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Background: Treatment of the elderly patients with dyslipidemia remains controversial with concerns about drug safety in the very old patient population. Objective: To report the course of a 102 year old woman who survived a severe myocardial infarction at age 75 years and has remained clinically free of atherothrombotic disease while receiving statin therapy for those 27 years and no other intervention. Methods: Case report covering one individual over 27 years. Results: The 102 year old woman survived for 27 years following a severe myocardial infarction while receiving statin/antihypertensive therapy and aspirin therapy, but no other intervention. Conclusion: This report supports the literature for statin treatment of dyslipidemia in the very old population to maintain a clinical disease free state following an acute myocardial infarction. The safety of such therapy is also recorded. This report supports the effectiveness of optimal medical therapy in such patients. Overview: The question of how best to treat dyslipidemia in the very old population remains unsettled, though most researchers would favor statin therapy. Concerns have been raised as to drug safety in the very old population. This report follows an elderly female survivor of an acute myocardial infarction at age 75 years, over the next 27 years, to an age of 102 years, on optimal medical therapy. No surgical interventions have been necessary. This report supports the concept of aggressive medical therapy in the very old.

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Introduction: Variant angina is an uncommon syndrome which is mostly benign, but carries a risk of serious complications. Coronary vasospasm has been described in kidney diseases; however, its manifestations have not been elucidated. Also, haemodynamic changes occur during haemodialysis, but its acute effect on coronary circulation is not well understood. We report a rare case of variant angina (VA) in a patient with chronic kidney disease (CKD), presented with myocardial infarction (MI) and cardiac arrest secondary to ventricular fibrillation (VF). Patient Information: A premenopausal female with CKD presented with acute coronary syndrome following haemodialysis. She complained of recurrent angina following haemodialysis sessions since few months which resolved with nitroglycerine. ECG revealed lateral wall myocardial infarction. Few minutes after admission, patient developed VF leading to cardiac arrest and was successfully resuscitated and shifted to the cardiac catheterization lab for emergency percutaneous coronary interventions (PCI). Coronary angiogram revealed >90% stenosis in mid left anterior descending coronary artery (LAD). In view of typical history suggestive of VA and no obvious thrombus or dissection in culprit artery, vasospasm of LAD was suspected as the likely etiology. Ergonovine provocative test was not performed. Instead, intracoronary nitroglycerine was administered which led to complete resolution of ST elevation, relief in chest pain and a patent LAD with improved calibre. Over next 24 hours, multiple episodes of ST elevation and chest pain occurred, resolving with sublingual nitroglycerine. High dose calcium channel blocker therapy was initiated and patient had no further clinical events. She had undergone several uneventful haemodialysis sessions on treatment and is doing well. Discussion & Conclusion: To our knowledge, this is the first reported case of patient with CKD having VA complicated by VF causing cardiac arrest. The association of coronary vasospasm following haemodialysis has also not been described. VA can angiographically mimic organic stenosis and should be kept in mind during primary PCI. 

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Congenital apical left ventricular (LV) aneurysms are rare in children and should be differentiated from congenital left ventricular diverticular. We present three cases of apical LV aneurysms in children. Case 1 is a five day old male infant, HIV exposed on nevirapine, who was referred for a soft systolic murmur. No cardiac failure was present and mild cardiomegaly was noted on chest X-ray. ECG demonstrated right axis with RVH. Echocardiogram showed a large apical left ventricular aneurysm measuring 16 mm by 19 mm with good ventricular function. This was confirmed on CT angiogram and the child underwent successful resection of the aneurysm. Histology demonstrated mural fibrosis and granulation tissue with no vasculitis. Case 2 is a two year old male, presented with one week history of coughing, shortness of breath and tachycardia. Clinical cardiac failure was present with cardiomegaly on CXR. Echocardiography demonstrated pericardial effusion with a LV apical aneurysm measuring 40 mm x 43 mm with good ventricular function. A CT angiogram further defined the aneurysm. HIV was positive with a high viral load and low CD4 count. TB work up was negative. He was started on antifailure medication and his clinical condition optimized. He was operated successfully two months after commencing antiretroviral therapy. Histology demonstrated transmural fibrosis. Case 3 was a nine year old male who was presented with palpitations, cough and dyspnoea. Cardiac failure and cardiomegaly were present. A large apical aneurysm with a pericardial effusion was again noted echocardiographically and further defined by CT angiography. Coronary angiogram was normal. He also tested HIV positive with a high viral load and low CD4 count. His tuberculosis (TB) work-up was negative. The child’s treatment started on antifailure medication and commenced on antiretroviral treatment. However, he was demised before he could be operated on. Patients with apical LV aneurysm may be asymptomatic or present with arrhythmias, heart failure, peripheral embolism, endocarditis, cardiac rupture or sudden death. We postulate a possible association with HIV infection or exposure. Surgical resection is the treatment of choice to prevent complications.

