Title: Biventricular function in patients on chronic ventricular pacing.

Abstract:

Aim and objectives- There is indirect evidence from a large number of pacing mode selection trials and observational studies , that conventional right ventricular apical pacing may have detrimental effects on cardiac structure and left ventricular function, which are associated with the development of heart failure. There are limited  studies with respect to right ventricular systolic and diastolic function in permanently paced patients. Hence it was proposed to study both LV and RV systolic and diastolic function in a population of permanently paced patients ,using standard echocardiographic  techniques. 

Methods- This study was  a cross sectional study, with a  sample size of 81 patients, who had undergone implantation of VVI pacemaker for at least a duration of 1 year.The control group comprised of patients who had pacemaker implanted in the atrial pacing mode,as well as patients with no structural heart disease and normal biventricular function selected from patients undergoing echo evaluation for screening before chemotherapy or surgery or for chest pain evaluation.Both groups  were evaluated with standard echocardiographic parameters  to assess both LV and RV systolic and diastolic function.

Results- LVEF(assessed by Simpson’s method)-was higher in the control group ( 70.6±4.2%) as compared to the paced group( 63.7±8.8%),but not of statistical significance (P =2.66) .LVPEP-The values in the paced patients were higher ( 104±16.67msecs) compared to the controls(87.8±3.3msecs), but not statistically significant(P=3.75). LVET- showed an increase in the paced group as compared to the control group(267.94±45.10) vs (284.49±40.03),the p value was significant(p=.02). LVPEP/LVET was increased in paced patients .The P value here was not significant (p=1.02.) LVIVRT-paced patients exhibited a higher value(107±19.47 msecs),than the control group(84.44±12.45 msecs), but was statistically insignificant. Mitral E/A-was decreased in the paced group(.9±.76) as compared to the controls(1.15±.40),this finding achieved statistical significance(p value=.02). Mitral E deceleration time-was prolonged (222.96±48.1msec) in the paced group compared to the controls( 203±49.2msec),this finding was statistically significant (p value=.01). Mitral E/E’ was increased in the paced group(9.23±3.08) vs controls(4.74±1.02),without statistical significance( p=2.45).

With regard to right ventricular systolic function, RVFAC(RV  fractional area change ) was lower in the paced group( 46.56±9.17) compared to the control group(49.39±5.67), and this finding was statistically significant( p=.019). RVEF( Right ventricular ejection fraction)- was lower in the controls (43.09±3.31%) compared to the paced group, however this finding was statistically insignificant.(p=3.8). TAPSE( tricuspid annular plane systolic excursion)was increased in the paced  group compared to the control group(22.96±4.4) vs 18.5±3.22mm) with no statistical significance(p=1.28). RVIVRT- right ventricular isovolumic relaxation time was  increased in the paced group( 22.96±4.4) , compared to the control group(84.2±9.9)without attaining statistical significance( p=1.28). TRICUSPID PEAK E VELOCITY- was higher in the paced group( 62.45±14.64cm/s) compared to the control group(55.9±9.9cm/sec)achieving statistical significance (p=.001). TRICUSPID PEAK A VELOCITY  - was greater in the control group(48.16±17.26 cm/sec vs 44.56±27.43cm/sec in the paced group), and was statistically insignificant. TRICUSPID E/A –was higher in the control group( 1.14±.380 vs paced group(.90±.5)and was statistically significant(p=.003). TRICUSPID E/A –was higher in the control group( 1.14±.380 vs paced group(.90±.5) and statistically significant(p=.003). TRICUSPID E/E’- was higher in the paced group( 5.45±2.15) compared to the controls ( 4.46±.848) and was statistically significant( p value of = .0001). Eccentricity index- was increased in the control group( 1.11±.07) compared to the paced group( 1.10±.08) without achieving statistical significance ( p=.46). SVC S/D FLOW- the ratio of  systolic to diastolic flow in the SVC was  increased in the paced group( 1.17±.34) compared to the control group( 1.06±.13), with statistical significance(p=.009).

