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.15. VIETNAMESE GERMAN HEART DAYS
Ho Chi Minh City 29.11.2015 Organization: Vietnamese Heart Association of Ho Chi Minh City in Cooperation with
Vietnamese German Scientific Symposium Lectures: Endovascular closure of the left atrial appendage - Why and How Dr. Christian Glatthor, Cardiovascular Center Ravensburg, Germany Since more than a decade there is growing experience in interventions for prophylaxis of cardiogenic thromboembolic events. Based on randomized date, notably PROTECT-AF and PREVAIL, the technical development of mainly two devices for transvenous transseptal left atrial appendage occlusion (LAAO) has reached a satisfactory state which is supplemtentary documented in a lot of registry data. Patients with non valvular atrial fibrillation who are not suitable for medical anticoagulation nowadays should be treated with one of the available LAA-closure devices. After some related initial hostile event experiences, the implantation procedure has developed and can be looked upon as safe and effective. The special design of an elaborate and thorough training phase together with a an acceptable learning curve makes that particular procedure become more and more indispensable part of daily practice. Intracoronary imaging and physiology for improvement of coronary interventions Prof. Dr. Volker Klauss, Cardiology Munich City Centre, Munich, Germany The decision for interventional treatment of a coronary lesion should be based on symptoms and prove of ischemia. However, in clinical practice, stenoses are often treated depending on the angiographic image, because symptoms are not clear and tests for ischemia have not been performed or the tests are inconclusive. By means of intracoronary pressure measurements (i.e. determination of fractional flow reserve – FFR, or instantaneous wave-free ratio - iFR) the hemodynamic relevance of a coronary stenoses can be determined during coronary angiography especially in intermediate lesions and thus the decision to treat or not to treat is based on an objective test of ischemia. Regarding coronary morphology, angiography is the standard for imaging of the coronary tree. However, this technique has limitations. Intravascular ultrasound (IVUS) allows a cross-sectional view of the coronary arteries. IVUS may help to diagnose and assess stent underexpansion and malapposition, and to guide interventions in complex cases. A new modality based on infrared light is the optical coherence tomography (OCT) with a resolution better than IVUS. It is now used for evaluation of new stent technologies i.e. bioabsorbable scaffolds. Modern antithrombotic treatment strategies in coronary heart disease and stroke prevention Prof. Dr. Florian Krötz, Clinic Starnberg, Department of Cardiology, 82319 Starnberg, Germany New oral anticoagulants and modern potent antiplatelet drugs offer a wide variety of therapeutic antithrombotic treatment strategies for acute coronary syndromes, coronary interventions and patients with atrial fibrillation. However, use of these drugs – especially when they are being combined - may not only bring about advantages but also impose increased bleeding risks, depending of patient comorbidities. In addition, depending on coronary intervention and clinical setting, the duration of antithrombotic treatment is a continuous topic of debate. Patricularly the need for a so called “triple therapy”, traditionally referred to as a combination of ASA, clopidogrel and warfarin, increases bleeding risk and may in many cases not be performed using the newer antiplatelet agents. Although data on triple therapy are scarce, in 2014, the European society of cardiology for the first time has published recommendations on which drugs may be combined in patients with recent stent implantation and atrial fibrillation. The presentation will discuss current European recommendations on use of antiplatelet and anticoagulant drugs with respect to indication, cardiovascular outcomes and bleeding risk and introduce the current evidence on these drugs. Electrical storm: treatment strategies Dr. Lutz Lichtenberg, Medical Clinic III, Department of Cardiology, St. Vinzenz-Hospital, Cologne, Germany Electrical storm is an increasingly common and life-threatening syndrome that is defined by 3 or more sustained episodes of ventricular tachycardia, ventricular fibrillation, or appropriate shocks from an implantable cardioverter-defibrillator within 24 hours. The clinical presentation can be dramatic. Electrical storm can manifest itself during acute myocardial infarction and in patients who have structural heart disease, an implantable cardioverter-defibrillator, or an inherited arrhythmic syndrome. The presence or absence of structural heart disease and the electrocardiographic morphology of the presenting arrhythmia can provide important diagnostic clues into the mechanism of electrical storm. Electrical storm typically has a poor outcome. The effective management of electrical storm requires an understanding of