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Statement of the Problem: Takayasu’s aortitis (TA) is a chronic systemic vasculitis of unknown origin. It often involves the aorta, its major branches and the aortic valve. Surgical treatment such as valve replacement is occasionally required when cardiovascular symptoms occur. The most serious complications after valve replacement in TA are prosthetic valve detachment and aortic root aneurysm. The purpose of this study is to describe a complicated surgical case of reoperation presented with all of these complications. Methodology & Theoretical Orientation: This study is based on a reoperation case of TA patient with previous double replacement, mainly focusing on the surgical technique and our experience during the treatment process. Findings: A 29-year old male with TA was admitted due to tachypnea and exertional palpitations, three years after his previous double valve replacement (DVR). Transesophageal echocardiography showed severe detachment of the aortic valve and fistula from the aortic root to both the left ventricle and the left atrium. Computed tomography showed aneurysmal dilation of the aortic root to a diameter of 64 mm. Conclusion & Significance: We successfully treated a case of aortic aneurysm combined with aortic valve detachment and aortic fistula after previous DVR in TA patient. The teaching points of this case were: The two key procedures in this operation, i.e. reconstruction of the central fibrous body and the shunt of aortic root-right atrial; due to the fragility of the tissue in TA patients, the surgical operation must be meticulous to ensure as little tension on the suture line as possible; for DVR operations in TA patients, proactively fixing the aortic valve to the mitral valve is recommended; and imaging follow-up should be done routinely. Even in such a challenging and complex case, surgery is still feasible and the preferable option. 

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Background: Endothelial progenitor cells (EPCs) play a key role in cardiovascular regeneration following acute myocardial infarction (AMI); however, in older patients, EPCs appear to lose their regenerative capacity. Objectives: This study aimed to evaluate the role of two potential anti-aging factors, TERT (the catalytic subunit of telomerase) and growth differentiation factor 11 (GDF11), in rejuvenating senescent EPCs in elderly patients with AMI. Methods: We compared the quantity and capabilities of EPCs from old-aged (>60 years), middle-aged (45–60 years), and young-aged (<45 years) AMI patients. The role of TERT and GDF11 in young and old-aged EPCs were examined in vitro. Finally, we validated our finding by comparing GDF11/TERT expression in AMI patients with poor/good prognosis. Results: Circulating count and survival of EPCs, and TERT and GDF11 expression levels, decline with age among patients with AMI. Meanwhile, upregulation of TERT and GDF11 can rejuvenate old-aged EPCs in vitro by renewing their survival and angiogenic abilities through activation of the eNOS- and pro-survival signaling pathways. Depletion of TERT causes senescence in vascular endothelial function and angiogenesis of young EPCs. An independent cohort of patients confirmed the predictive power of TERT and GDF11 expression as indicators of clinical outcomes post-AMI. Conclusions: TERT cooperates with GDF11 to enhance regenerative capabilities of older EPCs. When combined with GDF11, TERT may represent a potential therapeutic target for the treatment of elderly patients with AMI. 

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Renalase is an enzyme that mediates lowering of blood pressure by destroying catecholamines. Hypertension is one of the most common complications after coronary artery bypass (CABG) surgery, and this complication is usually averted by administration of sodium nitroprusside (SNP), which lowers blood pressure by dilating blood vessels through nitric oxide (NO). Thus, the aim of the present study is to examine the changes in renalase, catecholamine and nitric oxide (NO) before and after administration of sodium nitroprusside to lower blood pressure in patients developing hypertension following coronary artery bypass (CABG) surgery using biological samples collected in the first 6 to 8 hours, and at 24th, 48th and 72nd hours and to find out its relations with certain hemodynamic parameters. The study registered 26 patients who developed hypertension in the first 6 to 8 hours after CABG, 12 patients who had normal blood pressure after CABG, and 22 healthy individuals. ELISA method was used to measure renalase concentrations and catecholamine levels, and nitric oxide levels were quantified by spectrophotometry. Renalase concentrations and NO levels of the patients who developed hypertension in the first 6 to 8 hours were found significantly lower and catecholamine levels were significantly higher than those in controls and cases who did not develop hypertension. After starting sodium nitroprusside (SNP) administration, these patients showed a statistically significant increase in renalase concentrations and NO levels and a noteworthy decrease in catecholamine levels at 6 to 8, 24, 48 and 72 hours. In addition, a slight increase was found in heart rate and decreases was recorded in the systolic arterial pressure (SAP), diastolic arterial pressure (DAP) and mean arterial pressure (MAP) following sodium nitroprusside administration. Consequently, the data obtained in this study suggest that administration of nitroprusside lowers the blood pressure by not only increasing NO production (vasodilation), but also elevating the quantities of the renalase enzyme, which destroys catecholamines. It is believed that addition of renalase to medications used to lower blood pressure in the future can help in preventing hypertension. 

