Cardiogogy



Can mechanical pump regenerate heart muscle?

 


Could heart muscle that’s been damaged by a heart attack be prompted to repair itself?

Researchers with University of Texas (UT) Southwestern Medical Center’s Hamon Center for Regenerative Science and Medicine are launching clinical trials to find out. The trials will look at whether a type of mechanical pump – a ventricular assist device – can create an environment that results in regeneration of heart cells.

“Research at UT Southwestern over the past five years was the first to show that the heart muscle in mammals can actually regrow in the early days of life. This ability stops, in part because of the work load that the heart has to do, and we believe that taking away that load by using ventricular assist devices will reactivate this regenerative ability of the heart,” said Dr Hesham Sadek. Dr Sadek, who attended medical school at Ain Shams University in Cairo, Egypt, is Associate Professor of Internal Medicine with the Hamon Center for Regenerative Science and Medicine.

Heart disease is one of the leading cause of death worldwide. In the United States, an estimated 5.7 million people have heart failure, which is the inability of the heart to pump enough blood to keep up with the demands of the body, but does not mean the heart has stopped working. There are no current treatments to regenerate heart muscle.

“We are looking at a specific and accessible strategy to reawaken the regenerative ability of the adult heart,” said Dr Sadek, who holds the J. Fred Schoellkopf, Jr. Chair in Cardiology.

A ventricular assist device (VAD) is a mechanical pump used to support heart function and blood flow in people who have weakened hearts. The device takes blood from a lower chamber of the heart and helps pump it to the body and vital organs, just as a healthy heart would. A small tube carries blood out of the heart into a pump, while another tube carries blood from the pump to the blood vessels, which deliver the blood to the body.

UT Southwestern is establishing a Ventricular Assist Device Program through which the clinical trials will be conducted. The first series of clinical trials will be conducted with patients who currently have or will be getting VADs implanted to treat heart failure. Each trial will use a different measure to assess heart regeneration. The initial trial will use a nuclear imaging modality to assess heart mass. Eventually, the researchers expect to complete six or seven trials that assess the ability of VADs to promote heart regeneration and to discover biomarkers of the process in VAD patients.

The clinical trials build on previous research in Dr Sadek’s lab that found that heart muscle in newborn mammals is capable of regeneration, much like skin and bone are capable of regeneration throughout an animal’s life. But cardiomyocytes, or heart muscle cells, lose that ability in the days following birth due to the high-oxygen environment of the beating heart.

“Dr Sadek has brought an exciting new perspective to the clinical problem of heart disease. He has obtained evidence indicating that placing a heart on a VAD can active a regenerative response and create new cardiac muscle cells,” said Dr Eric Olson, Director of the Hamon Center for Regenerative Science and Medicine and Chairman of Molecular Biology.

“The opportunity to bring cutting-edge advances in science to our patients with advanced heart failure who require LVAD support is truly exciting and we hope will lead to major advances in the care of such patients in the future,” said Dr Mark Drazner, Medical Director of the Heart Failure, LVAD, and Cardiac Transplant program. UT Southwestern has played an integral role throughout the relatively short history of VAD therapy and in the devices’ rapidly evolving technology.

UT Southwestern participated in the landmark clinical trial (REMATCH) that led to US FDA approval of the first left ventricular assist device for destination therapy. UT Southwestern also participated in the HeartWare Bridgeto- Transplant trial, which was completed in 2012 and led to FDA approval of the device.

In 2015, Dr Sadek, Dr Pradeep Mammen, Associate Professor of Internal Medicine and Integrative Biology, and others found that long-term use of ventricular assist devices induces regeneration of heart muscle by preventing oxidative damage to cardiomyocytes.

“This work suggests that by reducing the load on the heart, a pathway for myocyte cell division that has been silenced by high demand can be turned back on. These trials are the clinical translation of that finding in the lab,” said Dr Olson, who holds the Pogue Distinguished Chair in Research on Cardiac Birth Defects, the Robert A. Welch Distinguished Chair in Science, and the Annie and Willie Nelson Professorship in Stem Cell Research.

