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Abstract and ProgramBook

هفتمین کنگـره بین المللی قلب و عروقبیمارستــان رضـوی

16 - 14 مـرداد ماه 1394With the Co-operation of

ناشر : واحداموربینالمللوکنگرههایبیمارستانرضوی گردآورنده :

امور فنی و چاپ : روابطعمومیبیمارستانرضوی صفحه آرایی و جلد : 84صفحه-14*20سانتیمتر تعداد صفحات :

اول/تابستان1394 نوبت چاپ : رقعی قطع :

1000جلد شمارگان : شابک :

سرشناسه : بیمارستان رضوی ، واحد امور بین الملل و کنگره هاــب و ــی قل ــن الملل ــره بی ــن کنگ ــاالت هفتمی ــه مق ــه خالص ــدگان : کتابچ ــام پدیدآورن ــوان و ن عن

ــوی ــروق رض عمشخصات نشر :

مشــخصات ظاهری : 84 صفحه ، 14 * 20 سانتیمترشابک :

موضوع : کتابچه خالصه مقاالت هفتمین کنگره بین المللی قلب و عروق بیمارستان رضوی

RAZAVIHOSPITAL

The 7 th Razavi International

Cardiovascular Congress5 - 7 August 2015

Abstract and ProgramBook

هفتمین کنگـره بین المللی قلب و عروقبیمارستــان رضـوی

16 - 14 مـرداد ماه 1394With the Co-operation of

4

The 7th Razavi International Cardiovascular Congress 5 - 7 August 2015

4

Dear Colleagues,On behalf of Astan Quds Razavi and Razavi Hospital, it is my great honor and pleasure as congress president to welcome you to the seventh Razavi International Cardiovascular Congress which will be held on 5 - 7 August 2015 at Razavi Hospital, Mashhad, Iran.Now, having held six international cardiovascular congresses and having considered the participants’ opinions, I can claim all these previous congresses have met with the biggest of success.This meeting will be an excellent opportunity to realize the changes in the field of cardiology and cardiac surgery and to envision new perspectives for basic and clinical research. The groundbreaking translational program will draw together experts from around the world and will encompass innovations in cardiology, cardiac surgery, interventional cardiology, echocardiography, electrophysiology, heart failure, cardiac imaging, peripheral vascular surgery , intervention and pediatric cardiology.During the past years the dramatic increase in the number of participants has confirmed that some new fields of cardiology such as EPS, CHF and the new cardiac imaging procedures have been flourishing and increasingly contributing to cutting-edge research in the field.I hope you will join us for an outstanding symphony of science and take a little extra time enjoying the spectacular and breathtaking beauty of the holy city of Mashhad.I am looking forward to meeting you.Best wishes, Saeed Hashemzadeh, M.D.CEO of Razavi Hospital

5


CEO of Razavi Hospital: Dr. Saeed Hashemzadeh

Scientific Chairman: Dr. Manoochehr Radpour

Executive Chairmen: Dr. Amir Hozhabrossadati Dr. Kamran Ghaffarzadegan

Vice-Chairmen: Dr. Jamshid Mohajeri Moghaddam Dr. Saeed Nazemi Dr. Homa Falsoleiman (Intervention) Dr. Shima Minaee (Heart Failure) Dr. Sepideh Afzalnia (Adult Congenital) Dr. Saeed Abtahi (Congenital) Dr. Alireza Heidari Bakavoli (Electrophysiology) Dr. Mahdi Taherpour (Electrophysiology) Dr. Mohammad Hadi Saeed Modaghegh (Vascular Surgery) Dr. Ali Fani (Vascular Surgery) Dr. Afsoun Fazlinezhad (Echocardiography) Dr. Seyeed Rasoul Zakavi (Imaging) Dr. Morteza Hadavand Mirzaee (Heart Surgery) Dr. Abbasali Rafighdoost (General Cardiology) Dr. Mahdi Hasanzadeh Dalooee (General Cardiology - Electrophysiology) Dr. Mohammad Mohammadi (General Cardiology)

Departments and Units : Health Care Department Education and Research Department International Affairs and Congresses Public Relations Unit Nursing Office Financial Unit Administrative Unit IT Unit Procurement Unit Public Affairs Unit Security Guard Unit Transportation Unit Food Service Unit

6


Fore

ign

Spe

aker

s Prof. Luigi P. BadanoDirector of the Echocardiography LaboratoryProfessor of Cardiovascular Imaging at the University of PaduaMember of the Italian Society of CardiologyFellow of the European Society of CardiologyItaly

Prof. Mehmet OzkanChief of the Kosuyolu Heart, Training and Research HospitalMember of Turkish Society of Cardiology and European Society of CardiologyTurkey

Prof. Alexander Marcus SeifalianCo-director of NanoRegMed Ltd, London, UKProfessor of Nanotechnology and Regenerative MedicineDirector of UCL Centre for Nanotechnology & Regenerative Medicine at University College LondonU.K.

Dr. Jae Young ChoiAssociate Professor, Division of Pediatric Cardiology, Yonsei University College of MedicineChief, Division of Pediatric Cardiology, Yonsei University Health SystemDirector, Center for Congenital Heart Disease, Yonsei University Health SystemSouth Korea

7


Dr. Bharat DalviConsultant Pediatric Cardiologist Glenmark Cardiac Centre Former Asso. Prof. of Cardiology K.E.M. Hospital & Seth G.S.Medical CollegeVisiting Fellow, Pediatric Cardiology Cleveland Clinic, Ohio, U.S.A.India

Dr. Mazeni AlwiSenior Consultant Paediatric Cardiology Paediatric & Congenital Heart Centre Institut Jantung Negara (National Heart Institute) Malaysia

Dr. Thomas LarzoonChief of the Endovascular Surgery at the Vascular Department and Consultant in Vascular Surgery Örebro UniversityWinner of Gore Award ”Pioneers in Performance” Sweden

Dr. Stefan SchlueterHead of the Department of Electrophysiology, GFO-KlinikenBonnSenior Consultant and Head of the Department of Device Therapy, Protestantic Hospital Düsseldorf Germany

8


Dr. Ahmet CelebiProfessor, Chair and Head of Department of Pediatric Cardiology at Dr Siyami Ersek HospitalMember of Council of Turkish Association of Pediatric Cardiology and Cardiac Surgery Turkey

Dr. Ali HamedanchiCardiologistDepartment of Internal Medicine I (Cardiology and Intensive Care Medicine and Pulmonologists), Friedrich-Schiller University Germany

Dr. Freidoon KeshavarziConsultant CardiologistMember of the British Cardiovascular Society (BSC)Member of the European Society of Cardiology (ESC)King

,s College Hospital-London

U.K.

Dr. Mohammad ShenasaProfessor of Medicine and Surgery at the University of PittsburghVisiting Professor in Munster, GermanySenior Editor of Cardiac Mapping Editions 1 - 4 U.S.A

9


Dr. Ali AzizzadehChief, Division of Vascular and Endovascular SurgeryProfessor with Tenure Department of Cardiothoracic and Vascular Surgery, The University of Texas Medical School at HoustonU.S.A

Dr. Ali KhoynezhadDirector of Thoracic Aortic SurgeryCo-director, Integrated Atrial Fibrillation ProgramStaff Surgeon IIIProfessor, Cedars Sinai Medical Center, Los Angeles, CAU.S.A

Dr. Mojgan LaaliCardiac Surgeon, Cardio-Thoracic Surgery Ward Pitie-Salpetriere Hospital Member of French Board of Cardiac SurgeryMember of French Society of Thoracic and Cardiovascular Surgery France

10


Nat

iona

l Sci

enti

fic C

omm

itte

e

NO Title First Name Last Name

1 Dr Mohammad Abbasi Torshizi

2 Dr Seifollah Abdi

3 Dr Shahram Akhlaghpour

4 Dr Hedieh Alimi

5 Dr Behzad Alizadeh

6 Dr Leila Alizadeh

7 Dr Zahra Alizadeh Sani

8 Dr Ahmad Amin

9 Dr Farimah Aminian

10 Dr Bahram Aminian

11 Dr Hamid Amozegar

12 Dr Kazem Babazadeh

13 Dr Hamid Barakpour

14 Dr Maryam Barkat

15 Dr Baktash Bayani

16 Dr Ali Akbar Beigi Borojeni

17 Dr Hasan Birjandi

18 Dr Mohammad Borzoee

19 Dr Mohammad Dalili

20 Dr Mahmoud Dargahi

21 Dr Seyed Hashem Danesh Sani

22 Dr Amir Derakhshan far

23 Dr Mahmoud Ebrahimi

24 Dr Mahmoud Eftekharzadeh

25 Dr Zahra Emkanloo

26 Dr Masoud Eslami

27 Dr Hossein Farsavian

28 Dr Amir Farjam Fazelifar

29 Dr Freshteh Ghaderi

30 Dr Hamed Ghoddousi

31 Dr Afshin Ghofraniha

32 Dr Arash Gholoubi

33 Dr Sheida Golmohammad zadeh

34 Dr Marjan Haj Ahmadi

35 Dr Ali mohammad Hajizeinali

36 Dr Elham Hashemi

37 Dr Hossein Hemmati

38 Dr Saeed Hosseini

39 Dr Farhad Jabbari

40 Dr Daryoush Javidi

41 Dr Vahid Jorat

42 DrMohammad Hasan Kalantar Motamedi

43 DrMohammad Reza Kalantar Motamedi

44 Dr Anahita Karimi

45 Dr Davood Kazemi Saleh

46 Dr Golam Hossein Kazemzadeh

47 Dr Zahra Khajeali

48 Dr Javad Kojuri

49 Dr Ebrahim Mahmoodi

50 Dr Naser Malekpour Alamdari

51 Dr Hamidreza Mashreghi Moghaddam

52 Dr Mohammad Mehranpour

53 Dr Ahmad Mirdamadi

54 Dr Majid Moeinee

55 Dr Afsaneh Mohammadi

56 Dr Akbar Molaee

57 Dr Behnam Molavi

58 Dr Fatemeh Moodi

60 Dr Hojjat Mortezaeian

61 Dr Hasan Mottaghi Moghaddam

62 Dr Behroz Mottahedi

63 Dr Mohammad Mozafar

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64 Dr Nasim Naderi

65 Dr Farah Naghashzadeh

66 DrMohammad Ha-san Namazi

67 Dr Hossein Navid

68 Dr Mohammad Ali Navvabi

69 Dr Hossein Nazari Hayanor

70 Dr Freidoon Noohi

71 Dr Saeeid Oraii

72 Dr Mohammad Ali Ostovan

73 Dr Rezayat Parvizi

74 Dr Masoud Pezeshki Rad

75 Dr Hoorak Poorzand

76 Dr Abbasali Rabani

77 Dr Ahmad Rajaii Khorasani

78 Dr Alireza Rasekhi

79 Dr Hasan Ravari

80 Dr Atousa Rohani

81 Dr Hadi Rokni

82 Dr Farideh Roshanali

83 Dr Morteza Saafe

84 Dr Mohammad Reza Sabri

85 Dr Ezatolah Sadeghi

86 Dr Anita Sadeghpoor

87 Dr Mohammad Sahebjam

88 Dr Mehrdad Salehi

89 Dr Javad Salimi

90 Dr Niloufar Samiei

91 Dr Roya Sattarzadeh

92 Dr Keihan Sayadpoor Zan-jani

93 Dr Jamil Sfehani

94 Dr Babak Sharifkashani

95 Dr Jalal Soltani

96 DrMohammad Hossein Soltani

97 Dr Sepideh Taghavi

98 Dr Pouya Tayebi

99 Dr Mohammad Tayyebi

100 Dr Mehrnoush Toufan Tabrizi

101 Dr Mehran Vahedian

102 Dr Farveh Vakilian

103 Dr Mohammad Ali Yousefnia

104 Dr Mohammad Reza Zafarghandi

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Firs

t D

ay

08:30-09:00 Opening Ceremony

FIRST SESSION: An Approach to CADCHAIRPERSONS: Prof. Luigi P. Badano, Dr. Freidoon Noohi,

Dr. Mohammad Shenasa, Dr. Fereidoun Keshavarzi, Dr. Abbas Ali Rafighdoost, Dr. Mahdi Hasan Zadeh Dalooee, Dr. Bahram Aminian,

Dr. Seyed Hashem Danesh SaniTime Topic Speaker

09:00-09:10 Case Presentation Dr. Mahdi Hasan Zadeh Dalooee, Iran

09:10-09:20 New Criteria in Diagnosis of ACS Dr. Mahdi Hasan Zadeh Dalooee, Iran

09:20-09:35 The Role of Unknown Risk Factors in CAD

Dr. Abbas Ali Rafighdoost, Iran

09:35-09:50 Non-Obstructive ACS Dr. Bahram Aminian, Iran

09:50-10:05 Non-Atherosclerotic CAD Dr. Elham Hashemi, Iran

10:05-10:25 Oates Advancement in the Management of ACS

Dr. Fereidoon Keshavarzi, UK

10:25-10:40 Distinguished Guest Lecture: Common Arrhythmia after MI

Dr. Mohammad Shenasa, USA

10:40-10:55 The Future of Cardiac Imaging Prof. Luigi P. Badano, Italy

10:55-11:00 Questions and Answers

11:00-11:30 Break

SECOND SESSION: RV Failure (Moderator: Dr. Ahmad Amin)CHAIRPERSONS: Dr. Ahmad Amin, Dr. Sepideh Taghavi, Dr. Nasim Naderi,

Dr. Shima Minaee, Dr. Ebrahim Mahmoudi

11:30-11:45 Etiology Dr. Sepideh Taghavi, Iran

11:45-12:00 Diagnostic Procedures Dr. Farah Naghashzadeh,Iran

12:00-12:15 Medical Treatment Dr. Shima Minaee, Iran

12:15-12:30 Surgical and Mechanical Circulatory Support

Dr. Nasim Naderi, Iran

12:30-12:45 Case Presentation Dr. Farveh Vakilian, Iran


14:00-13:00 Lunch

13

The 7th Razavi International Cardiovascular Congress 5 - 7 August 2015First Day: Wednesday, 5 Aug 2015

THIRD SESSION: LV FailureCHAIRPERSONS:

Dr. Ahmad Amin , Dr. Babak Sharifkashani, Dr. Farveh Vakilian, Prof. Alexander Marcus Seifalian,Dr. Shima Minaee

