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Clinical Cardiology and Cardiovascular Interventions

Journal Papers (100) Details Call for Paper Manuscript submission Publication Ethics Contact Authors' Guide Line
1 Case Report: Acetylcholine Spasm Provocation Test By Trans-Radial Artery And Vein Approach , Shozo Sueda 1*,  Hiroaki Kohno 1, Hirokazu Habara 1, and Kaori Fujimoto 1. 1 Department of Cardiology, Ehime Niihama Prefectural Hospital, Tsukazaki Hospital. *Corresponding author: Shozo Sueda, The Department of Cardiology, Ehime Niihama Prefectural Hospital, Niihama City, Japan. Email: EZF03146@nifty.com
70-year-old man admitted to our hospital because of chest discomfort on effort. Because we inserted the 6 Fr sheath into the wrong radial vein, we replaced the 5 Fr sheath into the radial vein. We inserted the 6 Fr sheath into the radial artery. We performed the acetylcholine and ergonovine spasm provocation tests under the temporary pace maker insertion. After the procedures, we compressed the radial artery and vein with radial band simultaneously. No bleeding or hematoma was found after the removal of radial band. We could perform the acetylcholine test via the radial artery and vein without any complications.
2 Chronic Heart Failure: An Epidemiological Study Of Impaired Oxidative Stress , Jenny Bjerre 1*, Simone Hofman 1 Rosenkranz 1, Anne Mielke Christensen 1 1 Department of Cardiology,University of Copenhagen,Denmark *Corresponding author; Jenny Bjerre, Department of Cardiology,University of Copenhagen,Denmark
Chronic heart failure (CHF) is the leading cause of hospitalization for those over the age of 65 and represents a significant clinical and economic burden. About half of hospital re-admissions are related to co-morbidities, polypharmacy and disabilities associated with CHF. Moreover, CHF also has an enormous cost in terms of poor prognosis with an average one year mortality of 33%–35%. While more than half of patients with CHF are over 75 years, most clinical trials have included younger patients with a mean age of 61 years. Inadequate data makes treatment decisions challenging for the providers. Older CHF patients are more often female, have less cardiovascular diseases and associated risk factors, but higher rates of non-cardiovascular conditions and diastolic dysfunction. The prevalence of CHF with reduced ejection fraction, ischemic heart disease, and its risk factors declines with age, whereas the prevalence of non-cardiac co-morbidities, such as chronic renal failure, dementia, anemia and malignancy increases with age. Diabetes and hypertension are among the strongest risk factors as predictors of CHF particularly among women with coronary heart disease. This review paper will focus on the specific consideration for CHF assessment in the older population. Management strategies will be reviewed, including non-pharmacologic, pharmacologic, quality care indicators, quality improvement in care transition and lastly, end-of-life issues. Palliative care should be an integral part of an interdisciplinary team approach for a comprehensive care plan over the whole disease trajectory. In addition, frailty contributes valuable prognostic insight incremental to existing risk models and assists clinicians in defining optimal care pathways for their patients.
3 A Short Review of Management of Cardiac Arrhythmia , Rahul Khanna 1*,  Iftekhar Kalsekar 1, and Abhishek Chitnis 1 1 Department of Geriatrics and Cardiology. * Corresponding author; Rahul Khanna, Department of Geriatrics and Cardiology.
During the past few years, the development of effective, empirical technologies for treatment of cardiac arrhythmias has exceeded the pace at which detailed knowledge of the underlying biology has accumulated. As a result, although some clinical arrhythmias can be cured with techniques such as catheter ablation, drug treatment and prediction of the risk of sudden death remain fairly primitive. The identification of key candidate genes for monogenic arrhythmia syndromes shows that to bring basic biology to the clinic is a powerful approach. Increasingly sophisticated experimental models and methods of measurement, including stem cell-based models of human cardiac arrhythmias, are being deployed to study how perturbations in several biologic pathways can result in an arrhythmia-prone heart. The biology of arrhythmia is largely quantifiable, which allows for systematic analysis that could transform treatment strategies that are often still empirical into management based on molecular evidence.