UT Southwestern established the Hamon Center for Regenerative Science and Medicine in 2014 with a US$10 million endowment gift from the Hamon Charitable Foundation to further researchinto the relatively new field of regenerative medicine. The Center’s goal is to understand the basic mechanisms for tissue and organ formation, and then to use that knowledge to regenerate, repair and replace tissues damaged by ageing and injury. The Center for Regenerative Science and Medicine is providing the funding for the VAD heart regeneration studies.

UT Southwestern collaborators include Dr Mark Drazner, Professor of Internal Medicine and Medical Director of the Heart Failure, LVAD, and Cardiac Transplantation Program, and Clinical Chief of Cardiology, who holds the James M. Wooten Chair in Cardiology; Dr Mammen, who is with the Hamon Center for Regenerative Science and Medicine; and Dr Matthias Peltz, Associate Professor of Cardiovascular and Thoracic Surgery. Additionally, the UT Southwestern researchers will be working with Washington University and the University of Utah, two of the largest VAD programs in the country, to recruit patients for the clinical trials.

VAD/Heart regeneration timeline

A diagrammatic representation of a Left Ventricle Assist Device (LVAD)

  • 1998-2001: UT Southwestern is one of 20 medical centres in the REMATCH trial comparing ventricular assist devices (VADs) to standard care for heart failure patients. Patients with VADs do significantly better.
  • Feb. 2011: Work by Dr Hesham Sadek, Dr Eric Olson and others showing the ability of the neonatal mouse heart to regenerate is published in Science.
  • April 2014: Cell publishes research by the Dr Sadek and others showing that oxygen metabolism causes damage to DNA in heart cells, which shuts down their ability to regenerate.
  • May 2014: UT Southwestern announces the formation of the Hamon Center for Regenerative Science and Medicine thanks to a $10 million gift from the Hamon Charitable Foundation to focus on tissue and organ regeneration research.
  • Jan. 2015: A small study by Dr Sadek, Dr Pradeep Mammen and others showing that longterm VAD use leads to heart muscle regeneration is published in the Journal of the American College of Cardiology.
  • Sept. 2016: The first patient is enrolled in a series of clinical trials at UTSW studying the ability of VADs to lead to heart regeneration.

 

 

Thumbay Hospital’s Cardiology Dept set to introduce advanced facilities and treatments
 

Affiliated to the Gulf Medical University, the Thumbay network of academic hospitals are widely-regarded as the champions of ‘quality healthcare at affordable costs’ and the pioneers of medical tourism in the region. The hospitals are located in Dubai, Ajman, Sharjah, Fujairah & Hyderabad (India) with 700-plus beds, and provides the most comprehensive range of care for cardiovascular problems in the region.

Led by expert doctors with extensive experience, the cardiology department uses the most modern technologies to provide a plethora of world-class services ranging from just a check-up to handling the most critical cases. The hospitals offer emergency cardiac services round-theclock.

In 2016, the Thumbay Hospital in Ajman made headlines when it successfully carried out the first Balloon Mitral Valvuloplasty in the Emirate, at its brand-new, most-modern Cath Lab. Balloon Mitral Valvuloplasty is a very demanding procedure, and requires special training to perform the dilatation of the mitral valve. However, it is beneficial for the patient, who otherwise would have to undergo an open-heart surgery to rectify the condition. An important advantage of this procedure vis-à-vis the surgical option is that the patient can resume his/ her normal routine just one day after the procedure, with no need for prolonged rest, and not more than a day of hospital admittance.

The hospital also excels in device-based therapy, and is fully prepared to perform different device implantations. Two pacemaker implants were successfully performed at the hospital recently. The Cath Lab is also well-equipped to implant life-saving devices like ICDs (Implantable Cardioverter Defibrillator) and CRTDs (Cardiac Resynchronization Therapy Devices) for heart failure cases. These are performed by doctors with successful track records spanning more than eight years.