14:00-14:20 Cell Therapy and Cardiac Regeneration in Heart Failure

Prof. Alexander Marcus Seifalian, UK

14:20-14:40 Ventricular Assist Device (VAD) Dr. Ahmad Amin, Iran

14:40-15:00 Pulmonary Hypertension in LV Failure Dr. Babak Sharifkashani, Iran

Fourth SESSION: Aortic Valve & Thoracic Aortic SurgeryCHAIRPERSONS:

Dr. Mohammad Yousefnia, Dr. Jalal Soltani, Dr. Ahmmad Rajaii Khorasani,Dr. Mohammad Abbasi, Dr. Behrouz Mottahedi, Dr. Jamil Esfahani

15:00-15:15 New Trends in Aortic Valve Surgery Dr. Mojgan Laali, France

15:15-15:30 Endovascular and Hybrid Repair of the Aortic Arc

Prof. Ali Khoynezhad, USA

15:30-15:45 Valve Sparing Aortic Root Surgery: Re-implantation VS Remodeling

Dr. Rezayat Parvizi, Iran

15:45-16:00 Thoraco Abdominal Aortic Aneurysm Prof. Ali Khoynezhad, USA

16:00-16:15 Redo Operation on the Proximal Aorta Dr. Ahmad Rajaii Khorasani, Iran

16:15-16:30 Small Aortic Root Surgery Dr. Saeid Hosseini, Iran

16:30-16:45 Cerebral Protection in the Aortic Arc Surgery

Dr. Morteza Hadavand Mirzaee, Iran

16:45-17:00 Aortic Valve Endocarditis Dr. Mehrdad Salehi, Iran

17:00-17:30 Break

CHAIRPERSONS: Dr. Mohammad Hasan Namazi, Dr. Morteza Saafi, Dr. Javad Kojuri, Dr. Mamoud Ebrahimi , Dr. Jamshid Mohajeri Moghaddam

17:30-18:30Presentation of

Some Interesting Cases by Mashhad Interventionalists

Dr. Afsaneh Mohammadi, IranDr. Baktash Bayani, Iran

Dr. Mahmoud Ebrahimi, IranDr. Arash Gholoobi, Iran

Dr. Sheida Golmohammadzadeh, IranDr. Mahmoud Dargahi, Iran

Dr. Farhad Jabbari, Iran

14


Sec

ond

Day

FIRST SESSION: An Approach to the Patient with Left Main StenosisCHAIRPERSONS: : Dr. Homa Falsoleiman, Dr. Daryoosh Javidi,

Dr. Seyfolah Abdi, Dr. Davood Kazemsaleh, Dr. Mohammad Ali OstovanTime Topic Speaker

08:00-08:20 Anatomy and Physiology of LM Stenosis and Risk Stratification

Dr. Homa Falsoleiman, Iran

08:20-08:40 Outcome of LM Revascularization (PCI VS CABG)

Dr. Daryoosh Javidi, Iran

08:40-09:00 LM Assessment (Role of Imaging in Diagnosis & Treatment of LMD)

Dr. Seyfolah Abdi, Iran

09:00-09:20 Interventional Techniques(Ostial – Midportion LM Stenosis)

Dr. Davood Kazem Saleh, Iran

09:20-09:40 Interventional Techniques(Distal – Bifurcation LM Stenosis)

Dr. Mohammad Ali Ostovan, Iran


10:00-10:30 Break

SECOND SESSION: Congenital and Structural CardiologyCHAIRPERSONS: Dr. Mohammad Mehranpour, Dr. Behzad Alizadeh,

Dr. Mohammad Hassan Namazi, Dr. Bharat Dalvi, Dr. Jae Young Choi, Dr. Majid Maleki

10:30-10:40Percutaneous Pulmonary Valve Implantation; Patient selection,

Complications and Expectation’sDr. Anita Sadeghpour,

Iran

10:40-10:55Edward’s_Sapien XT Valve;

Experience on Percutaneous Pulmonary Valve Implantation

Dr. Ahmed Celebi,Turky

10:55-11:10 Percutaneous Pulmonary Valvotomy in PA-IVS

Dr. Mazeni Alwi, Malaysia

11:10-11:20 Pulmonary Valve Implantation + RV Remodeling

Dr. Mohammad Ali Navabi, Iran

11:20-11:30 The Role of Echocardiography in Septal Defects Interventions

Dr. Sepideh Afzalnia, Iran

11:30-11:40 PAH in Adults with ASD; Evaluation and Management

Dr. Zahra Khajali, Iran

11:40-11:50Therapeutic Strategy for

Transcatheter Closure of Multiple ASDs.

Dr. Jae Young Choi, South Korea

15

The 7th Razavi International Cardiovascular Congress 5 - 7 August 2015Second Day: Thursday, 6 Aug 2015

11:50-12:00 Transcatheter VSD closure in Patients with Left Heart Disease Dr. Baharat Dalvi, India

12:00-12:10 Transcatheter VSD closure; Off label use of Occluder Devices

Dr. Behzad Alizadeh, Iran

12:10-12:20 Transcatheter VSD Closure; Using LE PFM Coil

Dr. Keihan Sayadpour, Iran

12:20-12:30 VSD Closure; Hybrid Procedure Dr. Akbar Molaei, Iran

12:30-13:30 Lunch

THIRD SESSION: Congenital Heart Disease-Fetal Stage to Adolescence

CHAIRPERSONS: Dr. Saeed Abtahi, Dr. Mohammad Borzoee, Dr. Mohammad Sabri, Dr. Gholam Hossein Ajami

13:30-13:45 Device Closure in Children Dr. Hojjat Mortezaeian, Iran

13:45-14:00 Management of Fetal Arrhythmia Dr. Mohammad Borzooee, Iran

14:00-14:15 Management of Critical AS in Neonate Dr. Saeed Abtahi, Iran

14:15-14:30 Kawasaki Disease in Children Dr. Hasan Mottaghi Moghaddam, Iran

14:30-14:45 Neonatal RVOT Stenting Dr. Hasan Birjandi, Iran

14:45-15:00 Management of Intractable SVT in Neonate

Dr. Mohammad Dalili, Iran

15:00-15:15 Cardiac Intervention in Fetus Dr. Hamid Amozegar, Iran

15:15-15:30Truncus Arteriosus with Intact

Ventricular Septum, a Rare Case Report

Dr. Gholam Hossein Ajami, Iran

15:30-16:00 Break

16

The 7th Razavi International Cardiovascular Congress 5 - 7 August 2015Second Day: Thursday, 6 Aug 2015

Fourth SESSION: Cardiac Arrhythmia

CHAIRPERSONS: Dr. Mahdi Hasanzadeh Dalooee, Dr. Amir Farjam Fazelifar, Dr. Mahdi Taherpoor, Dr. Mohammad Shenasa , Dr. Mahmoud Eftekharzadeh

16:00-16:15 Arrhytmia Ablation in Structural Heart Disease

Dr. Stefan Schlueter, Germany

16:15-16:30 Ischemic VT Ablation Dr. Saeed Oraii,Iran

16:30-16:45 Ablation of Arrhythmia in Congenital Heart Disease

Dr. Zahra Emkanjoo, Iran

16:45-17:00 Ablation of Outflow Tract VT/PVCs Dr. Stefan Schlueter, Germany

17:00-17:15 Role of CMR in Cardiac Arrhythmia Dr. Alireza Heidari –

Bakavoli,Iran

Fifth SESSION: Sudden Cardiac Death

CHAIRPERSONS: Dr. Hamidreza Mashreghi Moghaddam,Dr. Hamid Barakpoor, Dr. Saeed Nazemi, Dr. Mohammad Tayyebi

17:15-17:30 Drug Induced Sudden Cardiac Death Dr. Masoud Eslami, Iran

17:30-17:45 Prevention of Sudden Cardiac Death in Cardiac Channelopathies

Dr. Vahid Jorat, Iran


17


Third Day: Friday, 7 Aug 2015

Thi

rd D

ay

FIRST SESSION: Aortic Intervention

CHAIRPERSONS: Dr. Mohammad Reza Kalantar Motamedi, Dr. Abbas Rabani, Dr. Hossein Hojati, Dr. Ahmad Rajaii Khorasani, Dr. Iraj Fazel

Time Topic Speaker

08:00-08:20 Aortic Aneurism (Endovascular Approach)

Dr. Ali Azizzadeh, USA

08:20-08:40 Aortic Dissection (Endovascular Approach)

Dr. Thomas Larzon, Sweden

08:40-09:00 Aortoiliac Occlusion Disease (Endovascular Approach)

Dr. Louay Altarazi, Syria

09:00-10:30

Panel:Endovascular Approach to Aortic

Disease

Moderator:Dr. Mohammad Hadi Saeed

Modaghegh

Dr. Ali Azizzadeh, USA

Dr. Mohammad Hasan Kalantar Motamedi, IranDr. Ali mohammad Haj

Zeynali, Iran

Dr. Hossein Hemati, IranDr. Afshin Ghofraniha,

Iran Dr. Majid Moeini,

IranDr. Ali Fani

, IranDr. Mohammad Reza

Zafarghandi, Iran

Dr. Mohammad Mozafar, Iran

Dr. Masoud Pezeshkirad, Iran

10:30-11:00 Break

18

The 7th Razavi International Cardiovascular Congress 5 - 7 August 2015Third Day: Friday, 7 Aug 2015

SECOND SESSION: Optimal Diagnosis and Management of Mitral Regurgitation in 2015: a Heart-Team Approach

CHAIRPERSONS: Prof. Luigi P. Badano, Dr. Hoorak Poorzand, Dr. Ahmad Rajaaii khorasani, Dr. Saeed Hoseini, Dr. Farideh Roshanali,

11:00-11:20Distinguished Guest Lecture:

Echocardiographic Evaluation of Mitral Regurgitation in 2015: State-of-the-Art

Prof. Luigi P. Badano, Italy

11:20-11:40

Towards Optimal Management of MR: When to Refer to Surgery, Early

Operation in Asymptomatic Patients is Feasible? Repair VS Replacement?

Dr. Farideh Roshanali, Iran

11:40-11:55 Diagnostic Complexities of Secondary Mitral Regurgitation

Dr. Ali Hamedanchi, Germany

11:55-12:10 Ischemic Mitral Regurgitation: An Update for Heart Team

Dr. Mohammad Sahebjam,

Iran

12:10-12:30Interventional Management of

Functional Mitral Regurgitation: When to Consider MV Clipping.

Dr. Freidoon Keshavarzi, UK

12:30-12:45 Postoperative Echocardiographic Evaluation of MV Prosthesis

Dr. Afsoon Fazlinezhad, Iran

19

The 7th Razavi International Cardiovascular Congress 5 - 7 August 2015Third Day: Friday, 7 Aug 2015

THIRD SESSION: Evaluation of CAD Prognosis (Emphasis on Imaging)

CHAIRPERSONS: Dr. Rasoul Zakavi, Dr. Fereshteh Ghaderi,Dr. Leila Alizadeh, Dr. Zahra Alizadeh Sani, Dr. Arash Gholoobi,

Dr. Morteza Hadavand Mirzaee

14:30-14:40 Shifting Paradigm from Diagnosis to Prognosis Dr. Rasoul Zakavi, Iran

14:40-14:50CAD Prognosis; Perspectives from General Cardiology and

Echocardiography

Dr. Fereshteh Ghaderi, Iran

14:50-15:05 Prognostic Value of CTA Dr. Leila Alizadeh,Iran

15:05-15:20 Prognostic Value of CMR in CAD Dr. Zahra Alizadeh Sani, Iran

15:20-15:35 Prognostic Value of MPI Dr. Rasoul Zakavi,Iran

15:35-15:45 CAD Prognosis; Perspectives from Interventional Cardiology

Dr. Arash Gholoobi, Iran

15:45-15:55 CAD Prognosis; Perspectives from Cardiac Surgery

Dr. Morteza Hadavand Mirzaee, Iran

15:55-16:30 Questions & Answers

Panelist: Prof. Luigi Paolo Badano, Dr. Anita Sadeghpour , Dr. Saeed Hosseini, Dr. Rajaei khaorasani, Dr. Farideh Roshanali

12:45-13:30

Panel:Common Clinical

Scenarios and Debates

in the Management

of Mitral Regurgitation

Moderator: Dr. Ali

Hamedanchi ,Dr. Afsoon Fazlinezhad

1) A. 65 y old lady with moderate MR undergoing CABG: What to do? No touch, repair or

replacement, what does the evidence tell us?Dr. Ahmad Mirdamadi, Iran

Q-A panelist

2) A. 36 y/o. asymptomatic man with severe MR: stress echo? Deformation imaging? When to

consider surgery?Dr. Mehrnoush Toufan, Iran

Q&A panelist

3) A. 28y old. pregnant lady with thrombosed prosthetic mitral valve: What is the best approach?

Dr. Niloofar Samiee, IranQ&A-panelist

4) A.76 y/o man with CHF, NYHA Class 34- and severe MR: what is the next step?