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Biography:

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Cardiac fibrillation is one of the leading causes of morbidity and mortality in the Western world, where atrial fibrillation (AF) is the most common sustained arrhythmia. Because cardiac fibrillation and specifically AF can lead to stroke, early detection of these episodes has enormous clinical impact. To date there are no real-time devices that can precisely detect the R peaks in the ECG signal before, during and after cardiac fibrillation. Our main research objectives were to design an algorithm that accurately detects the R peaks from ECG strips during AF and other arrhythmogenic events in the presence of noise or movement, and to use it as the basis for an artificial intelligence algorithm that accurately identifies AF events in short single ECG lead recordings. An algorithm which subtracts motion artifacts, electrical drift and breathing oscillations was developed. The algorithm fixes the signal polarity, filters environmental noise, and deals with electrical spikes and premature beats by heuristic filtering. The algorithm was tested on the MITDB Physionet database. Based on the R peak annotation, the T, P, Q and S peaks were detected and ECG beat morphology was extracted. Machine learning techniques that include a combination of 61 features were used for classification in to four groups. On average, our algorithm precisely detects the R peaks with 0.26% false negative and false positive detection, for a sensitivity of 99.69% and positive prediction of 99.74%. The algorithm performs similarly on AF and non-AF patient data. Our arrhythmia classification algorithm will classify AF ECG data in 89% of the cases (F1). Precise real-time identification of the heart rate on a beat-to-beat basis and classification of ECG strips can serve as a clinical tool to prescreen for cardiac diseases.

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Introduction: Since the 1980s heart-lung transplantation has been an effective method for the treatment of cardio-pulmonary diseases. Heart-lung transplantation is often the last choice to prolong the life or improve the quality of life of patients with complex congenital heart disease (CCHD) with Eisenmenger-reaction and pulmonary arterial hypertension. Especially in patients with CCHD, who underwent previous operations (group-A) and without any previous operation in group-B and were in end stage cardiopulmonary failure. Methods: The study examined 51 patients, who were heart-lung transplanted in our hospital. We compared the patients into two groups: group I in children younger than 18 years and group II in adults older than 18 years. Particular postoperative parameters were collected by the inspection of files. Using the Chi-square test the significance of the results was shown. Survival is shown in Kaplan Meier curves and checked with the Log- Rank test. Results: Among the 51 patients there are 17 children and 34 adults. In the adult population the incidence of congenital heart disease is dominant. In the children sample there are also patients with pulmonary arterial hypertension. 15 with CCHD were in group-A, (4 children and 11 adults). The overall survival of the patients with a previous operation was 0.16 years in the median. The survival of group-B was in the median 8.03 years (p-value: 0,027). 6 of the 15 group-A died within the first 30 years. In the group-B 4 out of 36 died (p-value: 0.018) Discussion: In the Chi-square test a significantly higher 30 day mortality rate for the patients with previous operation. On the one hand this could be caused by complicated anatomy and strong adhesions. On the other hand there is a significantly higher rate of postoperative bleeding and early complications after heart-lung transplantation in the patients group with a previous operation, which could also be a cause for the higher 30-day mortality. In addition the sample shows a clear advantage of the patient group with no previous operation in relation to the overall survival. 

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Introduction: The aim of the study was to investigate a mechanical behavior of various types of artificial vessels in relation to the iliac arteries with the use of dedicated ex vivo bioengineering reactor. Methods: Artificial circulatory model (ACM) for computational projection of vessel structure under different flow conditions was designed and built. Analyzed vessels were supplying with the homemade fluid mimicking blood. Following types of vessels were analyzed: synthetic prostheses (ePTFE, ePTFE with spiral, Dacron), biosynthetic prostheses (Omniflow II, gelatin sealed ePTFE), iliac arteries and silicon tubes. Each time the same length of vessel (100 mm) was analyzed. Mechanical behavior was introduced with the use of following parameters: change of diameter, wall displacement, deformation factor and divergent factor. Moreover, ACM results were verified with medical data. 2D-speckle-tracking-technique (2DSTT) was applied to assess diameter dilatation for patients with ePTFE prostheses/iliac arteries. Results: It was presented that both Dacron and bio prostheses act similarly to real tissue. Approximately 21% difference for gelatin sealed ePTFE prostheses and 25% for Dacron prostheses compare to iliac arteries was observed. While, ePTFE prostheses presented about 2.4-fold increase of stiffness compare to the flexibility of iliac arteries. Moreover, ePTFE prostheses act much more like silicon tubes rather than iliac arteries. Conclusions: Artificial reconstruction of blood flow in different spatial configuration of human and artificial vessels allows simulating different mechanical response of tissue vascular grafts and silicon tubes. 