Insertion of BVS bio-absorbable stents is another area of expertise of Thumbay Hospital. An increasing number of patients nowadays are choosing to have the bio-absorbable stents inserted, as these become part of the body after 6 months of insertion, ruling out the need to follow long-term medication. The hospital also offers pediatric cardiology services, caring for children with congenital heart disease.

Upcoming facilities & treatments
The Cardiology Department of Thumbay Hospital is all set to see several major developments in the near future. The hospital will soon introduce cardiothoracic surgery, bringing in world-class expertise to tackle serious heart and lung conditions requiring surgical intervention.

The Cardiology Department will also update its non-invasive facilities through measures like optimizing the use of CT coronary angiography to identify narrowing of the coronary artery. Plans are also afoot to emphasize and optimize the use of 3D echo for real-time imaging of cardiac structure and function.

In the long-term, the hospital has plans to set-up an electrophysiology study (EPS) lab, which would not only check for abnormalities in heartbeat, but also enable doctors to perform cardiac ablation procedures to correct heart rhythm arrhythmias. The EPS lab will also enable easy insertion of cardiac resynchronization devices.

 

Study shows effects of long-term exposure to air pollution and traffic noise on blood pressure
 

Long-term exposure to air pollution is linked to a greater incidence of high blood pressure, according to the largest study to investigate the effects of both air pollution and traffic noise by following over 41,000 people in five different countries for five to nine years.

The study, which is published 23 October 2016 in the European Heart Journal, found that among adults, up to one extra person per 100 people of the same age group living in the most polluted areas of cities would develop high blood pressure (hypertension) compared to those living in the less polluted areas. This risk is similar to the effect of being overweight with a body mass index (BMI) between 25-30 compared to people with normal weight (BMI 18.5-25).

High blood pressure is the most important risk factor for premature illness and death.

This study is one of the first to investigate both air pollution and traffic noise simultaneously and it found that traffic noise is associated with an increase in cases of hypertension as well. The way the study was conducted enabled the researchers to estimate the risk that was linked to air pollution and the risk linked to noise separately. The association of air pollution with hypertension remained even when exposure to traffic noise was considered in the analysis. The researchers say this is an important finding because there are differing ways of reducing air pollution and noise.

A total of 41,072 people living in Norway, Sweden, Denmark, Germany and Spain participated in the study, which was part of the gEuropean Study of Cohorts for Air Pollution Effectsh (ESCAPE) project that is investigating long-term effects of exposure to air pollution on human health in Europe. Information on blood pressure was gathered when the participants joined the study and during a follow-up examination in later years. None had hypertension when they joined the study, but during the follow-up period 6,207 people (15%) reported that they developed hypertension or started to take blood pressure-lowering medications.

Between 2008 and 2011, the researchers measured air pollution during three separate two-week periods (to allow for seasonal effects). They used filters to capture information on concentrations of polluting particles known as gparticulate matterh (PM) of different sizes: PM10 (particles less than or equal to 10 microns in diameter), PM2.5 (less than or equal to 2.5 microns), PMcoarse (PM10 minus PM2.5) and PM2.5 absorbance (a measurement of soot particles). These measurements were taken at 20 sites in each of the areas being studied, and measurements of nitrogen oxides were measured at 40 different sites in each area. Traffic density was assessed outside the homes of the participants and traffic noise was modelled according to the EU Directive on environmental noise.

The researchers found that for every five micrograms per cubic metre (5 ƒÊg/m3) of PM2.5, the risk of hypertension increased by a fifth (22%) in people living in the most polluted areas compared to those in the least polluted areas. Higher soot concentrations also increased the risk.

Chronic traffic noise
For exposure to chronic traffic noise, the researchers found that people living in noisy streets, where there were average night time noise levels of 50 decibels, had a six percent increased risk of developing hypertension compared to those living on quieter streets where average noise levels were 40 decibels during the night.