Conclusions-Our study was more successful in detecting Doppler derived abnormalities of the right and left ventricle , rather than validation of  already known facts( such as diminution of LV ejection fraction ) with long term pacing. A paced heart has changes in both RV and LV systolic and diastolic function. Changes in systolic  and diastolic function do not seem to incapacitate the patients ,given our findings on functional status of the patients at echo evaluation. RV function in a  paced patient needs to be probed in greater detail, given the Doppler abnormalities our study uncovered, dyysnchrony assessment should therefore be directed to the right ventricle too.

Biography:

Vivek S Narayan Pillai is assistant professor at Pariyaram Medical College, India

Title: Comparison of two different types of stent platforms with biolimus eluting : 3-year Randomized, Prospective, Single center, Clinical and Angiographic trial

Abstract:

Aim: Biolimus eluting stents (BES) are the most popular stent technologies with biodegradable polymer in interventional cardiology. Many studies showed that restenosis rates were lower in BES than in other drug-eluting stents. Many different forms of BES are commercial now, but there isn’t any clinical trial that comparison of these platforms. This study is the first study that compares biolimus eluting stents with rigid metallic and flexible metallic platforms.
Methods: This trial is randomized, open-label, prospective, uncentered in Ankara Turkey. 481 patients presenting with stable coronary disease or acute coronary syndromes undergoing BES implantation in de novo native-vessel coronary lesions were randomly assigned to treatment with flex metallic stent platform BES (BES flex; n =120) or right metallic stent platform BES (BES right n:361) and underwent clinical follow-up or angiographically control to 3 years (Figure 1). The primary endpoint was death from any cause. The secondary endpoints were death from a cardiovascular cause, myocardial infarction, target lesion revascularization, and definite in-stent restenosis. 
Results: All of 481 randomized patients were analysed (Table 1). The primary end-point, death from all causes, was similar in both groups (BES-flex: 2.2% vs BES-rigid 2%; p: 0.74). The secondary endpoints, cardiac death (BSS-flex: 1.7% vs BSS-rigid 1.7%; p: 0.99), myocardial infarction (BSS-flex: 6% vs BSS-rigid 7%; p: 0 , 52), target vessel revascularization (BSS-flex: 15% vs BSS-rigid 16%; p: 0.63) were similar in both groups. Coronary angiography control was performed in 142 patients and angiographic restenosis rate was similar in both groups (BSS-flex 19.4% vs BSS-rigid 21.7%, p = 0.775) (Table 2).
Conclusion: BES rigid stents have the same efficacy and safety compared to BES flex stents, whose efficacy and safety have been proven in large studies. With this result, the use of BES rigid stents can provide the same effectiveness at a lower cost. This study is the first clinical study to compare BES with different metallic stent platforms.

Biography:

Veysel Özgür Barış has completed his cardiology fellowship at the age of 28 from Ankara University and his physiology Ph.D. at the age of 34 years from Hacettepe University. He has published more than 10 papers in reputed journals and has been serving as an editorial board member of repute.

Title: An innovative vay to cool the crystalloid cryoprotective cardioplegic solution during open heart surgery.

Abstract:

A new crystalloid cryoprotective cardioplegic solution was invented in Turkmenistan in 2020, which can withstand cooling down to - 5 - - 7 degrees. This is the first and only solution with a unique property to cool the myocardium to +5 - +3 degrees at a minimum calculated dose of 7.5 ml / kg of patient weight. After clamping the aorta, the effect of the injection of this solution into the coronary arteries occurs in the first 35-40 seconds through bradycardia, after which a stable asystole occurs for more than 70 minutes. If it is necessary to extend the time of myocardial protection to 120 minutes, it is necessary to inject half the calculated dose of this solution.The restoration of the heart rhythm after removing the clamp from the aorta occurs within 3 - 4 minutes independently through bradycardia (junctional rhythm) or through high-wave fibrillation without cardioversion and the introduction of cardiotonics. This solution works due to the cryoprotective effect with conformational flexibility and sufficient refrigeration capacity. Histological examinations after 60 and 120 minutes of myocardial cardioplegia showed edema in 25% and 45% of cardiomyocytes, respectively. After 15-30 minutes of myocardial reperfusion (after removing the clamp from the aorta), the edema of the cardiomyocytes disappears. The method of cooling the crystalloid cryoprotective cardioplegic solution below 0 degrees and its composition are protected by patent No. 819 dated 02/18/2020. It is a simple, convenient, reliable and practical "cryoprocard" solution with an economical 500 ml package.