Dr. Roya Sattarzadeh, Iran

13:30-14:30 Lunch

20


Wor

ksho

p an

d M

eeti

ng

Workshop 1 , Wed 5 Aug

Workshop 2 , Thu 6 Aug

Meeting The Expert and Workshop (Focus on RV & LV)Thursday, 6 Aug 2015

By: Prof. Luigi P. Badano

08:00-10:30

1.Advanced Evaluation of RV Size, function and mechanics

Q&A2.Optimal current echocardiographic assessment of

TV and TRQ&A

3.Future of LV systolic function evaluationQ&A

Case presentation

Coordinator: Dr. Afsoon Fazlinezhad

Prof. Luigi P. Badano,

Italy

Q-Lab 10 Education By Phillips Company /3D Echo Case Presentation Wednesday, 5 Aug 2015

Time Topic Speaker

16:00-17:30

Part 1: Q LAB 10 Education

what you need?0Live case study

Moderator:Dr. Hosein Nazari

IranDr. Ali Hamedanchi

Germany

Case presentation:Dr. Hosein Nazari

IranDr. Hedieh Alami

IranDr. Atousa Rohani

IranGuest Case presentation

16:00-18:30Part 2:

3D Echocardiography In Daily Clinical Practice, Case

Presentation

21

The 7th Razavi International Cardiovascular Congress 5 - 7 August 2015Workshop and meeting



Heart Failure Preserved EFThursday, 6 Aug 2015

Dr. Babak Sharifkashani, Dr. Ahmad Amin, Dr. Farah Naghashzadeh, Dr. Anahita Karimi

14:00-14:15 Etiology and Prevalence Dr. Davood Shafiee, Iran

14:15-14:30 Clinical Presentation Dr. Marjan Haj Ahmadi, Iran

14:30-14:45 Diagnostic Procedures Dr. Ebrahim Mahmoodi, Iran

14:45-15:00 PH in HFpEf versus idiopathic PH Dr. Maryam Barekat, Iran

15:00-15:15 Medical Treatment Dr. Mohammad Hosein Soltani, Iran

15:15-15:30 Case Presentation Dr. Hosein Navid, Iran15:30-16:00 Questions and Answers

16th Bimonthly Scientefic session of Iranian Heart Rhythm SocietyThursday, 6 Aug 2015

Moderator: Dr. Ali Reza Heidari BakavoliCHAIRPERSONS:

Dr. Saeed Oraii, Dr.Mahmood Eftekharzadeh, Dr. Stefan Schlueter10:30-10:50 Role of Ablation in Ischemic VT Dr. Saeed Oraii, Iran

10:50-11:10 Approach to electrical Storm Dr. Mohammad Ali Akbarzadeh, Iran

11:10-11:30 Idiopathic VF ablation Dr. Stefan Schlueter, Germany

11:30-11:50 ECG and Chest X ray in Implantable cardiac device

Dr. Peyman Tabatabaii, Iran

11:50-13:00Question and answers

Case presentation (EP and Device) Guest speakers and audience

22


Workshop 5 , Fri 7 Aug

Razavi Congenital & Structural Interventions Meeting RaCSIM_2015

Friday,7Aug 2015Moderator: Dr. Sepideh Afzalnia

07:30-08:10 Breakfast Session – Challenging Cases

Dr. Keyhan Sayadpour, Iran

Dr. Akbar Molaei, IranDr. Kazem Babazadeh,

Iran

08:10-08:15 Welcome and Introduction

Dr. Manoochehr Radpour, Iran

Dr. Jamshid Mohajeri Moghaddam, Iran


TAVI ProgramCHAIRPERSONS: Dr. Ali Hamedanchi, Dr. Freidoon Keshavarzi,

Dr. Mohammad Sahebjam

08:15-09:15

Current Landscape of TAVI; Indications, Outcome and more

Dr. Afsaneh Mohammadi, Iran

TAVI program in IranDr. Mohammad Sahebjam, Iran

Dr. Ali Mohammad Hajzeinali, Iran

The critical concept of heart team; How to develop a TAVI program



Echo Evaluation for TAVI; Interesting Cases and Complications


Valve Selection in TAVI; Does it all matter?



TAVI procedure; Tips and tricks Dr. Freidoon Keshavarzi, UK

Q and A

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Transcatheter Closure of Septal DefectsCHAIRPERSONS: Dr. Behzad Alizadeh, Dr. Bharat Dalvi,

Dr. Jae Young Choi

09:15-10:30

Pre-Procedural Evaluation Dr. Hoorak Poorzand, Iran

ASD closure; Different Devices description

Dr. Bharat Dalvi, India

ASD closure; Step by Step Dr. Mohammad Hassan Namazi, Iran

Tips and Tricks in transcatheter closure of complex ASDs

Dr. Jae Young Choi, South Korea

VSD closure; Step by Step(Case in Box)


Uncommon VSDs:Post TAVI, MI and more; Management

Dr. Farimah Aminian, Iran

Post-Procedural Evaluation; Management and follow up

Dr. Afsoon Fazlinezhad, Iran

Septal Defects and Pregnancyconsidrations

Dr. Niloufar Samiei, Iran

Transcatheter Pulmonary Artery Stenting & Pulmonary Valve ReplacmentCHAIRPERSONS: Dr. Hojjat Mortezaian, Dr. Ahmed Celebi,

Dr. Mazeni Alwi

10:30-11:30

Pre-Procedural Evaluation; Echo & MRI

Dr. Hassan Mottaghi Moghaddam, Iran

Dr. Anita Sadeghpour, Iran

Pulmonary Valve Replacement; Melody valve description & Step by Step

Dr. Ahmed Celebi, Turkey

Pulmonary Valve Stenting; Different Stents & Step by Step

Dr. Mazeni Alwi, Malaysia

Advanced Tips and Tricks in Stenting; Case Examples

Dr. Hojat Mortezaian, Iran

Dr. Hamid Amoozegar, Iran

Dr. Hassan Birjandi, Iran

Workshop and meeting

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Workshop 6 , Fri 7 Aug

Endovascular Aneurysmal RepairFriday, 7 Aug 2015

11:30-16:00 Moderator: Dr. Ali Fani

Dr. Shahram Akhlaghpour, IranDr. Hadi Rokni, Iran

Dr. Alireza Rasekhi, IranDr. Ali Akbar Beigi Borojeni, Iran

Dr. Javad Salimi, IranDr. Ezatolah Sadeghi, Iran

Dr. Amir Derakhshan Far, IranDr. Iraj Nazari, Iran

Dr. Mehrdad Vahedian, IranDr. Hosein Farsavian, IranDr. Hamed Ghoddusi, IranDr. Behnam Molavi, Iran

Dr. Naser Malekpour Alamdari, IranDr. Hasan Ravari, Iran

Dr. Gholam Hossein Kazem Zadeh, IranDr. Pouya Tayebi, Iran

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Inde

x

Page Topic Speaker

28 The Role of Unknown Risk Factors in Myocardial Infarction Rafighdoust Abbas Ali

30 Non Atherosclerotic Coronary Artery Disease Elham Hashemi, M.D.

31 Arrhythmias during myocardial ischemia and infarction

Mohammad Shenasa, M.D.

32 Management of RV failure Shima Minaee, M.D.

33 Evaluation of right ventricular function Farah Naghashzadeh, M.D.

34 Surgical and mechanical circulatory support for right ventricular failure Nasim Naderi, M.D.

35Treatment of cardiac diseases from stem

cells therapy and next generation of cardiovascular implants

Professor Alexander M. Seifalian

36 New generation surgical aortic biological prostheses: sutureless valves

Mojgan Laali , MD. Ph.D

37 Cerebral Protection in Aortic Arch Surgery Morteza Hadavand Mirzaee, M.D.

38 Aortic valve endocarditis and Bentall operation:Imam khomeini hospital experience Mehrdad Salehi, M.D.

39 Congenital and structural Cardiology session Sepideh Afzalnia, M.D.

40 Congenital and Structure Intervention Meeting, RaCSIM -2015 Sepideh Afzalnia, M.D.

41Percutaneous PulmonaryValve Implantation:Tips on Patient selection, Complications, and

Expectations

Anita Sadeghpour, M.D.

42Percutaneous Pulmonary Valve Implantation with

Edwards Sapien XT Valve in Conduitless Large Native RVOT without Stenosis

Ahmet Celebi, M.D.

43 The Role of Echocardiography in septal defects interventions

Sepideh Afzalnia, M.D.

44 Therapeutic Strategy for Transcatheter Closure of Multiple ASDs Jae Young Choi, M.D.

45 Description of devices for ASD closure Baharat Dalvi, M.D.48 ASD Closure in the presence of left heart disease Baharat Dalvi, M.D.

50 Transcatheter VSD closure; Off label use of Occluder Devices B. Alizadeh, M.D.

26


Inde

x

51 VSD Closure Using Le pfm CoilKeyhan Sayadpour

Zanjani, M.D.

52Per ventricular muscular ventricular septal defect (VSD) closure under epicardial echocardiography

guidanceAkbar molaei, M.D.

53 Transvascular balloon valvuloplasty for neonatal critical aortic stenosis Saeed Abtahi, M.D.

54 Title: Endothelial dysfunction in children(etiology, diagnosis and treatment)

Mohammad Reza Sabri, M.D.

56 Trans catheter closure of septal defects in pediatric patientswith CHD.

Hojjat Mortezaeian, M.D.

57 Management of Fetal Dysrhthmias Mohammad Borzouee, M.D.

58 Cardiovascular involvement in Kawasaki disease Mottaghi H, M.D.

59 Right Ventricular Outflow Tract Intervention andPulmonary Valvotmy using Ordinary Wires

Hassan Birjandi, M.D.

60 Management of Interfacttabl SVT in Neonate Mohammad Dalili, MD

61 Management of fetal cardiac disease Hamid Amoozgar, M.D.

62 16th bimonthly Scientific session of the Iranian Heart Rhythm Society (IHRS)

Alireza Heidari Bakavoli, M.D.

63 Arrhythmia ablation in structural heart disease Stefan Schlueter, M.D.

64 Catheter Ablation in the Treatment of VentricularTachycardia in Patient with Ischemic Heart Disease Saeed Oraii, M.D.

65 Ablation of Arrhythmia in congenital heart disease Zahra Emkanjoo, M.D.

66 Ablation of outflow tract VT/PVCs Stefan Schlueter, M.D.

67 Role of CMR in cardiac arrhythmia Alireza Heidari-Bakavoli, M.D.

68 Drug Induced Sudden Cardiac Death Masoud Islami, M.D.

69 Prevention of Sudden Cardiac Death in Cardiac Channelopathies Vahid Jorat, M.D.

70 Advanced Endovascular Aortic Repair For Challenging Aortic Cases

Ali Mohammad Haji Zeinali, M.D.

27


Inde

x71Echocardiographicevaluation of

mitralregurgitation in 2015:State-of-the-art

Luigi P. Badano, M.D.

72 Towards optimal management of MR: When to refer to surgery,

Farideh Roshanali, M.D.

73 Diagnostic Complexities of Secondary Mitral Regurgitation Ali Hamadanchi, M.D.

74 Ischemic Mitral Regurgitation: An Update for Heart Team

Mohammad Sahebjam, M.D.

75 Echocardiographic Evaluation of Prosthetic Mitral Valve

Afsoon Fazlinezhad, M.D.

77 Evaluation of CAD Prognosis (Emphasis on Imaging) Seyed Rasoul Zakavi, M.D.

78 Coronary Artery DiseaseShifting paradigm from diagnosis to prognosis

Seyed Rasoul Zakavi, M.D.

79 CAD Prognosis; Perspectives from General Cardiology and Echocardiography

Fereshteh Ghaderi, M.D.

80

Title:Prognostic Value of Computed TomographyAngiography in Coronary Artery Disease: Role of

Coronary Fractional Flow Reserve,Running title: Role of CTA in CAD

Leila Alizadeh, MD

81Prognostic value of stress cardiac magnetic resonanceimaging in patients with known or suspected coronary

artery disease

Zahra Alizadeh Sani, M.D.

83 Prognostic Value of Myocardial Perfusion SPECT Seyed Rasoul Zakavi, M.D.

84 Coronary artery disease prognosis: Perspectives frominterventional cardiology Arash Gholoobi, M.D.

28


The Role of Unknown Risk Factors in Myocardial Infarction

Rafighdoust Abbas Ali 1,4, Mirzaee Asadollah2, Rafigdoust Amir Hossien3

1: Cardiology department, Imam Reza hospital, Mashhad University of Medical Sciences,Mashhad, Iran 2: Cardiac surgery department, Ghaeem hospital, Mashhad University of Medical Sciences,Mashhad,Iran 3: Internal Medicine, Zahedan University of Medical Sciences, Mashhad, Iran 4: Corresponding author, E-mail: [email protected]

Background: Atherosclerosis of coronary arteries is the most common cause of myocardial infarction (MI), which is initiated from childhood and progresses gradually by aging. Several risk factors influence its progress, and are categorized as classic, traditional and novel factors. The role of unknown risk factors is becoming increasingly more significant recently. The aim of this study is to underscore the novel risk factors despite the importance of classic factors and consider these factors for future studies.

Methods: This is a prospective study on 180 myocardial infarction cases, conducted in the cardiology ward and CCU of Imam-Reza hospital (Mashad-IRAN). A number of risk factors identified and evaluated in these patients included: hyperlipidemia, hypertension, diabetes, smoking, activity, stress, hair of external ear canal and ear lobe crease, age, and sex. Then patients without any risk factor or with one or two risk factors were distinguished.

Results: The majority of our patients were old men in the age range of 60 - 69 years. Amongst all patients 42.2% were smokers, 68.3% were type A personality group, 19% were active, 81% were physically inactive, 37.2% had hairy ear canal, 35% had hypertension, 21.1% were diabetic, 14.4% had hyperlipidemia and 30% had positive family history of myocardial infarction. Of great interest was the fact that of the patients whose case was studied, many did not have any risk factor or in some cases had only one.

Conclusions: In regard of increasing rate of cardiovascular diseases and myocardial infarction even amongst the young population, and because of considerable need to improve vascular risk detection, much research over the past decade has focused on identification of novel atherosclerotic risk factors, and some

29


of these new risk factors are identified and some may be unknown. Amongst the new risk factors, inflammation has an important role, other risk factors that must be assessed are homocysteine, serum amyloid, and antibodies against Oxidized LDL. So we recommend that governments and heart associations must introduce new plans and policies in order to tackle the problem and reduce the frequency of cardiovascular disease. This requires the understanding of the conventional or classic risk factors and also the less known and new risk factors and ways which they may be prevented.

Keywords: Myocardial infarction; Risk factors; Arteriosclerosis; Inflammation

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Non Atherosclerotic Coronary Artery Disease

Elham Hashemi, M.D.

Razavi hospital, Mashad, Iran/ Department of CardiologyE-mail: [email protected]

Case report: A 55 years old man presented with acute severe chest pain and shortness of breath .He had no history of diabetes, Hypertension and had negative family history but he was smoker. ECG showed ST elevation in inferior leads with reciprocal changes in anterior.Bedside Echocardiography showed severe hypokinesis in inferior, Rv and posterior walls. Emergent angiography showed severe long stenosis in Rca, LAD and LCX. Before beginning PCI the injection was repeated and it was obvious that the stenosis of RCA was disappeared. Full medical treatment including ca channel blocker and IV nitrates bigan and the patient was transferred to ccu. But early after he had cardiac arrest following resistant ventricular fibrillation. Coronary spasm is one of the etiologies that can lead to ischemia, sometimes without any sign of atherosclerosis. Many pathologies has been described responsible for spasm ,like vagal withdrawal, sympathetic activity, endothelial dysfunction, hyper contractility of vascular smooth muscle cells, type A behavior, anxiety inflammation, illicit substances like Cocaine and PCI. Although most of the times, the treatment of absolute spasm is medical, but treatment of some resistant cases remains a challenging problem. PCI or CABG has been tried for some selected patients but they had not desirable results. Another aspect that is noticeable is that; the inability to distinguish vasospasm from obstruction disease of LM can lead to inappropriate referral for CABG.