4 Systemic Hypertension: An Over View Of Various Cardiovascular Risk Factors And Multiple Treatments , Changfu Liu 1*,  Xiao Bi 1, and Ran Zhang 1 1Department of Cardiology and Clinical Practice *Corresponding author; Changfu Liu, Department of Cardiology and Clinical Practice,Chine
Systemic hypertension is a major risk factor for cardiovascular disease and is present in 69% of patients with a first myocardial infarction, in 77% of patients with a first stroke, in 74% of patients with chronic heart failure, and in 60% of patients with peripheral arterial disease. Double-blind, randomized, placebo-controlled trials have found that antihypertensive drug therapy reduces cardiovascular events in patients aged younger than 80 years and in patients aged 80 years and older in the Hypertension in the Very Elderly Trial. Although the optimal blood pressure treatment goal has not been determined, existing epidemiologic and clinical trial data suggest that a reasonable therapeutic blood pressure goal should be <140/90 mm Hg in patients younger than 80 years and a systolic blood pressure of 140-145 mm Hg if tolerated in patients aged 80 years and older. Non-pharmacologic lifestyle measures should be encouraged both to prevent development of hypertension and as adjunctive therapy in patients with hypertension. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta blockers, calcium channel blockers, and diuretics have all reduced cardiovascular events in randomized trials. The choice of specific drugs depends on efficacy, tolerability, presence of specific comorbidities, and cost.
5 Cardiovascular Pharmacology: An Epidemiological Study Rheumatic Heart Disease , José González-Costello 1*,Josep Comín-Colet 1 and Josep Lupón 1 1 Department of Cardiology,Hospital Universitari de Bellvitge,Barcelona, Spain. *Corresponding author; José González-Costello, Department of Cardiology,Hospital Universitari de Bellvitge,Barcelona, Spain.
Rheumatic fever (RF) and rheumatic heart disease (RHD) continue to be a major health hazard in most developing countries as well as sporadically in developed economies. Despite reservations about the utility, echocardiographic and Doppler (E&D) studies have identified a massive burden of RHD suggesting the inadequacy of the Jones’ criteria updated by the American Heart Association in 1992. Subclinical carditis has been recognized by E&D in patients with acute RF without clinical carditis as well as by follow up of RHD patients presenting as isolated chorea or those without clinical evidence of carditis. Over the years, the medical management of RF has not changed. Paediatric and juvenile mitral stenosis (MS), upto the age of 12 and 20 yr respectively, severe enough to require operative treatement was documented. These negate the belief that patients of RHD become symptomatic ≥20 years after RF as well as the fact that congestive cardiac failure in childhood indicates active carditis and RF. Non-surgical balloon mitral valvotomy for MS has been initiated. Mitral and/or aortic valve replacement during active RF in patients not responding to medical treatment has been found to be lifesaving as well as confirming that congestive heart failure in acute RF is due to an acute haemodynamic overload. Pathogenesis as well as susceptibility to RF continue to be elusive. Prevention of RF morbidity depends on secondary prophylaxis which cannot reduce the burden of diseases. Primary prophylaxis is not feasible in the absence of a suitable vaccine. Attempts to design an antistreptococcal vaccine utilizing the M-protein has not succeeded in the last 40 years. Besides pathogenesis many other questions remain unanswered.  
6 Systemic Hypertension: An Over View Of Various Cardiovascular Risk Factors And Multiple Treatments , Changfu Liu 1*,  Xiao Bi 1, and Ran Zhang 1 1Department of Cardiology and Clinical Practice *Corresponding author; Changfu Liu, Department of Cardiology and Clinical Practice,Chine
Systemic hypertension is a major risk factor for cardiovascular disease and is present in 69% of patients with a first myocardial infarction, in 77% of patients with a first stroke, in 74% of patients with chronic heart failure, and in 60% of patients with peripheral arterial disease. Double-blind, randomized, placebo-controlled trials have found that antihypertensive drug therapy reduces cardiovascular events in patients aged younger than 80 years and in patients aged 80 years and older in the Hypertension in the Very Elderly Trial. Although the optimal blood pressure treatment goal has not been determined, existing epidemiologic and clinical trial data suggest that a reasonable therapeutic blood pressure goal should be <140/90 mm Hg in patients younger than 80 years and a systolic blood pressure of 140-145 mm Hg if tolerated in patients aged 80 years and older. Non-pharmacologic lifestyle measures should be encouraged both to prevent development of hypertension and as adjunctive therapy in patients with hypertension. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta blockers, calcium channel blockers, and diuretics have all reduced cardiovascular events in randomized trials. The choice of specific drugs depends on efficacy, tolerability, presence of specific comorbidities, and cost.
7 Cardiovascular Pharmacology: An Epidemiological Study Rheumatic Heart Disease , José González-Costello 1*,Josep Comín-Colet 1 and Josep Lupón 1 1 Department of Cardiology,Hospital Universitari de Bellvitge,Barcelona, Spain. *Corresponding author; José González-Costello, Department of Cardiology,Hospital Universitari de Bellvitge,Barcelona, Spain.