Biography:

Shatlyk Gurdov have 6 years of experience in the field of perfusion (cardiotechnical).He worked for 2 years in the operas of of Prof. Dr. med. Calin Vicol. He worked on all types of heart surgeries. He has been working with our own cardiac surgeons for the last 4 years. He has had 2 internships at the LMU Clinic in Munich to increase my 1 month work experience

Title: The implication of platelets in aortic valve calcification

Abstract:

Calcific aortic valve stenosis (AS) is the most prevalent valvular heart disease and the third most frequent cardiovascular disease after coronary artery disease and hypertension. Natural evolution of AS is characterized by a period of asymptomatic progressive valve calcification, which eventually leads to the development of a severe stenosis and to the onset of symptoms. Both in vivo and in vitro research has revealed that increased platelet activity is involved in the pathogenesis of AS, and can also be used as an indicator of AS severity. TGF-β1 enhances glycosaminoglycan (GAG) elongation, primarily located in the spongiosa layer of aortic valve, which increases lipid retention in the ECM. Lipid retention leads to the oxidation of lipid species which can activate the NF-κB pathway, leading to valve interstitial cells (VIC) osteogenic transition. Simultaneously, ADP released from activated platelets causes increased autotaxin (ATX) expression and release from VICs. ATX associates with platelets and ultimately assists in the conversion of lysophosphatidylcholine (LPC), a product of oxidized lipoproteins (Lp) and activated platelets, to lysophosphatidic acid (LPA). LPA binds to surface receptors on VICs causing signaling that activates the NF-κB pathway, leading to VIC osteogenic transition. Therefore, ADP released by activated platelets leads to LPA formation, enhanced by the availability of lipids retained in the ECM due to released TGF-𝛽𝛽1, which activates the NF-𝜅𝜅B pathway in VICs promoting osteogenic transition and thus mineralization of aortic valve.

Biography:

Rihab Bouchareb has completed her Ph.D. from Strasbourg University, France. She then achieved her postdoc at Heart and Lung Institute in Quebec, Canada. She is now an assistant professor at Mount Sinai, New York, USA. Her research is focused on the crosstalk between obesity and aortic valve calcification. She published over 30 publications published in international journals of high impact factors like European heart journal and Circulation; she attended and presented many presentations at international conferences.

Title: A Young Female with Syndrome of Inappropriate Sinus Tachycardia Seeking Preconception Counseling

Abstract:

Background:
Syndrome of inappropriate sinus tachycardia (IST) is defined as resting sinus heart rate (HR) of greater than 100 with a mean 24-hour HR of greater than 90 with no underlying etiology associated with symptoms of palpitations and an EKG with no change in P-wave morphology^1,3,4. Historically, it was thought to be a rare disease of young females, although recently it was shown to often happen in middle-aged patients without a gender preference³. Its effects and management during pregnancy is not well understood.

Objective:
We demonstrate a classic case of IST in a young female who is now coming in for preconception counseling.

Case/Result:
22-year-old female was diagnosed with IST after she presented with palpitations and lightheadedness and found to have resting HR in the 160s and EKG that showed sinus tachycardia with consistent P-wave morphology. Work-up including complete blood count, complete metabolic panel, urine pregnancy test, urine toxicology, thyroid function test, am cortisol, plasma metanephrines, 24-hour urine metanephrines, CT pulmonary embolism, and echocardiogram were unremarkable. She was started on diltiazem with improvement. She was doing well for 2 years until she came in for preconception counseling regarding the risks of her disease.