Keywords: Spas, Coronary Artery Disease, Ischemia.

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Arrhythmias during myocardial ischemia and infarction

Mohammad Shenasa, M.D.

Cardiology Department, Heart &Rhythm Medical Group, 105 North Bascom Ave, San Jose, California USA / E-mail: [email protected] atrial and ventricular arrhythmias pose a significant risk in patients with coronary artery disease. This risk is higher during acute ischemia, infarction, and in its chronic stage.

Ventricular Arrhythmias: Ventricular arrhythmias during the acute post myocardial infarction (MI) are divided into three phases. The first 230- minutes(phase one) are initially due to enhanced automaticity and focal mechanisms that may progress to reentrant arrhythmias. About 90% of sudden cardiac deaths in this phase are due to ventricular fibrillation. Phase 2 comprises up to 72 hours, where most ventricular arrhythmias are due to reentrant mechanisms. Phase 3 is after 72 hours and constitutes the ventricular arrhythmias in the subacute and chronic phase of myocardial ischemia and infarction, which is believed to be due to reentrant mechanisms and are considered the healing phase of MI.Several factors play a significant role in the genesis of ventricular arrhythmias during myocardial ischemia and infarction, such as:1.Extend and location of coronary disease, LV function, and location of the infarction2.Left ventricular hypertrophy, autonomic tone, reperfusion, potassium level and other biochemical substances that are released during ischemia and infarctionAtrial arrhythmias: Most of atrial fibrillation (AF) also increases the mortality and morbidity during all phase of myocardial infarction, including prolongation of hospital stay and cost. The presence of AF during acute and subacute phase of MI further complicates anticoagulation and antiarrhythmic therapy. Antiarrhythmic therapy in all phases of MI where there is significant electrical instability increases the risk of proarrhythmia, especially where irregular heart rate present promotes arrhythmias. Furthermore, AF requires additional anticoagulation that increases the risk of bleeding and hemorrhagic stroke. Therefore, both atrial and ventricular arrhythmias during myocardial ischemia and infarction increase the risk of sudden cardiac death, proarrhythmia, thromboembolic complications, hospital stay and cost, and require careful management

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Management of RV failure

Shima Minaee, M.D.

Department of cardiology ,Razavi Hospital/ E-mail: [email protected]

The evidence that guides the management of isolated RV failure is not nearly as well established as the evidence that

guides the management of chronic HF resulting from LV systolic dysfunction. Most recommendations are based on

either retrospective or small randomized studies.

The management of RV failure should always take into account the origin of and setting in which RV failure occurs.

Specific treatment goals include optimization of preload, afterload, and contractility. Maintenance of sinus rhythm and atrioventricular synchrony is especially important in RV failure because atrial fibrillation and high-grade atrioventricular block may have profound hemodynamic consequences.

Ventricular interdependence also is an important concept to consider when tailoring therapy. Excessive volume loading may increase pericardial constraint and decrease LV preload and cardiac output through the mechanism of ventricular

interdependence. Alternatively, hypovolemia may decrease RV preload and cardiac output.

In acute RV failure, every effort should be made to avoid hypotension, which may lead to a vicious cycle of RV ischemia and further hypotension.

An overview of the management of acute and chronic RV failure will be talked in this presentation.

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Evaluation of right ventricular function

Farah Naghashzadeh, M.D.

lung transplant research center ,national research institute of tuberculosis and lung disease (NRITLD), shahid Beheshti university of medical sciences, Tehran, Iran

RV function is a powerful prognostic factor in many clinical conditions, including CHF &pulmonary hypertension. But assessing RV function is a challenge because of the complex RV anatomy & its sensitivity to loading conditions and limited understanding of underlying mechanisms of failure .current approaches to assessment of RV function include, physical examination, echocardiography ,catheterization, angiography, cardiac CT, cardiac MRI, nuclear perfusion scintigraphy and PET scan.

Right heart catheterization is the gold standard method for direct measurements of RA pressure, cardiac output, PAP & pulmonary vascular resistance. But this technique is invasive & time consuming.

Imaging: Among several imaging modality for assessing RV function (RV EF), cardiac MRI , CT and echocardiography are most useful technique.

MRI Is increasingly being used as a gold standard method for evaluation of RV EF and RV size.

Cardiac CT is another imaging modality for assessing RV. Inpatients with lung disease, who has poor echo window, assessment of RV function & size by CT showed good correlation with MRI.

In clinical practice, echocardiography is the mainstay of evaluation of RV function.

RV systolic function has been evaluated using several parameters, namely, RIMP, TAPSE, 2D RV FAC, 2D RV ejection fraction (EF), three-dimensional (3D) RV EF, tissue Doppler–derived tricuspid lateral annular systolic velocity (S/), and longitudinal strain and strain rate.

Among them, more studies have demonstrated the clinical utility and value of RIMP, TAPSE, 2D FAC, and S/of the tricuspid annulus. Although 3D RV EF seems to be more reliable with fewer reproducibility errors, there are insufficient data demonstrating its clinical value at present.

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Surgical and mechanical circulatory support for right ventricular failure

Nasim Naderi, M.D.

MD, Assistant professor of Cardiology, fellowship of heart failure and transplantation, Rajaie cardiovascular medical and research center, Valiasr Ave, Niayesh Blvd, Tehran,Iran/ [email protected]

Right ventricular failure (RVF)is associated with high morbidity and mortality.RVF has very poor outcome in different medical setting including left ventricular failure, acute myocardial infarction, pulmonary emboli, pulmonary hypertension and after cardiac surgery.

The treatment approaches of RVF focus on reversing the underlying cause and optimizing the right heart performance by reducing RV afterload, maintaining optimize preload and improving the RV contractility.

In some cases, RVF may be refractory to medical managements and other treatment options including atrial septostomy,extra corporeal membrane oxygenation (ECMO) , RV assist device (RVAD) and heart transplantation should be used .

Keywords: Right ventricle failure, Circulatory support.

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Treatment of cardiac diseases from stem cells therapy and next generation of cardiovascular implants

Professor Alexander M. Seifalian

Co-Director of Nano Reg Med Ltd, London, UK& Centre for Nanotechnology & Regenerative MedicineDivision of Surgery & Interventional Science University College London, UK E-mail: [email protected]

The future treatment of cardiac diseases will be stem cells therapy as well as new generation of surgical and endovascular implants made with nanotechnology based materials and in-situ endothelisation with capturing stem cells from circulating blood.

Talk will be in two parts, initially highlight the clinical status of stem cell therapy for ischemic heart disease and future direction. The later part will concentrate application of nanotechnology for delivery of stem cells as well as development of cardiovascular implants using nanotechnology based materials and stem cells. Example of these devices will be given with coronary artery bypass graft undergoing clinical trial and stents with in-situ endothelisation and trancatheter heart valve at preclinical trial under GMP/GLP.

The cardiovascular implants ate made from nanocomposite materials and functionalized with antibodies CD-34 and CD133 for capturing endothelial stem cells in-situ from peripheral circulating blood.

36


New generation surgical aortic biological prostheses:sutureless valves

Mojgan Laali , MD. Ph.D

Pitié Salpêtrière hospital, Paris, France

With aging of population aortic stenosis has become the most frequent type of valvular heart disease. In the most recent period, operative mortality of isolated aortic valve replacement for aortic stenosis varies between 1–3% in low-risk patients younger than 70 years and between 4 and 8% in selected older adults. Even though the long-term survival following aortic valve replacement in any age groups is close to that observed in a control population of similar age. More recently to reduce operative mortality in older age groups or in patients with high surgical risk, transcatheter aortic valve implantation (TAVI) has been demonstrated to be feasible. Reported 30-day mortality ranges between 5 and 15% and is acceptable when compared to the risk predicted by the logistic EuroSCORE (varying between 20 and 35%) and the STS Score. But para valvular leak remain un important drawback of TAVI. There are a number of possible causes for that and the retained calcific native valve possibly is the most importantIn addition, the occurrence of paravalvular regurgitation in TAVI has been shown to be predictive for mid-term survival.Sutureless valves are an incoming technology that allows complete excision of the calcified native valve and quick placement of a bioprosthesis without a sewing cuff, which could be a solution for middle risk patients.Until now, there are 3 different sutureless prostheses that have been approved. The 3f Enable valve from ATS-Medtronic received CE market approval in 2010, the Perceval S from Sorin during Q1 of 2011 and the intuity sutureless prosthesis from Edwards in 2012. All these devices aim to facilitate valve surgery and therefore have the potential to decrease the invasivness and to shorten the conventional procedure without compromise in term of excision of the diseased valve. This review summarizes the history and the current knowledge of sutureless valve technology.Keywords: Aortic valve stenosis, aortic valve regurgitation, surgical replacement, sutureless valves.

37


Cerebral Protection in Aortic Arch Surgery

Morteza Hadavand Mirzaee, M.D.

Department of Cardiovascular Surgery, Razavi Hospital, Mashhad, Iran.

Despite impressive improvement in the safety of anesthesia over the last three decade ,cerebral damage remain a dreadful complication after surgical repair of the aortic arch irrespective of the technique used for brain protection. Hypofunction ,mulperfusion,and emboli are the major causative factors.Monitoringthe brain is an important component of cerebral protection strategies used during aortic arch surgery. Near-infrared specteroscopy (NIRS) is one method that is used to detect cerebral hypoperfusion that measures regional cerebral oxygen saturation.The primary role of cerebral oxymetry during cardiovascular surgery is to minimize desaturation and avoid cerebral complications by rapidly detecting rSo2 changes and altering surgeons,anesthesiologists and perfusionists of the need to modify or adjust cetain aspects the procedure.

In many centers, TCD(Trans cranial Doppler) has become an integral part of both adult and pediatric aortic arch surgery.This monitor provide important information both before and during CPB , and facilitate detection and correction of cerebal hypoperfusion and a significant reduction in neurologic injury .Hypothermic circulatory arrest remined and important element of all contemporary method of cerebral protection used in the surgery of the aortic arch. Strategic application of HCA in combination with other complementary methods of brain protection has made the surgery of aortic arch a safe and reliable procedure.

Antegrade SCP via direct cannulation of arch vessels allows us to perform the methiculus arch repair and facilitate the time-consuming total arch replacement for complex aortic arch pathology.

Keywords: cerebral protection- specteroscopy-carotid doppler-hypothermia-perfusion

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Aortic valve endocarditis and Bentall operation:Imam khomeini hospital experience

Mehrdad Salehi, M.D.

Background: The Bentall operation is considered the standard in the surgical treatment for aortic root aneurysm and aortic valve endocarditis , with low mortality and very good long results . Technical modifications have been added to the original description, regarding the coronary arteries reimplantation.

In 9 patients the ascending aorta and the aortic valve were replaced with a cryopreserved valved homograft conduit and the native coronary ostia were anastomosed directly to the homograft.

27 patients with echocardiography confirmed infective endocarditis underwent

Cardiac surgery. From 14 patients with AV involvement, 11 patients underwent Bentall operation with valved homograft conduit.

Material and method: between September 2014 and march 2015 at Tehran university, imam khomeyni hospital 30 patients underwent Bentall operation. From 30 patients, 20 (66.6%) with valved homograft conduit. Eighteen male patients (aged 23 to 74 years) and twelve female patients (aged 14 to 70 years) underwent Bentall procedures. Eight patients (26.6%) underwent Redo operations. The main risk factors were hypertension(50%) and infective endocarditis(30%). Deep hypothermic circulatory arrest(DHCA) was necessary in 5 patients(16.6%) with durations ranging from 717-(median 12) minutes. The average cross clamp and pump times were 115 and 165 minutes respectively. Overall mortality was 330/ patients (10%) .Echocardiography , which was performed intraoperatively , revealed good valve function without dilatation of the homograft conduits .

Conclusion: Technical modifications Bentall procedure and using homograft conduits can be performed in AV endocarditis , safely and with good results .

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Congenital and structural Cardiology session

Dr. Mohammad Mehranpour, Dr. Behzad Alizadeh, Dr. Mohammad Hassan Namazi, Dr. Bharat Dalvi,Dr. Jae Young Choi, Dr. Majid Maleki

Congenital and structural Cardiology session of The 7th Razavi International Cardiovascular Congress offers new topics in the diagnosis and therapy of congenital, structural and valvular heart disease in children and adults. The success of cardiac surgery in childhood has produced a large population of adults with congenital heart diseasein addition to many children with different kind of congenital and structural heart diseases.Adult and pediatric cardiologist, interventionists, cardiovascular surgeons, anesthesiologists and imaging specialists from Iran and other countries will come together to discuss their experiences on these issues . There are also opportunities to share viewpoints during the session and close access to faculty where you can sit with experts.

We look forward to seeing you at Congenital and Structure Cardiology session on 6th August 2015.

Yours sincerely,

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Congenital and Structure Intervention Meeting, RaCSIM -2015

Dr. Manouchehr Radpour, Dr. Jamshid Mohajeri Moghaddam, Dr. Behzad Alizadeh, Dr. Sepideh Afzalnia

The field of transcatheter treatment for congenital and structural/valvular heart disease has grown explosively over the past several years.Razavi Congenital and Structural Interventions Meeting ,RaCSIM-2015, is a new part of RazaviInternational Cardiology Congress and offers the new experiencesand overviews of major topics in the catheter therapy of congenital, structural and valvular heart disease in children and adults. Adult and pediatric cardiologist, interventionists and imaging specialists from Iran and other countries will come together to discuss their experiences on these issues.

We look forward to seeing you at Congenital and Structure Intervention Meeting, RaCSIM -2015, 7thAugust 2015.

Yours sincerely,

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Percutaneous PulmonaryValve Implantation: Tips on Patient selection, Complications, and Expectations

Anita Sadeghpour, MD, FACC, FASE

Department of Cardiology, Echocardiography Lab, ACHD Clinic,Rajaie Cardiovascular, Medical and Research Center, Tehran, IR IranE-mail: [email protected]

Percutaneous pulmonary valve implantation (PPVI) was the first therapeutic percutaneous intervention for valve lesions in humans. Successful PPVI paved the way fortranscatheter aortic valve implantation (TAVI). The most common indication of PPVI is the right ventricular outflow tract (RVOT) dysfunction, which can be stenotic, regurgitant, or mixed. PPVI has been accepted as a safe alternative approach to conventional surgery for reducing the total number of re-operations with a high rateof procedural success and encouraging short-term and long-term outcomes.