Rheumatic fever (RF) and rheumatic heart disease (RHD) continue to be a major health hazard in most developing countries as well as sporadically in developed economies. Despite reservations about the utility, echocardiographic and Doppler (E&D) studies have identified a massive burden of RHD suggesting the inadequacy of the Jones’ criteria updated by the American Heart Association in 1992. Subclinical carditis has been recognized by E&D in patients with acute RF without clinical carditis as well as by follow up of RHD patients presenting as isolated chorea or those without clinical evidence of carditis. Over the years, the medical management of RF has not changed. Paediatric and juvenile mitral stenosis (MS), upto the age of 12 and 20 yr respectively, severe enough to require operative treatement was documented. These negate the belief that patients of RHD become symptomatic ≥20 years after RF as well as the fact that congestive cardiac failure in childhood indicates active carditis and RF. Non-surgical balloon mitral valvotomy for MS has been initiated. Mitral and/or aortic valve replacement during active RF in patients not responding to medical treatment has been found to be lifesaving as well as confirming that congestive heart failure in acute RF is due to an acute haemodynamic overload. Pathogenesis as well as susceptibility to RF continue to be elusive. Prevention of RF morbidity depends on secondary prophylaxis which cannot reduce the burden of diseases. Primary prophylaxis is not feasible in the absence of a suitable vaccine. Attempts to design an antistreptococcal vaccine utilizing the M-protein has not succeeded in the last 40 years. Besides pathogenesis many other questions remain unanswered.  
8 Case Report: Situs Inversus With Dextrocardia and Transposition Of Great Arteries From Diagnosis to Management   , Neeraj Awasthy 1*, Swati Kapoor 1, Rajeev Upreti 1 and Kulbhushan Dagar 1. 1 Internal Medicine Department, Max Super Specialty Hospital. Saket, India. *Corresponding author: Swati Kapoor, Internal Medicine Department,Max Super Speciality Hospital,   Saket, India.
Situs inversus totalis is a rare anomaly. A 40 day old girl presented to our emergency with this condition. She also had intact ventricular septum and D-transposition of the great arteries. Balloon atrial septostomy is usually a lifesaving procedure in such patients, till the corrective surgery is performed. In our case, this procedure was performed in the patient and we discuss the implication of her abnormal anatomy in the ease of management of this case. To our knowledge, this is the first case report of such a procedure in a patient with this unusual presentation.  
9 Big Data Clustering in Cardiology Based on Modeling of Electrical Dynamics of the Heart in the form of Fermi-Pasta-Ulam Auto-Recurrence as a New Tool for the Study of Cardiac Activit , Shmid AV 1, Novopashin MA 1*, Zimina E.Y 1, Berezin AA 1 1 EC-leasing.Tikhonov Moscow Institute of Electronics and Mathematics, Higher School of Economics, Russia. *Corresponding author:  Novopashin MA, EC-leasing.Tikhonov Moscow Institute of Electronics and Mathematics, Higher School of Economics, Russia.
  The mass application of mobile cardiographs already leads to both explosive quantitative growth of the number of patients available for ECG study, registered daily outside the hospital (Big DATA in cardiology), and to the emergence of new qualitative opportunities for the study of long-term oscillatory processes (weeks, months, years) of the dynamics of the individual state of the Cardiovascular system    of any patient The article demonstrates that new opportunities of long-term continuous monitoring of the Cardiovascular system  state of patients ' mass allow to reveal the regularities (DATA MINING) of Cardiovascular system    dynamics, leading to the hypothesis of the existence of an adequate Cardiovascular system model as a distributed nonlinear self-oscillating system of the FPU recurrence  model class [1]. The presence of a meaningful mathematical model of Cardiovascular system    within the framework of the  FPU auto–recurrence [2], as a refinement of the traditional model of studying black box, further allows us to offer new computational methods for ECG analysis and prediction of Cardiovascular system dynamics for a refined diagnosis and evaluation of the effectiveness of the treatment.  
10 Safety of Extracorporeal Shockwave Myocardial Revascularization (ESMR) in Patient with a Mechanical Prosthetic Valve.   , Gianluca Alunni 1*, Salvatore D'amico 1, Dario Celentani 1, Carlo Alberto Biolè 1, Alessandro Andreis 1, Mauro Rinaldi 1, and Marra Sebastiano 2. 1 Department of Cardiology, City of Health and Science of Turin, Turin, Italy. 2 Villa Maria Hospital, Turin, Italy. *Corresponding author: Gianluca Alunni, City of Health and Science, 10100 Turin, Italy.