Discussion/Conclusion:
The etiology of IST is not well understood^2,4; recent study suggests that some IST patients have anti-β adrenergic receptor (AR) antibodies that stimulate the corresponding membrane receptor to result in an increase of cAMP without desensitization² leading to prolonged stimulation of sinus node β ARs and persistent sympathetic activity². IST can present as heart failure in pregnancy refractory to beta-blockers and nondihydropyridine calcium channel blockers⁵. Although it is not recommended in non-pregnant patients given its risk of complications⁴, ablation is often the next step for drug-resistant IST⁵. Ivabradine, an I_f channel inhibitor, has been shown to have greater efficacy in drug resistant IST¹, although its effects in pregnancy is unknown. Prior case studies have shown that ivabradine was effective in treating IST related cardiomyopathy with minimal maternal and fetal side effects⁵.

Keywords: inappropriate sinus tachycardia, preconception, pregnancy

Biography:

Danni Fu, MD is an internal medicine specialist in Manhasset, NY

Title: Mesenchymal stem cell ameliorate renal fibrosis by galectin -3 Akt/ GSK3? / snail signaling pathway in adenine induced nephropathy rat

Abstract:

Background: Tubulointerstitial fibrosis (TIF) is one of the main pathological features of various progressive renal damages and chronic kidney diseases. Mesenchymal stromal cells (MSCs) have been verified with significant improvement in the therapy of fibrosis diseases, but the mechanism is still unclear. We attempted to explore the new mechanism and therapeutic target of MSCs against renal fibrosis based on renal proteomics. Methods: TIF model was induced by adenine gavage. Bone marrow-derived MSCs was injected by tail vein after modeling. Renal function and fibrosis related parameters were assessed by Masson, Sirius red, immunohistochemistry, and western blot. Renal proteomics was analyzed using iTRAQ-based mass spectrometry. Further possible mechanism was explored by transfected galectin-3 gene for knockdown (Gal-3 KD) and overexpression (Gal-3 OE) in HK-2 cells with lentiviral vector. Results: MSCs treatment clearly decreased the expression of α-SMA, collagen type I, II, III, TGF-β1, Kim-1, p-Smad2/3, IL-6, IL-1β, and TNFα compared with model rats, while p38 MAPK increased. Proteomics showed that only 40 proteins exhibited significant differences (30 upregulated, 10 downregulated) compared MSCs group with the model group. Galectin-3 was downregulated significantly in renal tissues and TGF-β1-induced rat tubular epithelial cells and interstitial fibroblasts, consistent with the iTRAQ results. Gal-3 KD notably inhibited the expression of p-Akt, p-GSK3β and snail in TGF-β1-induced HK-2 cells fibrosis. On the contrary, Gal-3 OE obviously increased the expression of p-Akt, p-GSK3β and snail. Conclusion: The mechanism of MSCs anti-renal fibrosis was probably mediated by galectin-3/Akt/GSK3β/Snail signaling pathway. Galectin-3 may be a valuable target for treating renal fibrosis.

Keywords: Adenine, Mesenchymal stem cells, Interstitial fibrosis, Galectin-3, Proteomics

Biography:

Dr. Bo Chen, deputy director of Department of Human Anatomy and Embryology, comes from School of Basic Medical Sciences, Southwest Medical University, Luzhou city, Sichuan Province, China. He has his expertise in stem cells treatment for acute or chronic kidney diseases. He devotes to exploring the new mechanism of renal fibrosis in MSCs against renal fibrosis, and looking for the effective anti-fibrotic targets and drugs.

Title: Enterococcal Prosthetic Valve Infective Endocarditis Presenting as Complete Heart Block with Intramyocardial Abscess Causing Asystolic Cardiac Arrest

Abstract:

The extension of an intracardiac abscess causing complete heart block is a rare complication of infective endocarditis that is associated with a high mortality. Early identification of conduction abnormalities and a low threshold for suspecting infective endocarditis is crucial to provide prompt management to prevent intracardial extension of infection. We report a case of a patient presenting with complete heart block in the setting of profound hyperkalemia, and was then found to have enterococcal prosthetic valve endocarditis, which was complicated by an intracardiac aortic root abscess which led to asystolic cardiac arrest. The development of heart block in endocarditis serves as a marker for poor prognosis and can signify progression of infection. Management therefore requires immediate pacing, antibiotic delivery to lessen infectious burden, and evaluation for consideration of surgical options such as valve replacement. It is therefore recommended for patients with endocarditis complicated by conduction abnormalities or intracardial abscesses to be treated by a multi-disciplinary team consisting of cardiologists, cardiothoracic surgeons, and infectious disease specialists.