Optimum results, however, require meticulous patient selection, appropriate indications and contraindications, and in-depth intra- and postprocedural assessment. The latest study on PPVI has shown itsfavorable clinical outcome in short-, intermediate- and long-term follow-up (5 years’ follow-up), with 5-year freedom from reintervention and explantation ratesof764%± and 923%±, respectively. In addition, conduit prestenting and a lower discharge RVOT gradient were allied to longer freedom from reintervention. Primary valve failure is rare. Stent fracture is a well-recognizedcomplication, particularly in long-term follow-up; however, it will become infrequent once prestenting is more widely adopted.

There are potential adverse cardiovascular events such as peripheral vessel injury, pulmonary artery or conduit rupture,infective endocarditis, embolization or migration of the valve, and coronary artery compression, which is rare but can provecatastrophic.It has been suggested that early valve implantation(<16 years old) is associated with improvedRV function, exercise capacity, and RV dimensions.

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Percutaneous Pulmonary Valve Implantation with Edwards Sapien XT Valve in Conduitless Large Native RVOT without Stenosis

Ahmet Celebi, M.D.

Siyami Ersek Hospital for Cardiology and Cardiovascular SurgeryDepartment of Pediatric CardiologyIstanbul/Turkey

Introduction: Percutaneous pulmonary valve implantation (PPVI) has been used mainly for conduit dysfunction inright ventricular outflow tract (RVOT). Until recently, native RVOT without stenosis used to be considered a relative contraindication to transcatheter valvulation.

Background: New generation of Sapien XT (SXT) valve which has larger sized valvesup to 29 mm may give more opportunity in conduitless-native larger RVOT.

Method: We implanted 18 SXT valve in RVOT dysfunction.13of them were tetralogy of Fallot patients repaired with transannular patch, 12 of them without stenosis, one with mild to moderate stenosis. Balloon sizing/interrogationwas performed in all patients for secure pre-stenting. The size of the balloon catheters forAndra XXL stents would be mounted on was decided up to the waist diameter occurred on the interrogation balloon;at least1.5 mm larger.

Results: Median age and weight of the 12 patients were 16 (850-) years and 46 (2784-) kg, respectively. Median waist diameter was24.2(21.327.5-) mm, and balloon sizes for pre-stenting were 24 to 30 mm; a median of 27 mm. Successful valve implantation was achieved in all with 26 mm in four, 29 mm in others in the same or subsequent sessions, 20–47 days later. Valve function was good in all immediate after and during follow-up; median 2.5 (1- 9 months).

Conclusion: PPVI with SXT valve, which has larger sizes, 23, 26 and 29 mm, is feasible, effective and safe in patients larger native RVOT without stenosis in adolescents and adults.

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The Role of Echocardiography in septal defects interventions

Sepideh Afzalnia, M.D.

Adult and congenital cardiologist- Razavi Hospital, Mashhad, Iran

Transthorasic (TTE) and Transesophageal echocardiography (TEE) has been employed successfully for guiding transcatheter device closure of itracardiac septal defects. However, the use of TEE for device closure requires general anesthesia. Intracardiac echocardiography (ICE) can provide similar anatomical views that might replace the use of TEE for device closure. This article discusses the advantages and Limitation of each modality and also the key points should be notice during intervention guidance.

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Therapeutic Strategy for Transcatheter Closure of Multiple ASDs

Jae Young Choi, M.D., Ph.D., FSCAI

Division of Pediatric Cardiology, Center for Congenital Heart Disease, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, KoreaEmail: [email protected]

Transcatheter closure of atrial septal defect (ASD) is currently accepted as the treatment of choicein most patients with secundum ASD. The efficacy of this procedure has been proved as comparable to surgery, with superior safety profile comparing to surgery.However, this usually pretty obvious procedure can be complicated by complex atrial septal anatomy as well as individual factors. Of these, most frequently encountered difficulties are from large sized defect and/or rim deficiency, followed by multiple defects with/without septal aneurysm which comprise about 1013%- of morphologic variations of secundum ASD. Nevertheless, thanks to accumulation of experience, development of advanced implantation techniques and refinement of devices, the applicability of transcatheter option has continuously improved. There are many challenges or considering factors when planning closure of multiple ASDs, including number/sizeof defects, location/spatialrelationshipbetweenthedefectsorcardiacstructures, properties of supporting rims or intervening septum, as well as presence of septal aneurysm. Ultimately, the difficulties are from problems in understanding the accurate anatomy or morphologic characteristics. To overcome these problems, proper use of RT3D echocardiography (RT3DE) may be very helpful. RT3DE enables visualization of the wide-ranged septum in a single echo view, thus provides instantaneous understanding of the anatomy including number, size, shape of the defects as well as spatial relationship among the defects, surrounding rimsand/or cardiac structures. Also, temporary balloon occlusion may be very useful to investigate compliance of surrounding rims and intervening septum, as well as to predict changes in the defects and rims after device placement.When multiple devices are used to close multiple defects, interference between the devices should also be considered. An unwanted interference between the devices may be prevented by choosing the optimal combination of devices basedontheinformationfromRT3DE, and temporary balloonocclusiontest. An interventionalist should be well-acquainted with the basic principles to close multiple defects as well as the advantages/limitations of each equipment and technique. A meticulous and individualized strategy is required for each case to achieve the therapeutic goal in patients with multiple ASDs.

Keywords: atrial septal defect, device, catheter intervention

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Description of devices for ASD closure

Baharat Dalvi, M.D.

There are a large number of devices available to close atrial septal defect (ASD). This is due to the fact that there is so far no ideal device. Manufacturers are trying their best to improve upon efficacy, safety, ease and simplicity of use, availability in different parts of the world and last but not the least on costing. The most commonly used devices are Amplatzer Septal Occluder, Occlutech Figulla Flex Septal Occluder, Cocoon Septal Occluder, Cera Flex Septal Occluder, Pfm Septal Occluder, Gore Septal Occluder (Cardiform), Carag Bioresorbable Septal Occluder. One should not mistake every amendment for improvement and every change for progress – newer device is not necessarily better.

Amplatzer septal occlude (ASO) is made of 72 wire Nitinol mesh which has a precision welding at two points. It has two circular discs connected by cylindrical waist which is 3 to 4 mm thick and whose diameter varies between 4 to 40 mm. The LA disk is 12 to 16 mm > waist diameter while the RA disk is 8 to 10 mm > waist diameter. There are polyester sheets sewn to the discs and the waist to promote thrombosis which facilitates closure of the defect. It is a self expanding and self centering device which is repositionable. It is biocompatible, less thrombogenic and is corrosion and abrasion resistant. Its deployment sequence comprises opening of LA disk followed by pulling of the device-sheath assembly to abut against the LA aspect of the interatrial septum followed by release of waist and the RA disk. The release mechanism comprises a microscrew on the loading cable which is firmly screwed into the socket on the RA disc. Counteclockwise rotation of the cable with a plastic vise results in the release of the device. The unique selling features of this device are its track record of safety and efficacy and the maximum experience with this device the world over. Its major limitations are the occurrence of cardiac erosion which can have life threatening implications and the device recoil at the time of release. It can very rarely cause heart block or atrial arrhythmias, mitral or tricuspid regurgitation, thrombus on the LA or the RA disks and obstruction to the flow of pulmonary and/or systemic veins.

Occlutech Figulla Flex II ASD Occluder is made of individually braided Nitinol wires which are put together only proximally without any clamp or hub on the LA

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disc. It too has a double disk design with a connecting waist. There are ultrathin PET patches within the discs and the waist to promote thrombosis. It is available in the waist sizes of 440-mm with 4 to 6 mm devices being available in 1 mm increment, 7 to 18 in 1.5 mm increment and 21 to 39 mm in 3 mm increment. Like in ASO, the left disc is larger than the right. These devices go through 7Fr to 12Fr sheaths. For the sizes between 12 to 27 mm, the size of the required sheath is almost 2Fr larger than the one used for delivering ASO. The release mechanism consists of a bioptome like jaw which is located at the end of the pusher. In order to open the jaw, pusher needs to be pushed down with a spool which is situated at the rear end. Once the ball on the right atrial disk is inserted within the jaw, the push over the spool is released and the spool is locked. This release mechanism has an advantage over ASO because it allows the device a 45 degree movement over the pusher tip thereby preventing device recoil at the time of release.

Cocoon septal occluder (CSO) is very similar in design to ASO. The major difference is that the Nitinol wires are covered with platinum and the discs are filled with polypropylene. Platinum coating is supposedly superior in terms of biocompatibility. It allows slow Nickel release thereby preventing side effects from elevated Nickel levels in blood. It is also known to increase the radiopacity of the device and prevent corrosion of Nitinol wireframe. It is available in the waist sizes of 8 to 40 mm with increment of 2 mm. Like the other double disk devices, the LA disk tends to be larger than the RA disk. In case of CSO, the delivery sheath requirement is 1 to 2 Fr larger than the ASO for most of the sizes. The device is a little softer to feel as compared to ASO and is competitively priced in many parts of the world.

CeraFlex ASD occlude is yet another Nitinol made double disc occlude which is available in the waist diameters of 6 to 32 mm with an increment of 2 mm. The sheaths required for delivering the devices range from 8Fr to 14Fr which is about 2Fr more than those required for delivering the ASO. This device has the maximum flexibility over the tip of the pusher allowing for accurate positioning. Nitinol is coated with Titanium Nitride which accelerates endothelialisation and prevents 93% of Nickel release as compared to uncoated traditional occluders. The reduction in the amount of metal in the LA disk makes it less thrombogenic. It has a very unique release mechanism which is simple, safe and secured.

Nit-Occlud ASD-R also has a Nitinol double umbrella design with a Dacron

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membrane covering both the disks. Unlike its predecessors, it is a single wire knit with the LA disc being single layered. It is premounted and is self expandable and self centering like most of the devices with similar design. The devices are available from waist size of 8 mm to 30 mm with increments of 2 mm and require delivery sheaths ranging from 8Fr to 14Fr. It has o protruding fixation clamps making it less thrmbogenic and presence of a synthetic patch on both discs results in high acute closure rates. It has a unique release mechanism. The device is connected to the pusher via retaining wires and the locking wire passing through the device fixes the connection. To release the device, locking wire needs to be pulled through the retaining wires.

Gore septal occlude (GSO) is a non self-centring device which has a platinum filled Nitinol frame covered with PTFE. It also has a double disk configuration. The delivery system consists of a control catheter (grey), a delivery catheter (blue) and the handle assembly. The handle facilitates loading and deployment of the device with the help of a slider. It also carries a slide lock to lock the occluder. Before locking the occluder, it is essential to confirm that the occluder position is optimum. If not, it can be easily retrieved and repositioned. Once locked, the occluder can still be retrieved but only via the retrieval chord. This occluder can not be reloaded and repositioned. Some of the advantages of GSO include the preloaded delivery system, controlled and consistent deployment, ease repositioning and retrieval, conformation of the device to the septal anatomy, rapid and reliable closure, no case of erosion reported so far and its simple and secured release mechanism.

More recently, Carag Bioresorbable Septal Occluder has been introduced for closing ASDs. It is completely bioresorbable within the time frame of 18 to 24 months. It uses over the wire system for deployment and like all other devices this also can be retrieved and redeployed. Since there is no metal left behind, the chances of erosion, thrombus formation and arrhythmias are less likely in the long term. Moreover, its bioabsorbable character allows access to the left atrium for any future interventions.

In conclusion, many devices are available for ASD closure. Each one has its own strengths and weaknesses. The choice of the device depends upon its efficacy, safety, ease and familarity of use, availability and cost.

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ASD Closure in the presence of left heart diseaseBaharat Dalvi, M.D.

ASD closure in the presence of left heart disease is a very challenging clinical problem. On one hand, it increases the magnitude of the left to right shunt across the defect resulting in worsening of the symptoms prompting closure. On the other hand, closing ASD in those with a left heart disease can result in taking away the “pop off” resulting in pulmonary venous hypertension with pulmonary edema which can be life threatening. So, in a way it is a “catch 22” situation; you are damned if you close’t and you are also damned if you don’t.

Left heart diseases which are seen in association with ASD include elderly patients with isolated LV diastolic dysfunction, those with ischemic heart disease with left ventricular dysfunction, idiopathic dilated cardiomyopathy, hypertrophic cardiomyopathy – obstructive or non obstructive, restrictive cardiomyopathy, rheumatic mitral valve disease involving the mitral valve viz. Mitral stenosis, mitral regurgitation or a mixed lesion in the form of stenosis with regurgitation. Such patients need a thorough clinical evaluation with a detailed echo assessment including left ventricular diastolic function. The patient and the family need to undergo in depth counselling which includes information regarding occurrence of pulmonary edema requiring prolonged ICU care, use of diuretics, supported ventilation and in a rare instance removal of the device as well. It is our practise to prepare them with pharmacological therapy prior to bringing them to the catheterization laboratory for device closure. The therapy includes diuretics and vasodilators for at least 24- weeks prior to the procedure.

During the procedure, all patients have a detailed hemodynamic evaluation with a special emphasis on the assessment of left ventricular end diastolic pressure (LVEDP) or pulmonary artery wedge pressure (PAWP) or both. These pressures are recorded at rest and then with balloon occlusion and subsequently with device in place prior to its release. Any rise of pressure above 25 mm Hg in those with abnormal baseline PVEDP or PAWP and above 15 mm Hg in those with normal baseline LVEDP or PAWP are considered at high risk for development of pulmonary edema. However, these changes in pressures are not as straight forward to interpret as have been made out to be. This is because, there have been cases

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wherein abnormal increase in baseline pressures have not got translated in rise of pressure following device closure and there have also been patients where there was no pressure change on balloon occlusion or following device deployment but have landed up with life threatening pulmonary edema after 68- hours following the procedure. These are some of the vagaries of left atrial and/or pulmonary venous compliance. In view of this, if there is any doubt about the occurrence of pulmonary edema in this high risk population, it is recommended that the device be perforated in the catheterization laboratory or we use a ready made perforated device. The other option is to postpone the procedure and prepare the patient pharmacologically even further with more intense diuresis and vasoldilators, restudy him in the catheterization laboratory once again and then proceed with device closure. The bottom line should be “Do no harm” – the basic principle of medicine.