The number of patients with refractory angina without revascularization options is increasing. The prognosis and the quality of life in these patients is poor and maximal medical therapy is not enough for symptoms relieve.   
11 Short Communication:The Effects Chronic Acetaminophen Treatment on Age-Associated Alterations of Cardiac Function in the Female F344xBN Heart   , Kevin M. Rice 1*,  Jacqueline Fannin 1 ,  Nandini D.P.K. Manne 5 , Lucy Dornon 8 , Ravi Kumar Arvapalli 1 , Satyanarayana Paturi 1 ,  Murali K. Gadde 1 ,  Paulette Wehner 8 , Michael Hambuchen 7  and  Eric R. Blough 2. 1 Center for Diagnostic Nanosystems, Marshall University, Huntington, WV, USA. 2 Department of Pharmaceutical Science and Research, School of Pharmacy, Marshall University, Huntington, WV, USA. 3 Department of Internal Medicine, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA. 4 Biotechnology Graduate Program West Virginia State University, Institute, WV. 5 Department of Public Heath, Marshall University, Huntington, WV, USA. 6 Department of Health and Human Service, School of Kinesiology, Marshall University, Huntington, WV. 7 Department of Pharmacology, Physiology and Toxicology, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA. 8 Department of Cardiology, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA. *Corresponding author: Kevin M. Rice, Center for Diagnostic Nanosystems, Marshall University, USA
Background:  Although several studies have investigated the age-associated changes in male and female F344 as well as male Fischer 344/NNiaHSD x Brown Norway/BiNia F1 (F344xBN), no study to our knowledge has examined the age-associated changes in structure and function in the female F344xBN heart using echocardiographic measures.  This information is crucial in determining whether or not the female F344xBN is an appropriate aging model.  Additional studies have also suggested that age-associated increases in levels of oxidative stress may cause cardiac dysfunction and that chronic acetaminophen (APAP) ingestion may be protective against increased oxidative stress. On the basis of these studies we examined the function and structure of the aged female F344xBN heart in the absence and presence of chronic APAP treatment.  Methods:  To investigate if the aging-related changes in cardiovascular structure and function can be attenuated with APAP treatment, aged (22-month old) female F344xBN rats were administered APAP (30 mg/kg body weight/day) for 8 months in drinking water and echocardiograms assessments were performed. Results:  Aging was associated with evidence of diastolic (impaired left ventricle relaxation time) and systolic dysfunction (fractional shortening and end systolic volume).  The incidence of arrhythmias was not different with age. However, valvular dysfunction was increased. Chronic APAP treatment did not attenuate the age-associated changes in cardiac structure and function in the female F344xBN. However the occurrence of valve dysfunction with aging was significantly lowered in the APAP treated 30-month female hearts.
12 Relationship between the single nucleotide polymorphism rs4704963 (T> C) of the Early B-Cell Factor 1 gene and smoking in a population with risk factors for coronary heart disease with and without acu   , Carbajales J 1*, Principato MB 1, Michael Fuad Salamé Rodriguez1, Duarte A 3, Tomatti AL1,  Paolucci AG 1, Gonzalez PE 1, Bragagnolo JC 2, TPC Ciampi N 1, von Wulffen MA 1, Castilla R 4, División Cardiología 1| 1División de Cardiología. Hospital General de Agudos J.M. Ramos Mejía. Ciudad Autónoma  de   Buenos Aires. 2Servicio de Diabetes y Nutrición. Hospital General de Agudos J.M. Ramos Mejía. Ciudad   Autónoma de Buenos Aires. 3Academia Nacional de Medicina . Argentina 4Instituto de Investigaciones Cardiológicas Prof. Dr. Alberto Taquini. Facultad de  Medicina. Universidad de Buenos Aires. Corresponding Author; Carbajales J, División de Cardiología. Hospital General de Agudos J.M. Ramos Mejía. Ciudad Autónoma de   Buenos Aires.  