Biography:

Ben Borokhovsky is a current internal medicine resident at Lehigh Valley Health Network. He completed his medical education at Cooper Medical School of Rowan University. He completed his undergraduate education at Widener University and graduated Summa Cum Laude with a degree in Biochemistry. Ben did research throughout his entire undergraduate education and has consistently been asked to speak at Widener’s Research Symposium and has given a keynote presentation on his senior thesis, for which he won a first-place award. During his time at Cooper Medical School of Rowan University, Ben’s research led to multiple publications in the fields of internal medicine, cardiology, endocrinology, and biochemistry. He has attended and presented his research at various conferences including the Annual Drosophila Research Conference hosted by the Genetics Society of America and the International Conference on Human Genetics and Genetic Diseases.

Title: An Exceptional Manifestation of Snake Bite

Abstract:

Introduction: Snakebites have become a major health concern in India. The American Society of Tropical Medicine and Hygiene said in India 46,000 people are dying every year from snake bites against the official figure of only 2000. Aplastic anemia is a rare hematological disorder where the bone marrow fails to produce blood cells due to a decrease in the bone marrow stem cells. In about more than 60% of cases, the cause of bone marrow failure is not known and is called idiopathic aplastic anemia.
Case Descriptions: 17-year-old previously healthy boy with no comorbidities presented to the emergency department with a history of suspected snake bite on his right big toe. Investigations showed features of severe DIC (abnormal PT, aPTT, decreased platelets and decreased fibrinogen, increased FDP, D dimer) for which he was given several units of blood products (FFP, PRBC, and platelets). He was also given appropriate doses of anti-snake venom. In the intensive care, he developed severe sepsis and multiorgan dysfunction. During the course of the treatment, his sepsis cleared but we noted that he developed severe pancytopenia in spite of several units of blood products like PRBC and platelets and even after the stoppage of suspecting antibiotics. We did a bone marrow aspiration and trephine biopsy. Bone marrow aspiration showed dilute marrow with occasional scattered normoblast, scattered myeloid cells, and absent megakaryocytes The trephine biopsy showed severe aplastic anemia with the marrow cellularity around 10% which was quite surprising. He became clinically better, especially with the bleeding tendencies. His coagulation parameters started returning to normal. He was discharged and asked to come for regular follow-up. After one month, the bone marrow was repeated which showed a remarkable recovery with 50-60% cellularity and normal trilineage hematopoiesis. In the last follow-up, the blood counts were Hb 12.1g/dl, WBC 5800 per cubic mm, ANC 2000, and platelet 2,16,000. Other blood parameters like were normal.
Discussion: This patient has a very rare manifestation of snake bite producing severe aplastic anemia. To our best knowledge, we could not find a similar case reported in the literature. Any mechanisms postulated for aplastic anemia are futile because of the lack of cases in the literature. This patient was lucky to have a reversible Bone Marrow aplasia which is not common in a short period of time without specific treatment whatever the cause. It may be better to keep the patient on a long-term follow-up as many other similar circumstances (like drugs, chemicals, infections, etc) could lead to a suppression of Bone Marrow in this patient again.
Conclusion: It is possible that the postulation behind the variation in the constituents in the venom which account for this phenomenon could be possible for the cause of the pathology in our case. Any unusual constituent which could have suppressed the bone marrow temporally either directly or through immunological mechanisms could be postulated as the cause in our case. What that particular unusual constituent was, remains a mystery.

Biography:

Hridya Harimohan is a medical graduate from the Kerala university of health sciences. She is a USMLE aspirant, actively pursuing research right from her undergraduate days. She has passed Step 1 and is now preparing for step 2 CK. Her aim is to get accustomed to Advanced Medical health practices and to make it accessible to underserved and underprivileged communities.