arrhythmia mechanisms, therapeutic options, device programming, and indications for radiofrequency catheter ablation. Initial management involves determining and correcting the underlying ischemia, electrolyte imbalances, or other causative factors. Amiodarone and β-blockers, especially propranolol, effectively resolve arrhythmias in most patients. Nonpharmacologic treatment, including radiofrequency ablation, can control electrical storm in drug-refractory patients. Patients who have implantable cardioverter-defibrillators can present with multiple shocks and may require drug therapy and device reprogramming. After the acute phase of electrical storm, the treatment focus should shift toward maximizing heart-failure therapy, performing revascularization, and preventing subsequent ventricular arrhythmias. Atrial fibrillation: differential use of ablation techniques Dr. Dinh Quang Nguyen, Medical Clinic III, Department of Cardiology, St. Vinzenz-Hospital, Cologne, Germany The impact of atrial fibrillation on the healthcare systems is overwhelming, due to its independent association with death, systemic thromboembolism, impaired quality of life and hospitalizations. Catheter ablation is the only treatment thus far demonstrated capable of achieving cure in a substantial proportion of patients. Pulmonary vein antrum isolation (PVAI) is the cornerstone of current atrial fibrillation ablation techniques, with the greatest efficacy as a stand-alone procedure in patients with paroxysmal atrial fibrillation. Use of general anesthesia, open-irrigated ablation catheters, “single shot devices” (Cryo balloon, Laser balloon, PVAC) and maintenance of periprocedural therapeutic warfarin has been demonstrated to increase the safety and effectiveness of PVAI. A more extensive ablation approach extending to the entire left atrial posterior wall and to complex fractionated electrograms (CFAEs) is warranted in nonparoxysmal atrial fibrillation patients, in whom nonpulmonary vein trigger sites are frequently identified. Up to one-third of these patients experiencing atrial fibrillation recurrence after ablation have evidence of triggers from extra pulmonary locations (SVC, CS, left atrial appendage). Isolation of this structure can improve the long-term success rate. In recent years, in addition to the development of ablation techniques to increase the success rate, outcomes of atrial fibrillation treatment trials have been reconsidered. This presentation will summarize the state-of-the art techniques for atrial fibrillation ablation, and will discuss the contribution of ongoing studies to the future of atrial fibrillation ablation. Non-invasive positive pressure ventilation for the treatment of chronic obstructive pulmonary disease (COPD) Prof. Dr. Si Huyen Nguyen, Vietnamese German Faculty of Medicine at Pham Ngoc Thach University of Medicine HCMC, HELIOS St. Marienberg Hospital Helmstedt, Academic Hospital of the Otto-von-Guericke University Magdeburg, Germany The non-invasive ventilation (NIV) has been established for about 20 years as a successful treatment method for acute respiratory insufficiency (ARI), as home ventilation it has been used in the last 10 years by hypercapnic COPD patients increasingly. NIV reduced hypercapnic ARF, the rate of tube-associated pneumonia, duration of hospital stay and in-hospital mortality. If possible, it should be applied preferably for ARI to avoid complications of mechanical ventilation. NIV has also proved to be a very useful therapeutic measure during cardiac pulmonary edema and for weaning from invasive long-term ventilation. A persistent hypercapnia for medically treated patients with COPD is a manifest sign of the failure of the respiratory pump and thus indicates a poor prognosis of the disease. It is also regarded as a criterion for initiating nocturnal home ventilation with a non-invasive, pressure-controlled ventilation (NPPV). This measure is primarily to improve the quality of life. In a recently published study by Köhnlein et al a relevant life extension by NPPV has now been documented in patients with a chronic failure of the respiratory pump in COPD for the first time. The pathophysiology of COPD, indications and contraindications for NIV in ARI and nocturnal home ventilation, techniques and practical application of non-invasive ventilation are presented. Intracoronary assessment – OCT or IVUS? Dr. Klaus Schlotterbeck, FESC, MBA, Cardiovascular Center Ravensburg, Germany The gold standard for diagnostic imaging of the coronary arteries is still the angiography. Many limitations of this technique are known, so advancements in technology has been developed. Intravascular ultrasound was the first intravascular imaging technique developed to overcome the limitations of angiography. The use of intravascular ultrasound (IVUS) has enabled a transmural in-vivo imaging of the coronary arteries while creating cross-sectional images of the vessel wall. The role of IVUS is to assess stent underexpansion and malapposition, to identify coronary plaques with potential