Introduction: Early B-cell factor 1 (EBF1) gene participates in the development of the central nervous system and is expressed in adipocytes and olfactory neuroepithelium, which is intimately linked with the emotion and reward system in adults. For this reason, it could be linked to tobacco addiction Objective: The aim of this study was to determine probable association between the EBF1 gene rs4704963 SNP (T>C) with smoking habits in a population of patients with multiple coronary risk factors (CRF) with and without acute coronary syndromes (ACS). Materials and methods: Between December 2015 and March 2017, 104 consecutive patients with two or more risk factors, with or without ACS were included. A 10-mL blood sample was collected from all the patients for SNP determination. DNA genotyping was carried out using the nested PCR technique and subsequent sequencing. Results: Mean age was 59.1 ± 9.17 years and 59.6% were men. The most common CRF were smoking habits (60.6%) hypertension (56.7%) and diabetes (48.1%).None of the patients had the homozygous T / T haplotype while 17 patients (16.3%) presented the T / C haplotype for heterozygous SNP. Among the 17 patients with the SNP detected, 16 (94.1%) were smokers compared to 54% of smokers in those patients without the SNP detected (p = 0.002). In those patients with ACS and smoking habits, the SNP was detected in 21.3% versus 0% in those with ACS and no history of smoking habits (p= 0.029) Conclusion: A significant association was observed between the EBF1 gene rs4704963 SNP (T> C) with smoking habits in patients with ACS and in those with CRF without ACS. Further research including more patients is necessary to confirm these findings in order to customize decision-making to prevent this addiction and indicate the appropriate treatment when smoking is present.
13 Dyspnoea symptom intensity and impact on health-related quality of life in patients with cardiovascular or pulmonary diseases: a longitudinal observational study   , Nasser S. Ahmadi 1*, Ulf Lindblad 1 , and  Jörgen Månsson1 .  1 Department of Public Health and Community Medicine/Primary Health Care Sweden. *Corresponding author; Nasser S. Ahmadi, Department of Public Health and Community Medicine/Primary Health Care Sweden.
Introduction: Dyspnoea is a prevalent symptom associated with significantly reduced health-related quality of life (HRQoL). Accurate estimates of the severity and intensity of dyspnoea using standard tools in the clinic are important for the assessment of the severity of symptoms at later follow ups. Objectives: The current study had two aims. First, we sought to determine one-year changes in dyspnoea and health-related quality of life in patients with cardiac or respiratory diseases. Second, we sought to analyse the long-term associations between one-dimensional measurement methods and a generic instrument reflecting the multi-dimensionality of dyspnoea using the Short-Form Health Survey (SF-36). Methods: We prospectively recruited adult dyspnoeic patients in a rural primary health care centre. Participants were assessed for demographics, symptoms, medications, and N-terminal B-Type natriuretic pro-peptide (Nt-proBNP) level, and underwent spirometry and echocardiography. Results were analysed at baseline and one-year after enrolment. Based on the assessment results, we categorized the patients into one of three groups as the underlying disorder for dyspnoea: cardiovascular, pulmonary or psychiatric disease. Results: The ordinal scales [New York Heart Association (NYHA), modified Medical Research Council (mMRC) and Verbal Rating Scale (VRS)] indicated a slight but not significant decrease in dyspnoea severity, whereas the VAS showed a significant reduction in dyspnoea severity (p = 0.001) overall as well as in the cardiovascular group. By contrast, patients with pulmonary disease showed no improvement. HRQoL, as determined by the eight domains of SF-36, was unchanged, and dyspnoea severity had no impact on the worsening of health status. The correlation coefficient by test-re-test (reliability) of values at baseline and at the end of the study was highly significant. Conclusion: As appropriate measurements for the assessment of dyspnoea using one-dimensional scales, both mMRC and VAS should be considered for measuring changes in dyspnoea severity. VAS should be considered particularly for long-term changes in dyspnoeic patients with cardiovascular disorders. Changes in the different domains of the SF-36 were not seen after one year.
14 Echocardiography Parameters Predicting Postoperative Atrial Fibrillation: their Influence on Early left Atrial Remodelling and Right Ventricular Function after Heart Valve Surgery   , Yolanda Carrascal 1*, Ana Revilla A 2, Teresa Sevilla 2, Roman J Arnold 2, Luis de la Fuente 2, Gregorio Laguna 2, and Miriam Blanco.2  1 Cardiac Surgery Department Hospital Avda. Ramón y Cajal, spain.  2  Cardiac Surgery Department University Hospital Avda. Ramón y Cajal, spain. *Corresponding author;  Yolanda Carrascal, Cardiac Surgery Department University Hospital Avda. Ramón y Cajal, spain. 