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Transcatheter VSD closure; Off label use of Occluder Devices

B. Alizadeh, M.D1,H. Birjandi, M.D2

1,2: Pediatric and Congenital CardiologistAssistant professor, Congenital and Structural Cardiology division, Pediatric Dep.Imam Reza University hospital, Mashhad University of Medical Sciences, Mashhad, Iran

The progress in both device technology as well as echocardiographic imaging have permitted the safe and effective catheter-based closure of numerous intracardiac defects and catheter-based closure procedures now considered the treatment of choice in most cases of intracardiac defect repair.There are many devices used to treat congenital cardiac lesions on an off-label basis. This article discusses the predicaments faced by the interventionistduring implanting devices on an off-label basis, using procedural examples of VSD closure.

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VSD Closure Using Le pfm Coil

Keyhan Sayadpour Zanjani, M.D, Aliakbar Zeinaloo, M.D.

Department of Pediatrics, Tehran University of Medical Sciences, Tehran, IranE-mail: [email protected]

Background: Closure of ventricular septal defects (VSD) by transcatheter approach is increasingly practiced worldwide. In the past, heart block was a risk for this procedure. Use of softer devices can lower this risk. Le pfm coil is the only coil made for VSD closure. It is a softer device than mesh devices and presumed to cause less heart block.

Objectives: to study effectiveness and safety of Le pfm coil for the transcatheter closure of VSD.

Materials: For VSD closure by this device, an arteriovenous loop should be created first. There are five coil sizes: 88/14 ,8/12 ,6/10 ,6/, and 168/. The larger number should be at least twice the narrowest VSD size. The coil loops are first pulled out in the aorta and then it was passed through this valve and placed in the defect. The last loop should be placed in RV and after confirming the position of the device, it can be released.

Results: Since 2009, we attempted 15 VSD closures in our center. One coil attached to the aortic cusps during passage and the patient was operated. Another attempt to close an 8.5 mm postsurgical defect was also unsuccessful. The remaining 13 attempts were successful. One patient had residual defect after six months on echocardiography. Angiography showed that it is another defect close to the occluded defect by device and not a true residual. Only one patient developed transient heart block (<24 hours). His defect was occluded by the largest device (168/).

Conclusion: Le pfm coil is a valuable device for closure of these defects. Attachment of the device is an important complication which occurred in 115/ of our patients.

Keywords: Ventricular septal defect, children, catheterization closure devices

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Per ventricular muscular ventricular septal defect (VSD) closure under epicardial echocardiography guidance

Akbar molaei M.D1.٭, Abbas afrasiabi M.D1, Eisabilejani M.D1. Mahmud samadi1M.D.

1: Madani heart center, Tabriz university of medical sciences,Tabriz, iran ,Corresponding author: Akbar molaei/ E-mail: [email protected] :٭

Background: VSDs are among the most common congenital cardiac lesions. Large defects at apicomuscular regions especially, in young patients, are far from availability to surgeons for conventional surgery. Catheterization laboratory closureof VSD in these patients is difficult, and carriesa high risk of complications because of large sheath size relativeto patient size. In the meantime, catheters are difficult to manipulate,which in turn increases cardiac catheterization time, radiation, andrisk of dysrhythmias. Simplifying VSD closure the periventricular approach eliminates the potential complications of cardiac catheterizationand fluoroscopy as it is performedunder echocardiographic guidance.

The per ventricular technique was firstly introduced in 1997, yet thefirst patient who underwent intraoperative device closure ofa muscular VSD without Cardio Pulmonary Bypass (CPB) was reported by Amin and colleaguesin 1998.

Case report: Here we report a 3 year old girl who underwent periventricular apicomuscular VSD closure under epicardial echocardiography guidance without cardiopulmonary bypass. While the pulmonary artery pressure (PAP) of the patient was sub systemic, it significantly decreased following the closure of defect. After two years of follow up she is hemodynamically stable with normal PAP.

Conclusion: Per ventricular VSD closure is a feasible and safe approach in selected patients, ultimately the procedure can be performed under epicardial echocardiography.

Keywords: per ventricular VSD closure, epicardial echocardiography

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Transvascular balloon valvuloplasty for neonatal critical aortic stenosis

Saeed Abtahi, M.D.

Department of pediatric cardiology, mashhad branch, Islamic azad university,mashhad, iran

BACKGROUND: Open surgical valvotomy and transcatheter balloon valvuloplasty are recognised treatments for neonatal critical aortic stenosis.Balloon dilation has been used as an alternative to surgical treatment.

METHODS: A retrospective analysis was undertaken of all newborns with critical aortic valve stenosis between 2010 and 2014 presenting to a tertiary centre and who required intervention.From 2010 to 2014, 19 neonates had dilation at a mean age of 12 days and a mean weight of 3.2 kg..

RESULTS: The dilation was completed retrograde in all 19 of the neonates The mean peak systolic gradient prior to cardiac catheterization was 75 mm Hg (range, 36–119 mm Hg) and decreased to 35 mm Hg (range, 23–62 mm Hg) after the dilation. Aortic regurgitation after balloon valvoplasty was absent or mild in 1419/ patients, moderate in 4 patients, and severe in 1 patient.The average immediate peak gradient and left ventricular end-diastolic pressure reductions were 61% and 22%, respectively. There was one unrelated hospital death All 19 neonates dilated through a femoral. At 4 years, survival and freedom of reintervention probability rates were 93% and 88%, respectively. At mean 4.3 years of follow-up, 83% of the survivors were asymptomatic; Doppler study revealed a maximal instantaneous gradient < 30 mm Hg in 72% of neonates and significant aortic regurgitation in 12%.

CONCLUSIONS: Anterograde balloon valvoplasty can be safely and effectively performed to palliate neonates with critical aortic valve stenosis . This study confirms that dilation of aortic stenosis in neonates is effective; reintervention (mostlyredilation) is not frequent (20%); and midterm survival is encouraging (93%).

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Title: Endothelial dysfunction in children (etiology, diagnosis and treatment)

Mohammad Reza Sabri, M.D.

Pediatrics Department, Isfahan University of Medical Sciences, Isfahan, IranE-mail: [email protected]

Endothelium as a barrier to blood elements considered to be neutral and is biologically active. The single layer of endothelium of arteries and veins that cover their lumen is resistant to thrombosis of blood and separate the blood from thrombogenic tissue around it. Endothelium also maintains the tone, growth, homeostasis and inflammatory response in the circulatory system.

There is no gold standard for assessment of endothelial function. However there are two physical and biochemical methods. In physical method the changes in blood flow in vascular system is assessed invasively or non-invasively. In biochemical method, special biomarkers are measured in the serum to evaluate the endothelial function. These biomarkers include: Endothelin, vWF (von Willebrand Factor), Thrombomodulin, Selectin and adhesion molecules, including VCAM, ICAM, and NO.

Endothelial dysfunction (ED) has been reported in adults in various pathological conditions in addition to atherosclerosis, including: hypercholesterolemia, diabetes mellitus, hypertension, heart failure, smoking and in old age.

In children and adolescents endothelial dysfunction and vascular reactivity injury, is also seen in the following groups:

• Young people with family history of premature CAD and asymptomatic coronary artery disease

• Mild to moderate Hyprtryglyceridemia

• In cases of overweight (BMI = 2530-) and obese (BMI> 30) with normal coronary arteries

• In premature born infants

• Kawasaki disease

• Chronic renal failure and other conditions as adults

Vasodilation after temporary ischemia is called Flow-Mediated Dilatation (FMD).

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Measurement of FMD is a clinical method to assess endothelial function. Brachial artery ultrasound imaging during reactive hyperemia is a tool to measure the Endothelium-dependent vasomotion and so the ED.

In recent years, advances achieved for treatment of ED with vitamin C, folic acid, L Carnitine and phosphodiastrase 5 inhibitors (Sildenafil). Beneficial effects of these treatments include increase in functional capacity, improve quality of life and increased longevity. A few researches in this regard by the author and his colleagues will be presented also.

Keywords: Endothelial dysfunction, children and adolescents, Etiology, treatment

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Trans catheter closure of septal defects in pediatric patients with CHD.

Hojjat Mortezaeian, M.D.

Rajaie Cardiovascular , Medical and Research Center, Tehran, Iran.

Catheter-based techniques, whether palliative or corrective procedure,are now the accepted therapy for many congenital cardiacdefects.The development of transcatheter devices for the occlusionof septal defects has been progressing at a rapidly accelerating.

Despite the recent concern about device complications associated with some devices, albeit very rare, trans catheter device closurehas continued to be a very safe procedure with comparable results to surgical closure, and long-term follow up studies haveshown that the overall outcomes remain excellent. Device closure of the appropriate defect is an attractive alternative option to open surgical techniques.

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Management of Fetal Dysrhthmias

Mohammad Borzouee, M.D.

Pediatric Cardiology Division, Pediatric Department , Shiraz University of medical sciences

Background: Arrhythmias result from abnormal automaticity, abnormal conduction, or both. Fetal cardiac arrhythmias have been recognized with increasing frequency during the past several years and in general have been associated with a greater degree of maternal and physician anxiety than they deserve.

The Statistical likelihood of this occurring in the fetal period is in the range of 0.5% to 2 %. Most irregularities of fetal cardiac rhythm represent isolated extrasystoles, which frequently present as a perceived skipping of fetal heart beats. Extrasystoles are significant only because of the potential for an appropriately timed extrasystole to initiate sustained reentry tachycardia.The most common, important, sustained fetal arrhythmias are orthodromic reciprocating supraventricular tachycardia (SVT), AF with varying degrees of AV block, and severe bradycardia associated with complete AV block .

Who to detect : Echocardiography, especially Doppler and color Doppler are used to diagnose the specific arrhythmia, evaluate cardiac anatomy, evaluate cardiac function, and look for signs of hydrops fetalis. The cardiac anatomy should be carefully reviewed, as arrhythmias can be associated with congenital heart disease.

Managements: We should be aware that we expose a mother and fetus to the potential hazards of antiarrhythmic therapy. The most common dysrhthmias (PAC’s and PVC’s) and supra ventricular tachycardia without hydrops fetalis need no management. Digoxin , propranolo, sotalol, flecanide and amiodaron are used according to dysrhythmias mechanism. Complete AV block needs termination of pregnancy in third semester especially with hydrops fetalis, dexamethason is recomend earlier.

Keywords: fetus , dysrhythmia ,therapy , echocardiography.

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Cardiovascular involvement in Kawasaki disease

Hasan Mottaghi, M.D.

Mashhad University of medical sciences

Cardiovascular involvement is the most serious manifestation of Kawasaki disease (KD) and is responsible for the morbidity and mortality associated with this disease. Kawasaki disease has replaced acute rheumatic fever as the most common cause of acquired heart disease in children. Early recognition, treatment and follow-up of these children are vital in order to decrease cardiovascular morbidity and mortality. Delayed diagnosis will increase risk of coronary aneurysm. In addition to presenting an interesting case ofcardiovascular involvement, risk factors, risk stratification and KD in infants also will be reviewed.

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Right Ventricular Outflow Tract Intervention and Pulmonary Valvotmy using Ordinary Wires

Hassan Birjandi *1, Hojjat Mortazaeian 2, Behzad Alizadeh 3

1. MD, Corresponding author, Assistant Professor of Pediatric Interventional Cardiology, Congenital and structural heart division, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran2. MD, Assistant professor of Pediatric Interventional Cardiology, Pediatric Department, Rajaee Heart Center, Tehran, Iran3. MD, Assistant Professor of Pediatric Cardiology, Congenital and structural heart division, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran

Introduction: Surgical Intervention on RVOT of early infants is high risk. In recent decade it increasingly has been replaced by transcatheter intervention. Pulmonary Valvotomy is usually performed by radiofrequency catheters.

Case presentation: We present 11 infants including 6 cases of transcatheter pulmonary valvotomy in pulmonary valve atresia with intact ventricular septum, 3 cases of RVOT stenting and 2 cases of pulmonic balloon valvuloplasty in tetralogy of Fallot during about 10 months (20142015-).

There was no coronary sinusoid in pulmonary valve atresia cases and one of them was an infant of a diabetic mother. RF catheter was not available in our center. Pulmonary valvotomy was performed using Conquest-pro or Progress coronary wires. In 3 cases wire unintentionally passed to the pericardium for 1 time without any complication.

Raising in oxygen saturation was optimal. Growth of the main pulmonary artery and pulmonary artery branches as well as the children growth was optimal. There was no complication. Two cases of pulmonary valvotomies remained PDA dependent for 710- days.

Conclusion: Transcatheter RVOT intervention is an excellent choice for pulmonary valvotomy and RVOT palliation even with ordinary coronary wires

Keywords: Transcatheter Pulmonary Valvotomy, Ordinary Coronary Wires

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Management of Interfacttabl SVT in Neonate

Mohammad Dalili, MD

Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran / Email: [email protected]

Management of cardiac arrhythmias is challenging and difficult in neonates. The arrhythmia types are somewhat different from those seen in older children and adults. Abnormal cardiac anatomies and cardiac tumors may play roles for inducing the arrhythmia. Although diagnosis is the main step for managing neonatal arrhythmia, the treatment is not so easy. Some drugs, like calcium blockers, are contraindicated in infancy and many others had not been sufficiently studied for using in neonate and infant. Interventional procedures for ablating the arrhythmia sources are also less studied and may have additional risks. Sufficient knowledge about cardiac anatomy, drug pharmacology, and treatment skills are the main requirements for correct diagnosis and management of neonatal arrhythmias.

Keywords: Arrhythmia, Neonate

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Management of fetal cardiac disease

Hamid Amoozgar, M.D, Hamid Forotan, Homira Vafaii, M.D, Maryam Kasraian , M.D.

Fetal intervention and surgery research center, Shiraz university of medical sciences, Shiraz, Iran / Corresponding author: Hamid Amoozgar/ E-mail: [email protected]

Incidence of congenital heart disease (CHD) is 81000/ live births and about 1.5% in the fetus population.Nearly all types of post-natally diagnosed CHD types were diagnosed prenatally.Medical management of heart failure and arrythmia in fetus is well estabish treatment of fetal heart disease.Some CHD types are shown to evolve and progress in utero e.g valvar aortic stenosis and pulmonary stenosis.Prenatal intervention for fetus with obstractve heart diseae is a challenging issue in treatment of these cardiac problem.

