HFpEF was tested in the TOPCAT study.

The recent increase in human lifespan, coupled with unhealthy diets and lifestyles have led to an unprecedented increase in cardiovascular diseases. Even in the presence of a wide range of therapeutic options with variable efficacy, mortality due to heart failure is still high and there is a need to identify new therapeutic targets. Genetic and in vitro studies have implicated the Notch signalling in the development and maintenance of the cardiovascular system through a direct effect on biological functions of vascular cells (endothelial and vascular smooth muscle cells) and cardiomyocytes. Notch signalling is also involved in the modulation of inflammation, which plays a major role in causing and exacerbating cardiovascular diseases. The Notch pathway could represent a new therapeutic target for the treatment of cardiovascular diseases.

Background: To report our experience with the Ross operation in patients with predominant aortic stenosis (AS) using an inclusion cylinder (IC) method. Methods: Out of 324 adults undergoing a Ross operation, 204 patients of mean age of 41.3 years (limits 16–62) underwent this procedure for either AS or mixed AS and regurgitation (AS/AR) between October, 1992 and February, 2012, implanting the PA with an IC method. Clinical follow up and serial echo data for this group is 97% complete with late mortality follow up 99% complete. Results: There has been zero (0%) early mortality, and late survival at 15 years is 98% (96%, 100%). Only one re-operation on the aortic valve for progressive aortic regurgitation (AR) has been required with freedom from re-operation on the aortic valve at 15 years being 99% (96%, 100%). The freedom from all re-operations on the aortic and pulmonary valves at 15 years is 97% (94%, 100%). Echo analysis at the most recent study shows that 98% have nil, trivial or mild AR. Aortic root size has remained stable, shown by long-term (15 year) echo follow up. Conclusions: In an experience spanning 19 years, the Ross operation used for predominant AS using the IC method described, results in 99% freedom from re-operation on the aortic valve at 15 years, better than any other tissue or mechanical valve. For adults under 65 years without significant co-morbidities who present with predominant AS, the pulmonary autograft inserted with this technique gives excellent results.

The recent ability to create detailed 3D models of the atrial and ventricular chambers using CT, MRI and rapid prototyping offers unique opportunities to study the size and shape of the different cardiac chambers both before and following operation for complex cardiac anomalies. We here describe the techniques for creating detailed 3D models of the heart and demonstrate the utility of these techniques in a patient studied after the Mustard operation. This can give important insights into the changes in size and shape of the different chambers and the patterns of blood flow from the pulmonary and systemic veins to the ‘appropriate’ ventricle. This information in turn could be extremely helpful in understanding and optimizing the overall hemodynamic function after the Mustard operation.

Venous thromboembolism is associated with a high morbidity and, if left untreated, may progress to fatal outcome. The standard treatment of venous thromboembolism consists of heparin followed by long-term treatment with a vitamin K antagonist. However, the use of vitamin K antagonist has several inherent problems and practical challenges. These challenges have prompted the search for new oral anticoagulant drugs including direct factor Xa inhibitors (e.g., rivaroxaban, apixaban and edoxaban) and thrombin inhibitors (e.g., dabigatran). To date, results for dabigatran, rivaroxaban, apixaban, for the treatment of VTE have been published. Recently, results of the 4th new oral anticoagulant agent, edoxaban, have been published in the Hokusai-VTE study. This review discusses the Hokusai-VTE study with special emphasis on its salient features (compared to other new oral anticoagulant studies) in addition to an overview on some key lessons learnt.