Objective: To identify relationship between echocardiographic parameters variations and risk of postoperative atrial fibrillation (POAF) after cardiac valve surgery. Design: Prospective. Case-control study. Setting: A university hospital. Participants: We analysed the incidence of POAF in 90 patients undergoing elective heart valve surgery.  POAF was considered when episodes equal or longer than 5 minutes, and those under 5 minutes with hemodynamic disturbances. Interventions: None.Measurements and main results: POAF incidence was 36.7%. Preoperative echocardiographic study showed higher systolic pulmonary pressure (p: 0.047) and longer atrial electromechanical interval (AEI) (0.049) in POAF group. Postoperative echocardiographic evaluation revealed higher TAPSE decreasing related with preoperative values (8.18± 4.33 mm in No-POAF vs. 10.35 ± 3.83 mm in POAF group) (p: 0.026). In multivariate logistic regression POAF correlated with age> 65 years (p: 0.007) OR: 4.80; IC 95% (1.52-15.14), longer preoperative AEI (p: 0.042) OR: 1.029 IC 95% (1.001-1.059), higher TAPSE reduction (p: 0.040) OR: 1.15 IC 95% (1.006-1.316) and postoperative left atrial volume index> 36 ml / m2 (p = 0.0203) OR: 3.63; 95% CI (1.23-11.92).Conclusions: After heart valve surgery, POAF favoured right ventricular dysfunction (evidenced by higher postoperative TAPSE decreasing) and impaired early left atrial remodelling. In older patients and those with preoperative longer AEI, biatrial pacing and pharmacological prophylaxis might prevent these undesirable POAF effects.
15 Integrating A Clinical Decision Support Reminder To Improve Blood Pressure Reassessment For Patients With Uncontrolled Hypertension   , K. Souffront 1*, L. Rivera 1, G. Loo 1, N. Genes 1, P. L. Richardson 1   Levy  2 . 1Ichan School of Medicine at Mount Sinai/Mount Sinai Hospital, Department of Emergency Medicine, New York, NY 2Wayne State University, Department of Emergency Medicine, Detroit, MI
Background: Emergency department clinicians often overlook asymptomatic hypertension (HTN). Clinical decision support can help improve adherence to the emergency nursing and emergency medicine clinical policy for asymptomatic HTN. While the policy indicates referral for all adults with two or more elevated blood pressures, less than 10% of patients are referred.  We sought to determine the efficacy of an electronic health record clinical reminder on nursing (RN) reassessment of blood pressure (BP) for hypertensive patients. Methods: We conducted a 2-arm, pilot RCT, at an academic medical center in New York City. 107 RNs were randomized to the control group or to the intervention of a 'Best Practice Alert' (BPA) reminding him/her to recheck the BP in adult patients with an initial BP reading ≥140/90 mmHg. Descriptive statistics that included univariate and bivariate analyses were used to obtain adjusted measures of association between the intervention and control group. Results: RNs were more likely to repeat BP after receiving a BPA alert (56%) compared to RNs who did not receive an alert (44%) (OR=2.3, CI 2.1-2.5; p<.001). Patients who received BP reassessment were more likely to be triaged category 4 (OR 2.88, CI 1.81-4.59, p=.0001); age>75 years (OR 1.47; CI 1.07-2.03; p=.02); had Stage II HTN (OR 3.48; CI 2.63-4.59, p=.0001) and an ED length of stay of 3-4 hours (OR 5.85; CI 4.43-7.73; p=.0001). Conclusion: The BPA alert was effective in increasing BP reassessment by ED nurses.  The findings of this study will help us translate this evidence ED practices.
16 Estimating Cardiovascular Risk in the 21st Century: Role of Serological Markers and Imaging as new Tools for Risk Stratification , Sonia Kunstmann F 1*, Fernanda Gaínza K 2, and Thomas Akel O 2.  1 Department of Cardiology, Clínica Las Condes, Santiago, Chile.  2  School of Medicine Universidad del Desarrollo, Santiago, Chile.
Cardiovascular diseases continue to be the primary cause of death worldwide, thus making their high burden a call for adequate prevention strategies. Estimating individual risk of suffering cardiac or cerebral vascular events allows the implementation of disease-modifying measures.Risk stratification charts based on traditional risk factors (sex, age, smoking, hypercholesterolemia, diabetes mellitus and hypertension) are the most recommended methods, given their easy use, high applicability and predictive value. Nevertheless, intermediate risk patients undergoing further stratification may require additional tools, such as serological markers and imaging. This review focuses on the utility and applicability of various tools designed for cardiovascular risk assessment.  