Keywords: Fetus, Heart, Intervention

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16th bimonthly Scientific session of the Iranian Heart Rhythm Society (IHRS)

Alireza Heidari Bakavoli, M.D.

This is the first meeting of this society to be held out of Tehran as a satellite symposium in Razavi international congress.despite previous meetings target audience are including general cardiologists

Four important topics will be discussed in this meeting:

Role of Ablation in ischemic VT: Surviving more patients is the result of Modern

management of cardiovascular disease. But the consequence of better survival is more

patients with structural abnormal hearts with substrates for Arrhythmogenicity. ICD

has an important role in prevention of sudden cardiac death in patients, but important

issue in this modality of treatment is frequent ICD shocks.In recent years VT ablation

as an adjuant therapy and also in some selected cases as an alternative therapy play an

important role.

This important topic will be discussed in more detail for cardiac electrophysiologists and

also general cardiologist interested in management of arrhythmia.

The other important challenging topic electrical storm:

In this topic the pharmacologic and non pharmacologic approach to frequent ICD

therapies due VT/Vf will be discussed. This presentation provide information that is

valuable for not only electrophysiologists but also Non Ep Cardiologists involving in the

management of arrhythmia.

Third discussion is about Idiopathic Vf ablation. Using the latest technologies for

mapping and ablation of arrhythmia almost every arrhythmia can be ablatable including

VF. the Indications and techniques of Vf ablation is discussed in this session.

With increasing numbers of cardiac device patients every cardiologist must be

familiar with chest x-ray of pace makers and ICDs and also the most important

electrocardiographic features of these devices

In this session we learn about basic concepts of chest x ray and ECGs of implantable

cardiac devices during normal and bnormal function .

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Arrhythmia ablation in structural heart disease

Stefan Schlueter, M.D.

One of the most important challenge in management of non-ischemic structural

heart disease is cardiac arrhythmia.

Antiarrhythmic drugs and implantable cardiac devices play important role. In

recent years by improvement in EP mapping techniques and ablative therapy

, this modality of therapy as an adjuant therapy with drugs and ICDs plays an

important role in cardiac arrhythmia management .In this session the speaker

will share his knowledge end experience with audience both about the indication

and performing blation.in this presentation both techniques and indications of

Ablation will be discussed.

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Catheter Ablation in the Treatment of Ventricular Tachycardia in Patient with Ischemic Heart Disease

Saeed Oraii, M.D.

Interventional Electrophysiologist, Tehran Arrhythmia Center, Day General Hospital

Five year mortality of patients with ischemic left ventricular dysfunction has gradually declined coincident with improvements in the management of cardiac failure from 70% in 1981 to approximately 20% according to more recent reports. Still, its yearly mortality exceeds that of the most common cancers. Sudden cardiac death accounts for 3050%- of deaths in this population and malignant ventricular arrhythmias remain the most common single cause of sudden death in patients with ischemic heart failure.

Therapeutic options for ventricular tachyarrhythmias in this setting include correction of underlying abnormalities, non-antiarrhythmic drugs, antiarrhythmic drugs, implantable defibrillators and radiofrequency ablation. RF ablation has had an increasingly important role in the management of ventricular tachycardia (VT)in patients with low ejection fraction. It is proved to be useful for reducing VT episodes and can be life-saving when VT is incessant. Currently, Catheter ablation is primarily used as an effective adjuvant therapy for frequent episodes of symptomatic VT andcan be expected to reduce the frequency of recurrent VT in 75% of patients. However, trials comparing ablation to antiarrhythmic drug therapy earlier in the clinical course of recurrent VT are in the development phase.

At the rate of recent progress, ultimately catheter ablation is likely to emerge as a safe alternative to ICD therapy for many patients with VT due to structural heart disease.

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Ablation of Arrhythmia in congenital heart disease

Zahra Emkanjoo, M.D.

Arrhythmias in patients with congenital heart disease, most commonly related to

previous surgical procedures.Arrhythmia are a frequent comorbidity in this increasing

population thanks to the improved outcome of surgical techniques.

Re-entrant circuits around areas of scarring and natural barriers, combined with

abnormal haemodynamics and the underlying anatomy, are the most common cause

for these arrhythmias.

They are often poorly tolerated and medical treatment is frequently inadequate. In recent

years, catheter ablation has emerged as a successful therapeutic option. New advances

in Ablation techniques have contributed to better understanding of the arrhythmia

mechanisms and higher success rates of the ablation procedures. In this Lecturewe

briefly discuss some key aspects in their treatment by catheter ablation.

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Ablation of outflow tract VT/PVCs

Stefan Schlueter, M.D.

In structurally normal hearts, VT/PVCs commonly arises from the outflow tracts The

prognosis for outflow tract VT is generally favorable, but there is potential for developing

PVC-related cardiomyopathy and, rarely, for sudden cardiac death.Occasionalythese

arrhythmia are very symptomatic and may reduce the quality of life. Sometimes this

arrhythmia poorly controlled with anti arrhythmics. Catheter ablation of the automatic

focus is an effective therapeutic option.

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Role of CMR in cardiac arrhythmia

Alireza Heidari-Bakavoli, M.D.

Cardiac MRI is a highly accurate, method for the assessment of cardiac disease. Beyond

these roleIt is becoming an important tool for diagnosing patients at risk of future

sudden cardiac death in structural heart disease. Another important role that is under

development is a guide for finding the target for ablation before the procedure.

Now a day with merging 3D anatomy provided by CMR with 3D EP electroanatomical

mapping, it is become a useful guide for ablative therapy of complex arrhythmia.

Recent advances in this cardiac imaging technique and arrhythmia will be presented

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Drug Induced Sudden Cardiac Death

Masoud Islami, M.D.

Adverse drug effects range from mild to fatal. At the extreme of that range are cardiac

arrhythmias, which may be a consequence of both cardiac and noncardiac drugs.

Familiarity with these agents and their effects on heart rhythm will keep you on the alert

and allow you to anticipate these adverse events before they arise.

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Prevention of Sudden Cardiac Death in Cardiac Channelopathies

Vahid Jorat, M.D.

Cardiac MRI is a highly accurate, method for the assessment of cardiac disease. Beyond

these roleIt is becoming an important tool for diagnosing patients at risk of future

sudden cardiac death in structural heart disease. Another important role that is under

development is a guide for finding the target for ablation before the procedure.

Now a day with merging 3D anatomy provided by CMR with 3D EP electroanatomical

mapping, it is become a useful guide for ablative therapy of complex arrhythmia.

Recent advances in this cardiac imaging technique and arrhythmia will be presented

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Advanced Endovascular Aortic Repair For Challenging Aortic Cases

Ali Mohammad Haji Zeinali, Kiomars Abbasi, Mahmoud Shirzad

Address of correspondence : Ali mohammad Haji Zeinali, MD, FSCAI Associated Professor of Tehran University of Medical Science Tehran Heart Center, Interventional Cardiology Department Email : [email protected]

Background : Advanced TEVAR and EVAR was a good alternative to open surgery in high risk patients.

Methods : From 2006 to 2015 we do over 300 endovascular repair of aorta, that there were some advanced EVAR & TEVAR that presented in this presentation. One new T branch EVAR for thoracoabdominal aneurysm, five chimney EVAR for Juxtarrenal aneurysm, four iliac branch devise (IBD) implantation for iliac aneurysms and eleven carotid arteries debranching TEVAR for ascending or arch aneurysms.

Results : All procedures were successful (success rate 100%). No any major complications were seen in procedural and inhospital period. Minor complications like elevated creatinine level & vascular access problems were controlled. Six month CT angiographic follow up revealed good exclusion of aneurysms without any endoleak.

Conclusion : Advanced endovascular repair for complex aorta disease could successfully done with new techniques and devices.

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Echocardiographicevaluation of mitralregurgitation in 2015: State-of-the-art

Luigi Paolo Badano MD, PhD, FESC, FACC

Department of cardiological, thoracic and vascularsciences, University of Padua, Padua, Italy / E-mail: [email protected]

Chronic mitralregurgitation (MR) is a common valvularlesion.

Duringrecentyears, ithasbecomeincreasinglyevidentthat moderate to severe MR, even in the absence of leftventriculardilatation and dysfunction, mayhaveadverseprognosticconsequences. Thus, the accurate quantification of MR, using echocardiography, isvitallyimportant in clinical medicine. Because of the mitral valve›sstructuralcomplexity, MR isoftendifficult to define, especially with two-dimensional (2D) imagingmethods. Both qualitative and quantitative approaches to the quantification of MR are widelyused. Color Doppler imagingallowsmeasurement of the regurgitant jet area and vena contracta (VC) width; thesetwo qualitative methods are simple to apply in dailypracticebutoften are inaccurate, especially in patients with eccentricorganicMR of functional MR. 2D quantitative methodsinclude the calculation of regurgitantfraction, regurgitant volume, and proximalisovelocitysurface area. Whiletheseparameters are well-establishedindicators of MR severity, theyare heavilydependentongeometricassumptionsabout the geometry of the regurgitantorifice, requiretailored image acquisition and additionalcalculations; moreover, theiraccuracymay be compromised in the setting of eccentric MR,aortic insufficiency and in patients with functional MR. With three-dimensional (3D) echocardiography, many of the geometricassumptionsnecessary with 2D imaging are obviated. A realisticdepiction of the VC, whichoftenis non-circular, and of the anatomicregurgitantorifice area, whichusuallyis non-planar, becomespossible with 3D zoom-mode imaging. Ongoingefforts to characterize MR in asymptomatic or minimallysymptomaticpatients include investigationsinto stress echocardiographyandstrain rate imaging. The distinctgeometry of the mitral valve, and the variousmechanisms of MR, will continue to challengecardiacresearch teams during the comingyears

Keywords: mitral regurgitation, echocardiography, Doppler, Three-dimensional echocardiography; quantitation

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Towards optimal management of MR: When to refer to surgery, early operation in asymptomatic patients is feasible?

Repai versus replacementFarideh Roshanali, M.D.

Mitral regurgitation remains the most common global valvular heart disease. From otherwise unsuspecting healthy patients without overt symptoms to those with recalcitrant heart failure, mitral valve disease touches millions of patients per year. While MV prolapse without regurgitation remains benign, once regurgitation begins, quantification of severity is related to prognosis. Understanding the mechanism of regurgitation guides appropriate treatment. Current management guidelines emphasize early therapy after careful assessment of both anatomy and severity of mitral regurgitation. Although surgical indications are clearly defined for the management of valvular heart disease, a gap exists between current guidelines and their effective application.

The management of patients with severe valvular heart disease without symptoms, ventricular dysfunction, or other identified triggers for surgery is controversial.

With degenerative MR, severity can be inaccurately estimated. Stress testing might clarify whether the patient is truly asymptomatic and identify features associated with worse prognosis and symptom onset. Selecting patients with high probability of repair can be challenging. Perioperative risk and postoperative risks including those of unanticipated valve replacement and recurrent MR after repair are also considerations. In aggregate, management of patients with valvular disease who are asymptomatic and who have no clear trigger for surgery is complex, requires individualization, and should be carried out by or in collaboration with a heart valve centre of excellence.

In this review, we frame the debate between prophylactic surgery vs close follow-up until triggers occur (watchful waiting) for severe aortic stenosis and degenerative mitral regurgitation, the two conditions for which the pros and cons of these approaches are best articulated.

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Diagnostic Complexities of Secondary Mitral Regurgitation

Ali Hamadanchi, M.D.

Division of Echocardiography, Department of cardiology, pulmonology and intensive medicine (KIM-I), University of Jena, Germany E-mail: [email protected]

Mitral regurgitation (MR) is among the most common valvular heart diseases. Secondary MR, a functional consequence of ventricular dysfunction is more common than primary MR. In any degree it is associated with a worse prognosis, and in contrast to primary MR the benefits of MV surgery or any other intervention are still uncertain.

Appropriate management of secondary MR remains to be enigmatic.

Echocardiography continues to be the gold standard initial tool of diagnosis. In borderline cases however, MRI has shown very promising results. Common diagnostic challenges include: exact definition, correct quantification and logical prognostication of secondary MR. MR severity changes -sometimes significantly- with loading conditions, LV size, interactions between the pressures in LA and LV and with after load.

Echocardiographer needs a stepwise logical and holistic approach, and no single criteria is accurate enough to make any judgment about MR severity. Accordingly, it is very important to notice that diagnosis of severe secondary MR should be deferred until guideline- directed medical therapy, resynchronization, and revascularization are optimized.

The next major topic is that whether we can simplify the classification of secondary MR into hemodynamically significant and non- significant, avoiding from continuously debating grading system.

In this 15-minute-lecture, it is tried to highlight the most important diagnostic challenges of secondary MR facing our heart team, addressing the application of new 3D methods as a complimentary tool, and stressing new horizons and expectations.

In summary, regardless of its etiology the development of secondary MR is strongly associated with a worsened prognosis. Accurate assessment of secondary MR can be challenging time consuming and complex, but is crucial to help delineate patient risks and guide treatment decisions.

Keywords: Mitral Regurgitatiion, Funktional, Secondary.

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Ischemic Mitral Regurgitation: An Update for Heart Team

Mohammad Sahebjam, M.D.

Echocardiography Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran. / E-mail:[email protected]

Ischemic mitral regurgitation (IMR) remains a common and morbid clinical entity, for which no simple therapeutic approach seems satisfactory. Diagnostic criteria usually include mitral regurgitation (MR) after myocardial infarction (MI) with one or more segmental wall motion abnormalities, significant coronary artery disease in one of the territories supplying the wall motion abnormalities, and structurally normal mitral valve leaflet and chordae tendinae .The key event in the pathogenesis of IMR is the distortion of normal LV geometry - regional and global LV remodeling - with subsequent apical and lateral displacement of papillary muscles, which, in turn, draws the chordae tendinea away from the line of coaptation. Noninvasive imaging and, in particular, echocardiography (2D and 3D), plays a critical role for the initial andlongitudinal assessment, for individual risk stratification andoutcome prediction, and for guiding intervention in patients with chronic IMR.