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Over last few years, transcarotid TAVI has proved to be an acceptable substitute to other known approaches of TAVI, mainly transfemoral and transapical TAVI whenever the later ones are unfavorable due to severe femoral arteriopathy or previous iliofemoral surgery or when the patient is too frail to withstand transapical TAVI as in case of severe pulmonary or ventricular dysfunction for instance. When transcarotid TAVI becomes a must in case of inappropriate other approaches of TAVI, the presence of critical stenosis in the ipsilateral internal carotid artery as comorbidity could expose such fragile patients to be operated twice in two separate settings, for ICA endarterectomy at the first setting then for TAVI, which may entail double risk of bleeding, severe vascular and neurological complications, long hospital stay and mortality. " We report cases of transcatheter aortic valve implantation (TAVI) with the self-expanding Medtronic CoreValve bioprosthesis (Medtronic, Minneapolis, MI) through a left common carotid (LCC) artery in patients with a diseased ipsilateral internal carotid artery and high EUROSCORE risk who were rejected to undergo surgery and a transcatheter approach was planned. Due to severe peripheral vascular disease with iliofemoral lesions, significant calcifications and unfavourable angulations of the innominate artery as well as prior heart surgery precluding a direct aortic and subclavian approach, none of the established access sites were suitable. Therefore, we considered a left carotid access, which had to be combined with a surgical endarterectomy for treatment of a significant ipsilateral internal carotid artery. The procedure was successful without cardiac, cerebrovascular, or access complications. These cases illustrate a true heart team approach, establishing a unique access for TAVI for patients without regular access options".

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Statement of the Problem: Lack of Nrf2-regulated antioxidative heme oxygenase-1 (HO-1) may exacerbate abdominal aortic aneurysm (AAA). However, the effect of simvastatin on Nrf2/HO-1 pathway in patients with AAA has not been studied yet. Methodology & Theoretical Orientation: We analyzed the localization of Nrf2 and HO-1 in human AAA wall and verified the influence of simvastatin treatment on Nrf2. We took AAA tissue from patients treated with simvastatin (N=28) or without statins (N=14) and verified the effect of simvastatin on primary human aortic endothelial (EC) and smooth muscle cells (SMC). Findings: We found a positive correlation between expression of  gene and glutathione (GSH) in AAA wall. Both, HMOX-1 and GSH are regulated by Nrf2. However, the expression of Nrf2 and HO-1 seemed not to colocalize in AAA wall. Simvastatin treatment up-regulated HO-1 in AAA, but Nrf2 level was only higher in vasa vasorum. In vitro studies showed that simvastatin raises HO-1 protein in EC and SMC but independently on NFE2L2. Conclusion & Significance: Simvastatin-induced modulation of HO-1 in ECs and SMCs in vitro is not related to Nrf2/ARE activity. Different HO-1 and Nrf2 localization together with stable expression of Nrf2 target genes in AAA tissue signify Nrf2independency. 

Biography:

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Introduction: The aim of the study was to reconstruct a blood hemodynamic for patients with type IIIb aortic dissection (TBAD) before and after thoracic endovascular aortic repair (TEVAR) with the use of computational fluid dynamics (CFD). Methods: We prepared 3D models of the aorta with adjacent arteries using pre- and post-operative CT data from five patients treated for TBAD. Hemodynamic parameters (like, blood flow rate or wall shear stress (WSS)) were calculated with CFD technique. Results were verified with ultrasonography (USG) data. Results: CFD indicated that TEVAR caused 7-fold improvement in overall blood flow through aorta (p=0.0001). Comparison of CFD and ultrasonography (USG) showed no significant change in blood flow through analysed arteries but a significant increase in flow rate for thoracic trunk and renal arteries, which was in accordance with USG (accuracy 90% and 99.9%). Moreover, we observed a significant decrease in wall shear stress (WSS) values within the whole aorta after-TEVAR compared to pre-TEVAR (1.34±0.20 Pa vs. 3.80±0.59 Pa; p=0.0001). This decrease was associated with a significant reduction in WSS in the thoracic Conclusions: CFD technique denoted that post-operative remodeling of the aorta after TEVAR for TBAD improved hemodynamic patterns reflected by flow, velocity and WSS with accuracy of 99%. Aorta (3.10±0.27Pa -1.34±0.11Pa; p=0.043) and renal arteries (4.40±0.25 Pa -1.50±0.22 Pa; p=0.043).