Professor Barbara Hoffmann, Professor of Environmental Epidemiology at the Centre for Health and Society at Heinrich- Heine-University of Dusseldorf, Germany, who led the analysis, said: gOur findings show that long-term exposure to particulate air pollution is associated with a higher incidence of self-reported hypertension and with intake of anti-hypertensive medication. As virtually everybody is exposed to air pollution for all of their lives, this leads to a high number of hypertension cases, posing a great burden on the individual and on society. "Exposure to traffic noise shares many of the same sources with air pollution and so has the potential to confound the estimates of the adverse effects of pollution on human health. However, this study controlled for traffic noise exposure and found that the associations of air pollution with hypertension did not vanish. This is important because preventive measures for air pollution and noise differ.

One very important aspect is that these associations can be seen in people living well below current European air pollution standards. This means, the current legislation does not protect the European population adequately from adverse effects of air pollution. Given the ubiquitous presence of air pollution and the importance of hypertension as the most important risk factor for cardiovascular disease, these results have important public health consequences and call for more stringent air quality regulations.

  • doi: 10.1093/eurheartj/ehw413

 


Saving a Superhero

 

This is a story of a real-life superhero, Eric DelaTorre, who was born with lifethreatening heart defects. Today, the 5-year-old boy has the powers he needs to live a healthy and energetic life.

 

At the time of Eric’s birth in October 2011, an echocardiogram showed a serious heart condition. Cardiologists at two hospitals had differing opinions about which side of the heart had the more critical problem. That’s when Eric’s family turned to the University of Chicago Medicine Comer Children’s Hospital, where a comprehensive echocardiogram showed the infant had complex congenital heart disease significantly affecting both sides of his heart. “For the first time, we felt like more than just a number,” said Eric’s mother Alma. “We loved the hospital’s boutique feel and personal touches, like the echo technician stroking Eric’s head and the cardiologist playing classical music during the test.”

When Eric was just three months old, Gerhard Ziemer, MD, PhD, performed open-heart surgery on the left side of his heart. Due to the severity of the condition, the little boy’s chest needed to be left open for three days with a life support machine at his bedside.

“Our world came crashing down when we were told Eric might not pull through,” Alma said. “Our PICU nurses assured us everything was going to be okay and never left his side. Child Life specialists also comforted and helped us.”

Eric recovered and grew stronger. And he was able to go home from the hospital seven weeks later.

But when the pulmonary arteries on the right side of his heart failed to grow as expected, another open-heart surgery followed just over a year after the first one. The main pulmonary artery was widened and the entire pulmonary artery between his right and left lungs was replaced with artificial tubes.

“We were included in rounds and Dr Ziemer spent hours answering our questions,” Alma said. “Everyone – from the valets and receptionists to the cleaning people – was so nice and warm to us.”

The power of X-ray vision
Reconstructing the heart of a growing superhero is no easy feat, and the cardiac team continued to follow Eric closely to ensure he didn’t miss a beat.

In December 2015, Comer Children’s interventional cardiologist, Daniel H. Gruenstein, MD, used Eric’s love of superheroes to ease his patient’s fears. When Eric avoided making eye contact with his new doctor, the nurses suggested wearing superhero lead aprons and matching surgical caps during a procedure. As soon as Gruenstein donned his Superman gear, “Eric and I were best friends,” he said, adding: “We also played superhero cartoons on a monitor to make him more comfortable.”

Eric’s procedures took place in ComerChildren’s Hybrid Cardiac Catheterization Lab, a state-of-the-art facility for treating children and adults with heart conditions. The cardiovascular X-ray system in the lab gives the physicians real-time feedback on radiation dosage so they can make adjustments while doing procedures. The only one of its kind in Chicago, the system also enables the interventional cardiologist to focus the radiation on a small region of the patient’s body, further reducing the exposure for patients like Eric who may require several catheterizations throughout their lifetime.

“Superheroes use X-ray vision to save people, and we use it to help keep the hearts of little superheroes pumping,” Gruenstein said. “At the same time, we are protecting their bodies from excess radiation over the long term.”