17 Takotsubo Syndrome Versus Myocardial Infarction: what is the role of Echocardiography?   , Raquel Menezes Fernandes 1,2*, Hugo Costa 1,2, Teresa Mota 1,2, João Bispo 1,2, Pedro   Azevedo 1,2, Dina Bento 1,2, Nuno Marques 1,2 1Cardiology Department, Centro Hospitalar Universitário do Algarve - Faro, Portugal 2Algarve Biomedical Center, Faro, Portugal *Corresponding author: Raquel Menezes Fernandes, Cardiology Department, Centro Hospitalar Universitário do Algarve - Faro, Portugal.
Reversible left ventricle dysfunction is a key feature of Takotsubo syndrome (TTS), but in the acute phase it can mimic an acute coronary syndrome, making this differentiation a significant challenge. Echocardiography is widely used in the early evaluation of these patients, and advanced imaging tools have highlighted the differences between both syndromes. The symmetrical pattern of left ventricular dysfunction, extending beyond the territory of a single coronary artery, associated with a less severe diastolic dysfunction, right ventricle involvement and a typical complete recovery of wall-motion abnormalities points towards the diagnosis of TTS. Despite all the imaging advances made so far, evaluation of coronary anatomy remains mandatory in these patients.
18 Eosinophilic Myo-Pericarditis Presenting as Cardiac Tamponade   , Salman Farhat MD1*, Mathew T Olson MD2, Mohamad H Yamani MD1 1Department of Cardiovascular Medicine 2Department of Pathology Mayo Clinic, Jacksonville, FL *Corresponding author: Mohamad H Yamani, Department of Cardiovascular Medicine,USA.
Eosinophilic myocarditis is a rare and acute life threatening condition often associated with drug reactions, eosinophilic granulomatous polyangiitis (formerly Churg-Strauss syndrome), Loeffler endomyocardial disease, parasite infections, and idiopathic hypereosinophilic syndrome. We describe a case of eosinophilic granulomatous polyangiitis presenting as progressive pericardial effusion and cardiac tamponade.  
19 Cardiovascular Disorders in Autoimmune Disease   , Delcio G Silva Junior Universidade Federal de Mato Grosso do Sul, Mato Grosso do Sul, MS, Brazil Corresponding Author: Delcio G Silva Junior, Universidade Federal de Mato Grosso do Sul, Mato Grosso do Sul, MS – Brazil.
The presence of Cardio Vascular Disease (CVD) impacts negatively on expectation and quality of life of the population, being one of the main causes of disability. Many of those who become cardiovascular patients throughout their life could have had different evolution if preventive attitudes were taken. Since 50’s decade, Framingham studies have shown the importance of predetermining factors for CVD occurrence. The classical CVD risk factors such as diabetes, metabolic syndrome, dyslipidemia, hypertension, smoking and family history are well established as predictors of cardiovascular events. The presence of Cardio Vascular Disease (CVD) impacts negatively on expectation and quality of life of the population, being one of the main causes of disability. Many of those who become cardiovascular patients throughout their life could have had different evolution if preventive attitudes were taken. Since 50’s decade, Framingham studies have shown the importance of predetermining factors for CVD occurrence. The classical CVD risk factors such as diabetes, metabolic syndrome, dyslipidemia, hypertension, smoking and family history are well established as predictors of cardiovascular events. However, in certain clinical conditions, traditional risk factors seem not to fully explain the incidence of CVD. Coronary artery disease and early atherosclerosis in young women with Systemic Lupus Erythematosus (SLE) are one of the best examples of how chronic inflammatory diseases can affect individuals who are normally poorly exposed to traditional risk factors. Even with the plurality of extra-articular manifestations of rheumatologic diseases, such as pulmonary hypertension and SLE encephalopathy, uveitis in spondyloarthritis, or as Achalasia in scleroderma, attention is being paid to the frequent cardiovascular system involvement in these patients, especially in the vascular territory
20 Will Innovations in the 2019 ESC Guidelines for Chronic Coronary Syndromes Change the Approaches of Cardiologists?   , Cetin Sanlialp Sara Servergazi State Hospital, Cardiology, Bereketler No:1, 20000, Merkezefendi-Denizli Turkey Corresponding Author: Sara Cetin Sanlialp, MD, Servergazi State Hospital, Cardiology, Bereketler No:1, 20000, Merkezefendi-Denizli Turkey
Coronary heart diseases (CHD) and miyocardial enfarction are the most widespread  diseases  on the human  population .  