The 2014 ACC/AHA valvular heart disease guidelines contain 3 recommendations for surgery in secondary MR including IMR. The first states that MV surgery is reasonable for patients with chronic, severe secondary MR undergoing CABG or aortic valve replacement (Class IIa). The second states that MV repair may be considered for patients with chronic moderate secondary MR undergoing other cardiac surgery (Class IIb). The third recommendation states that isolated MV surgery may be considered for severely symptomatic patients with chronic severe secondary MR who have persistent symptoms despite optimal medical therapy for heart failure (Class IIb).The lesser-invasive transcatheter technologies such as Mitraclip also have been developed to treat secondary MR.

Keywords: Ischemic, Mitral, Regurgitation

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Echocardiographic Evaluation of Prosthetic Mitral Valve

Afsoon Fazlinezhad, M.D.

Associate professor of cardiology, fellowship of echocardiography, Mashhad University of Medical Sciences (MUM-CRC)

Prosthetic Valves are classified as tissue or mechanical.Tissue valve, one made of biologic tissue from an animal (bioprosthesis or heterograft) or human (homograft or autograft) source.Mechanical ,Made of nonbiologic material (pyrolitic carbon, polymeric silicone substances, or titanium)Blood flow characteristics, hemodynamics, durability, and thromboembolic tendency vary depending on the type and size of the prosthesis and characteristics of the patient.Mechanical Valves are extremely durable with overall survival rates of 94% at 10 years,Primary structural abnormalities are rare.Most malfunctions are secondary to perivalvular leak and thrombosis. Fulll evaluation of prosthetic valve must include :clinical data including reason for the study and the patient’s symptoms,Type & size of replacement valve, date of surgery,BP & HR,HR particularly important in mitral and tricuspid evaluations because the mean gradient is dependent on the diastolic filling periodPatient’s height, weight, and BSA should be recorded to assess whether prosthesis-patient mismatch (PPM) is present. A major consideration with transthoracic echo is the effect of acoustic shadowing by the prosthesis on assessment of MR.

Problem is worse with mechanical valves.On TTE, LA is often obscured for imaging and doppler interrogation..TEE provides visualization of the LA and MR but shadowing limits visualization of the LVThus, comprehensive assessment of PMV requires both TTE & TEE when valve dysfunction is suspected.Complete exam should include:

Peak early velocityEstimate of mean pressure gradientHeart RatePressure half-time (PHT)Determination of whether regurgitation is present

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DVI and/or EOA as neededLV/RV size and functionLA size if possiblePA systolic pressure

Finally with introduction of 3-Dimensional echocardiography, especially 3D-TEE, detail evaluation of paravalvular leakge, detail anatomy of regurgitation orifice, repair plan or treatment guiding, evaluation of thrombosis or pannus formation are posssible and is the best modality of prosthetic mitral valve evaluation.Keywords: mitral valve, prosthesis, echocardiography

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Evaluation of CAD Prognosis (Emphasis on Imaging)


Professor of Medicine, Nuclear Medicine research Center, Mashhad University of Medical Sciences, Mashhad, Iran/ E-mail: [email protected]

Coronary artery disease (CAD) is the leading cause of death in different populations. Different techniques of imaging have been used for many years in detection of CAD including Echocardiography, Computed tomography Angiography(CTA), Magnetic resonance imaging (MRI) and Myocardial perfusion imaging (MPI). Although detection of severe disease is easily done using any of these techniques, new advanced imaging modalities may detect subtle coronary artery abnormalities too. Also screening and check up programs in some centers may unveil large number of patients with insigniicant CAD. The impact of detection and treatment of these subtle disease on mortality and morbidity is not well known. The ultimate goal of any theraputic procedure in patients with CAD is decreasing the rate of cardiac death and myocardial infarction. Accordingly, the main goal of imaging modalities are predicting the risk of the disease or prognostic evaluation. Different imaging modalities including stress Echocardiography, CTA, MRI, Nuclear Medicine techniques as well as invasive interventional techniques have been used for prognostic evaluation too. Each of these modalities has its own limitations and advantages that will be discussed in this session. Dr.Fereshte Ghaderi with talk about prognostic evaluation using echocardiography and from perspectives of general cardiology. CTA has been used increasingly in recent years and Dr.leila Alizadeh will talk about its strengths and weakness regarding prognostic evaluation. Concerns on effect of radiation on health resulted in development of different techniques of MRI in the evaluation of patients with CAD. Dr.Zahra Alizadeh Sani will talk on the indications and prognostic effect of MRI studies on patients with CAD. Myocardial perfusion imaging using nuclear medicine techniques has been extensively studied and different meta-analysis published in this regard.Dr.S.Rasoul Zakavi will present new findings in this regard. A combination of these modalities may be used in clinical setting. Evaluation of prognosis of CAD will not be complete without perspectives from intervential cardiology and cardiac surgeon. Dr.Arash Gholoubi from interventional cardiology and Dr.Hodavand Mirzaee from cardiac surgery group will discuss on this issues and shed more light on prognosis from clinical view points and their field of expertise.

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Coronary Artery DiseaseShifting paradigm from diagnosis to prognosis


Professor of Medicine, Nuclear Medicine research Center, Mashhad University of Medical Sciences, Mashhad, Iran / E-mail: [email protected]

Traditionally diagnostic modalities for Coronary Artery Disease (CAD) focus on sensitivity, specificity and accuracy of the test for detection of coronary artery stenosis. A gold standard is usually defined for comparison which may be another diagnostic modality. However advances in the diagnostic modalities made clear that present “gold standard” modality could not detect subtle disease. Also it is shown that no all patients with severe disease on an imaging modality, may have poor prognosis.

Decreasing mortality and morbidity is the ultimate goal of the treatment of a patient with CAD. The diagnosis of CAD, usually followed by revascularization of stenotic artery with the hope of decreasing major cardiac events (MCE). However recent clinical trials (COURAGE, FAME,….) showed no significant difference in major cardiac events between patients treated with conservative treatments compared to aggressive therapies if functional variables was not applied. It showed that not all patients benefit from aggressive treatments. Any modality which defines the risk of cardiac death or myocardial infarction could be very helpful in management of the patient. Diagnostic and treatment related morbidity and mortality is another important subject that should be seen in the light of any benefit from that procedure. The benefit of the patient, must be the first priority in the selection of appropriate treatment for the patient.

Recent paradigms in CAD focuses on risk based management of the patients and therefore the main object of any diagnostic modality (including imaging) would be risk determination and its impact on patient›s outcome.

Keywords: Coronary artery disease, Prognosis, Practice

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CAD Prognosis; Perspectives from General Cardiology and Echocardiography

Fereshteh Ghaderi, M.D.

Assistant Professor of Cardiology Fellowship of Echocardiography .Atherosclerosis Prevention Research Center Mashhad University of Medical Sciences

For many patients with chronic coronary artery disease (CAD), risk stratification as to likelihood of cardiac death lays at the basis of choosing between the two major therapeutic options of medical management or revascularisation. Clinical, noninvasive, and invasive tools are useful for refining the estimated risk in individual patients with CAD. The presence of heart failure, dyspnea and severity of angina, especially the tempo of intensification are important clinical predictors of outcome Noninvasively acquired information is valuable in identifying patients who are candidates for invasive evaluation with cardiac catheterization Patients with chest pain and a normal resting ECG who are able to exercise will often be adequately risk stratified by exercise electrocardiography. Intermediate risk results, occurring in approximately 30–55% cases —and it is in these patients, perfusion imaging or stress echocardiography have a major role. Several studies have demonstrated incremental utility of echocardiography, beyond clinical assessment and electrocardiography in predicting clinical outcome of patients with CAD. Assessment of LV function is one of the most valuable aspects of echocardiography. In patients with a history of MI, ST-T wave changes, or conduction defects or Q waves on the ECG, LV function should be measured via echocardiography. The presence or absence of inducible regional wall motion abnormalities and the response of the ejection fraction to exercise or pharmacologic stress echocardiography provide incremental prognostic information to that provided by the resting ECG. Moreover, a negative stress echocardiographic result portends a low risk for future events.

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Title:Prognostic Value of Computed Tomography Angiography in Coronary Artery Disease: Role of Coronary

Fractional Flow Reserve,Running title: Role of CTA in CAD Leila Alizadeh 1, Mohammad Vejdanparast 2

ABAN HEART CENTER

Corresponding author:L.Alizadeh M.D , Cardiologist Fellowship of cardiac imaging No 86 Ebne Sina Street , Ebne Sina 61/, Mashad IRAN

Abstract: Coronary computed tomography angiography (coronary CTA) has been used as a diagnostic and prognostic imaging modality for coronary artery disease (CAD) evaluation for more than a decade.

Introduction of novel possibilities based on coronary CTA including Fractional Flow reserve (FFR) measurement has been a big step in prognostic evaluation.

This review is focused on non invasive evaluation of FFR by Coronary CTA: FFRCT as a potential gold standard for significant CAD, and whether this modality is ready to use in our daily practice decision making.

Keywords: Coronary artery disease, CT angiography, Fractional flow reserve.

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Prognostic value of stress cardiac magnetic resonance imaging in patients with known or suspected coronary

artery disease

Zahra Alizadeh Sani, M.D.

Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, IRAN

Objective: This discussion sought to perform a systematic review to understand the role of stress cardiac magnetic resonance imaging (CMR) in assessing cardiovascular prognosis in patients with known or suspected coronary artery disease (CAD).

Background: Although stress CMR is excellent for the diagnosis of obstructive CAD, the prognostic value of stress CMR has been less well described.

Materials: Stress cardiac magnetic resonance imaging (CMR), either with vasodilator or dobutamine stress, has been shown to have excellent diagnostic accuracy for detection of significant coronary artery disease (CAD). In addition, CMR provides valuable clinical data, including details on left ventricular function, the presence of late gadolinium enhancement (LGE), and whether there is structural or valvular heart disease. As a result, stress CMR is increasingly being used to assess chest pain in patients with known or suspected CAD. In addition, stress CMR may have a role after ST-segment elevation myocardial infarction (MI) to assess for residual ischemia due to coronary stenoses in noninfarct-related arteries .Furthermore, stress CMR can be used in patients with dilated cardiomyopathy to assess for ischemia and myocardial scar burden with LGE. Given the increasing health care costs associated with cardiovascular imaging, it is critical to validate the prognostic utility of stress CMR. Over the past several years, multiple studies have been published regarding stress CMR assessment of prognosis. Prognostic validation of stress CMR is critical because a negative stress CMR can be reassuring that the patient has a very low risk for major adverse cardiovascular events (MACE). Alternatively, patients with stress-induced wall motion abnormalities, abnormal perfusion, and/or LGE are at higher risk of MACE. In the current environment of escalating medical costs, the prognostic performance of stress CMR may also help justify its use compared with more commonly used stress modalities such as stress echocardiography and stress

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nuclear perfusion imaging.

Conclusions: A negative stress CMR study is associated with very low risk of cardiovascular death and MI. Stress CMR has excellent prognostic characteristics and may help guide risk stratification of patients with known or suspected CAD.

Keywords: Cardiac magnetic resonance imaging; coronary artery disease; late gadolinium enhancement; major adverse cardiovascular event(s); myocardial infarction; myocardial perfusion; prognosis; stress cardiac MRI

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Prognostic Value of Myocardial Perfusion SPECT


Professor of Medicine, Nuclear Medicine research Center, Mashhad University of Medical Sciences, Mashhad, Iran/ E-mail: [email protected]

Previous studies showed that stress myocardial perfusion SPECT could categorize high risk and low risk patients according to the scan findings. Multiple perfusion defects or involvement of >10% of left ventricle(LV) volume, increased lung uptake and Transient ischemic dilatation (TID) of LV are among the most important scan findings associated with high risk of adverse cardiac events. Therefore semiquantification of the myocardial perfusion SPECT is mandatory for risk stratification. Addition of functional data like left ventricular ejection fraction significantly added to prognostic power of myocardial perfusion SPECT. Large number of studies assessed the prognostic impact of a normal stress myocardial perfusion SPECT. Different meta-analysis, showed a very low rate (<1%) of annual mortality in this group. A warranty period of about 18 months is suggested for a normal stress myocardial perfusion SPECT. It is also shown that with normal stress MPI, exercise electrocardiography had no added prognostic value. In abnormal MPI, many studies demonstrated a direct relationship between stress perfusion abnormalities and rate of adverse cardiac events. As the extent and severity of perfusion abnormalities increased, the rates of major adverse cardiac events increased as well. Informed choices regarding revascularization procedures or medical therapy can only be made after accurately identifying the patients who may benefit most from a given treatment strategy. Stress MPI is proved to be very successful in identifying patients who benefit from revascularization. Myocardial perfusion imaging was successful in risk stratification of a variety of conditions including women, elderly, diabetic and in CRF patients.

Keywords: Coronary artery disease, Prognosis, Myocardial Perfusion SPECT

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Coronary artery disease prognosis: Perspectives from interventional cardiology

Arash Gholoobi, M.D.

Department of Cardiology, Mashhad University of Medical Sciences, Mashhad, Iran/ E-mail: [email protected]

The use of percutaneous coronary intervention (PCI) to treat ischemic coronary artery disease (CAD) has expanded dramatically over the past three decades. Prognosis of CAD from interventional cardiology perspective has improved significantly because of improved safety and efficacy of current drug-eluting stents (DESs) in acute coronary syndrome and stable CAD compared to first generation devices as well as improvements in other equipment design. Advances in stent, polymer, and drug design could lead to improvements in restenosis and thrombosis rates, which in turn may reduce rates of myocardial infarction and even death. Additional technologies are currently in clinical testing for the treatment of complex bifurcation stenosis with dedicated bifurcation stent systems .Better techniques to treat chronic total occlusions are being developed and the success rate to treat such complex lesions has been reached around 90 percent in hands of experienced operators. Ongoing large-scale multicenter randomized trials (Excel trial) will assess the safety and efficacy of PCI with DESs in patients with unprotected left main coronary artery stenosis. Better hemodynamic support devices in “ultrahigh”-risk patients allows to manage such patients percutaneously now a days. Percutaneous delivery of autologous stem cell or progenitor cell lines is a new opportunity to move toward myocardial regeneration therapy following acute myocardial infarction as well as chronic heart failure. A better understanding of the patients who will benefit from revascularization (Ischemia guided vs. anatomically guided) has improved safety and efficacy of PCI especially in stable CAD.

Keywords: Percutaneous Coronary Intervention, Coronary Artery Disease, prognosis.

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