Recently, Gruenstein became one of the first cardiologists in the US to receive a new board certification in adult congenital heart disease. This means he is now certified to care for Eric and other pediatric and congenital heart disease patients through adulthood.

Today, Eric is an energetic and outgoing little boy. His family spends a lot of time outdoors, where Eric loves to roll in the dirt, hunt fossils and observe nature. He also loves playing with robots and building things.

“Eric wants to participate in everything,” Alma said. “None of this would be possible without the staff at Comer Children’s Hospital, who gave our family all the attention and love we needed. It was the right decision to come to Comer Children’s.”

 

New clinical practice guidelines recommend more use of surgical ablation for treating Afib

 

New clinical practice guidelines have been issued by The Society of Thoracic Surgeons (STS) that include major recommendations for the use of surgical ablation when treating atrial fi brillation (Afi b), the most common type of irregular heartbeat. The guidelines were posted online 19 December 2016 in The Annals of Thoracic Surgery."

"These guidelines represent nearly 2 years of effort by some of the United Statesf leading experts in the surgical treatment of atrial fibrillation," said guidelines coauthor Vinay Badhwar, MD, Gordon F. Murray Professor and Chair of the West Virginia University Heart & Vascular Institute. "This important document highlights the increasing global evidence on the safety and effi cacy of surgical ablation for the treatment of Afib."

STS believes that the practice of summarizing current scientifi c evidence into clinical practice guidelines and recommendations may contribute importantly to improving surgical outcomes, as well as the quality of patient care. In this case, the literature revealed that surgical ablation as a treatment option for Afib has experienced continued development over the last 30 years, with its frequency and success steadily increasing. The guideline writing committee merged these findings into a singular consensus paper to shape practice, concluding that surgical ablation is effective in reducing Afib and improving quality of life, and so deserves a more prominent role in adult cardiac surgery.

In patients with Afib, rapid, disorganized electrical signals cause the atria to quiver. The quivering upsets the normal rhythm between the atria and the the ventricles. As a result, the ventricles may beat fast and without a regular rhythm.

Afib can lead to blood clots, strokes, heart failure, and other heart-related complications. According to the American Heart Association (AHA), untreated Afib doubles the risk of heart-related deaths and is associated with a signifi cantly increased risk for stroke. gIt is recognized that surgical ablation impacts long-term outcomes with improvements in normal heart rhythm, quality of life, and stroke reduction," said Dr Badhwar. "Current evidence reveals that surgical ablation can be performed without signifi cant impact to major complications or death.

"One option for Afib treatment - as the new clinical guidelines recommend - is surgical ablation, also known as the maze procedure. When performing surgical ablation, the surgeon makes very specifi c and defi ned lesions in the heart. Scar tissue forms, blocking the abnormal electrical signals while also creating a controlled path for electricity in the heart to follow. The heartbeat should eventually normalize.

Surgical ablation can be done as a standalone procedure or in combination with another heart surgery. In developing these new guidelines, the authors assessed the safety of performing surgical ablation for three surgical approaches: primary open atrial operations where the left atrium is already being opened, such as mitral valve repair or replacement and/or tricuspid valve repair; primary closed atrial operations when the left atrium would not otherwise be open, such as coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) operations; and standalone operations when the only goal is to perform surgical ablation to treat Afib.

The new clinical practice guidelines offer evidence-based recommendations that include:

  • Surgical ablation for Afi b at the time of concomitant mitral operations to restore cardiac rhythm;
  • Surgical ablation for Afi b at the time of concomitant isolated AVR, isolated CABG, and AVR+CABG operations to restore cardiac rhythm; and
  • Surgical ablation as a primary standalone procedure to restore cardiac rhythm for symptomatic Afib that is resistant to medication or catheter ablation.

The authors also recommend a multidisciplinary heart team assessment, treatment planning, and long-term followup in order to optimize patient outcomes in the treatment of Afib.

"These guidelines may help guide surgeons when faced with a challenging decision on the management of Afi b,h said Dr Badhwar. gThe guidelines represent an assimilation of the worldfs literature; they do not supersede the fi nal medical decision of the surgeon. It is important to remember that the ultimate choice of any therapy remains between the patient and their doctor."