rupture, to plan intervention in complex cases, identify significant left main stem stenosis. The spectral analysis, derived from radiofrequency (RF) data enables more precise analysis of the plaque composition and plaque type. In the PROSPECT study, tissue characterization of plaques had a predominant role and a positive association was found between specific tissue types and clinical events. A newer modality based on infrared light is the optical coherence tomography (OCT). With a resolution of 10-20 µm, which is better than IVUS, this method provides intraluminal and extraluminal imaging of the vessels. OCT gives in vivo imaging of coronary stents with the ODESSA and LEADERS trials pioneering OCT in multicenter, randomized clinical settings. Based on OCT it is able to distinguish between different tissue types, such as fibrous, lipid rich, necrotic or calcified tissue. OCT helps to assess patients with acute coronary syndrome with insights into plaque nature, rupture and progression. It also has been established as a gold standard for stent evaluation. However it is currently not capable of providing the operator with functional information to assess e.g. the haemodynamic relevance of stenosis. A number of research have successfully combined OCT with an ultrasonic transducer allowing the combination of high-resolution of OCT in the near field with the penetration depth if IVUS to visualise the complete plaque as well as to assess plaque burden. Conclusion: IVUS and OCT have an important but different role in intravascular imaging. Promising concepts for quantitative tissue characterization and combination of both techniques might further improve the diagnostic capabilities in the future. New Drugs in CVD Therapy - Update 2015 Dr. Alexander Trompler, Cardiovascular Center Ravensburg, Germany An update on 2014/2015 Evolution of CVD Drug Therapy will be given. Among others to be covered: Angiotensin receptor-neprilysin inhibitor Oral Anticoagulants including reversal agents Lipid Lowering Drugs including PCSK9 inhibitors Duration of dual antiplatelet therapy after MI Berlin Myocardial Infarction Registry (BMIR) - managing the Acute Coronary Syndrome (ACS) at the city of Berlin Prof. Dr. Hans-F. Voehringer, DRK Clinics Berlin, Germany The BMIR is an ongoing joint registry of hospitals within the metropolitan area of Berlin, prospectively collecting data on treatment and outcome of patients with myocardial infarction since 1999. Judging hospitals according to their quality of care is one approach to improve hospital performance. It is the aim of the presented data showing the feasibility of comparing the quality of care between departments of cardiology in different hospitals addressing the problems of random variation and differences in patients’ mix. The analysis is a cross-sectional interhospital comparison of more than 36 000 ACS patients (end of 2014) within different time intervals. The patients were admitted into 22 different hospitals of Berlin with PCI facilities in order of regular monitoring. Data were collected on demography, concomitant diseases, treatment strategies, and outcome measures. In the cross-sectional as well as in the longitudinal comparison there were large interhospital differences in crude hospital mortality rates. After Bayesian shrinkage and adjustment for the differences in patient mix, the range in hospital mortality was reduced in the cross-sectional as well as in the longitudinal comparison with no significant differences between hospitals. Adjusted mortality rates were 8.9 % in 2007/08, 8.7 % in 2009/10, and 8.5 % in 2011/12, respectively (p = 0.609). The analysis demonstrates that the naïve comparison of hospitals by crude means may be unfair and misleading. A statistical analysis that makes population differences and random effects into account may result in different conclusions and may show stable results for average-size German city hospitals, if data are pooled over 3 years. Aortic stenosis: Noninvasive assessment - interventional therapy PD Dr Werner Zwehl, 80638 München, Germany FACULTY: Dr. Christian Glatthor, Cardiovascular Center Ravensburg, Germany Prof. Dr. Volker Klauss, Cardiology Munich City Centre, Munich, Germany Prof. Dr. Florian Krötz, Clinic Starnberg, Department of Cardiology, 82319 Starnberg, Germany Dr. Lutz Lichtenberg, Medical Clinic III, Department of Cardiology, St. Vinzenz-Hospital, Köln, Germany Dr. Dinh Quang Nguyen, Medical Clinic III, Department of Cardiology, St. Vinzenz-Hospital, Köln, Germany Prof. Dr. Si Huyen Nguyen, Vietnamese German Faculty of Medicine at Pham Ngoc Thach University of Medicine HCMC, HELIOS St. Marienberg Hospital Helmstedt, Academic Hospital of the Otto-von-Guericke University Magdeburg, Germany Dr. Klaus Schlotterbeck, FESC, MBA, Cardiovascular Center Ravensburg, Germany Dr. Alexander Trompler, Cardiovascular Center Ravensburg, Germany Prof. Dr. Hans-F. Voehringer, DRK Clinics Berlin, Germany PD Dr. Werner Zwehl, 80638 München, Germany
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