  • doi: 10.1016/j.athoracsur.2016.10.076
 

SKMC Cardiac Sciences Institute is renowned for its expertise and ability to handle complex cases

 

The Cardiac Sciences Institute at Sheikh Khalifa Medical City in Abu Dhabi, one of Abu Dhabi Health Services Company’s entities, is a comprehensive and cuttingedge facility that provides complete invasive and non-invasive care for both adult and pediatric patients. From diagnosis to rehabilitation, the institute provides a full-service solution. The Institute is renowned for its expertise, its integration of disciplines, its state-of-theart equipment and facilities as well as for its highly trained and qualified personnel.

Adult Cardiology
The division of Adult Cardiology is one of the largest divisions of cardiology in the UAE. It encompasses many subspecialties. It has an inpatient service that covers both a coronary care unit as well as a regularly monitored cardiology ward.

The non-invasive laboratory includes all forms of echocardiography i.e. transthoracic echocardiograms, transoesophageal echocardiograms, exercise echocardiograms, dobutamine echocardiograms and contrast echocardiograms; in addition to other forms of non-invasive testing i.e. exercise treadmill testing, Holter monitoring, blood pressure monitoring, event recording and Tilt Table Testing.

It has a very well established electrophysiology service with regular device implantations, both regular pacemakers and high voltage devices, as well as simple and complex ablations. This includes very busy electrophysiology and pacemaker clinics.

It has a very active interventional cardiology service with 24/7 primary Percutaneous Coronary Intervention (PCI) service covering a large catchment area. It also has a multidisciplinary heart failure clinic, which includes a heart failure specialist, a clinical pharmacist, a cardiac rehabilitation physiotherapist and a dietitian. The division is a recognized American College of Cardiology International Centre of Excellence (ICOE). It is involved in many international registries and is accredited as a Chest Pain PCI Centre by the Cardiovascular Society of Chest Pain.

Its Echocardiography laboratory is the first to be accredited by the European Association of Cardiovascular Imaging outside Europe. The division is the first to be accredited as an Arab Board center for conducting a Cardiology Fellowship Program. It accommodates the many internal medicine residents as part of their residency program.

Adult Cardiac Surgery
The division of Adult Cardiac Surgery is the largest cardiac surgery provider for Abu Dhabi and the rest of the UAE. It has some of the best cardiac surgeons in the country. It not only performs cardiac bypass grafting surgery, but also all types of cardiac valve repairs and replacements. This includes low, intermediate and high risk patients. It also includes emergency surgeries such as patients with cardiogenic shock and severe left main coronary stenosis. They provide a 24/7 service.

It is capable of performing Extra- Corporeal Membrane Oxygenation (ECMO) and Ventricular Assist Device (VAD) implantations.

Pediatric Cardiology
The division of
Pediatric Cardiology provides 24/7 coverage for pediatric cardiology patients from the whole of the UAE. Patients with congenital heart disease who require surgical intervention are evaluated and managed prior to and after the surgical intervention by the pediatric cardiology team.

Our services include non-invasive imaging like echocardiography, electrocardiography, Holter monitoring, blood pressure monitoring and CT angiography in addition to diagnostic and interventional cardiac catheterizations for a wide range of anomalies from the very simple to extremely complex lesions.

The pediatric cardiology team provides teaching and mentoring to the pediatric residents and neonatal fellows and actively participates in local and international meetings. It is active in research and publications in peer-reviewed journals.

Pediatric Cardiac Surgery
The division of Pediatric Cardiac Surgery is the only provider of congenital heart disease corrective surgery for both pediatric and adult patients in the UAE. It performs both simple and complex cardiac surgeries. It has performed more than 2000 congenital heart disease corrective surgeries with a very good track record for having low morbidity and mortality. The division has high complexity index compared to other centres in the world.

 

Date of upload: 11th Jan 2017

                                  
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