21 Will New Approaches in The Treatment of Supraventricular Tachycardia Affect The Cardiologists’ Perspective?   , Cetin Sanlialp Sara   Servergazi State Hospital, Cardiology, Bereketler No:1, 20000, Merkezefendi-Denizli Turkey   Corresponding Author: Sara Cetin Sanlialp, MD, Servergazi State Hospital, Cardiology, Bereketler No:1, 20000, Merkezefendi-Denizli Turkey.  
Junctional ectopic tachycardia(JET) is one of the rare supraventricular arrhythmias(1). JET is categorized by two types. The less common type of JET is congenital form and the more common type has been seen in postoperative period of congenital cardiac surgery  
22 Vasoreactivity Test to Evaluate the Pulmonary Vascular Resistance and Mean Pulmonary Arterial Pressure by Doppler Echocardiography   , Tania T. Muñoz H Department of Cardiology, Military Hospital “Dr. Carlos Arvelo” Caracas, Venezuela. Corresponding Author: Tania T. Muñoz H, Department of Cardiology, Military Hospital “Dr. Carlos Arvelo” Caracas, Venezuela
The pulmonary vascular reactivity test (PVRT) is essential to define patients with pulmonary hypertension(PH) responders to calcium antagonist treatment, this is possible evaluating the changes registered in the 3 hemodynamic variables: pulmonary vascular resistance (PVR), mean pulmonary arterial pressure(MPAP) and cardiac output(CO).Cardiac catheterization is unquestionably the gold standard for performing the test, but its application implies high costs, technical boarding limitations, risks and complications minor to serious inherent to the procedure. On the other hand, Doppler echocardiography is harmless and economical, offering in the last 15 years a considerable advance in techniques and practical methods for estimating these variables, being the most analyzed and documented to date, the PVR. In this study we will review the different echocardiographic equations proposed by different authors to calculate the PVR and MPAP, in all cases, comparing the results obtained with the measurements made by the right heart catheterization (RHC) .The results obtained in them will be briefly mentioned and will give an important reference to the reader of a study done in our research center, where we grant a new use to the non-invasive measurement of MPAP applied in the PVRT.
23 Vasoreactivity Test to Evaluate the Pulmonary Vascular Resistance and Mean Pulmonary Arterial Pressure by Doppler Echocardiography   , Tania T. Muñoz H Department of Cardiology, Military Hospital “Dr. Carlos Arvelo” Caracas, Venezuela. Corresponding Author: Tania T. Muñoz H, Department of Cardiology, Military Hospital “Dr. Carlos Arvelo” Caracas, Venezuela
The pulmonary vascular reactivity test (PVRT) is essential to define patients with pulmonary hypertension(PH) responders to calcium antagonist treatment, this is possible evaluating the changes registered in the 3 hemodynamic variables: pulmonary vascular resistance (PVR), mean pulmonary arterial pressure(MPAP) and cardiac output(CO).Cardiac catheterization is unquestionably the gold standard for performing the test, but its application implies high costs, technical boarding limitations, risks and complications minor to serious inherent to the procedure. On the other hand, Doppler echocardiography is harmless and economical, offering in the last 15 years a considerable advance in techniques and practical methods for estimating these variables, being the most analyzed and documented to date, the PVR. In this study we will review the different echocardiographic equations proposed by different authors to calculate the PVR and MPAP, in all cases, comparing the results obtained with the measurements made by the right heart catheterization (RHC) .The results obtained in them will be briefly mentioned and will give an important reference to the reader of a study done in our research center, where we grant a new use to the non-invasive measurement of MPAP applied in the PVRT.
24 Routine Measurements of Cardiac Parasympathetic and Sympathetic Nervous Systems assists in Primary and Secondary Risk Stratification and Management of Cardiovascular Clinic Patients   , Gary L. Murray1*, MD, FACC, FICA, Joseph Colombo2, PhD 1Director of Clinical Research The Heart and Vascular Institute, Germantown, TN-USA 2Parasympathetic & Sympathetic Nervous System Consultant, Richboro, PA; and CTO & Senior Medical Director, TMCAMS, Inc., Atlanta, GA-USA *Corresponding Author: Gary L. Murray, MD, The Heart and Vascular Institute, 7205 Wolf River Blvd, Germantown, TN, 38138, phone : 901-507-3100, fax :901-507-3101
Objective: To review our studies of the ease and importance of parasympathetic and sympathetic (P&S) measures in managing cardiovascular patients. Background: The autonomic nervous system is responsible for the development or progression of hypertension (HTN), orthostasis, coronary disease (CAD), heart failure (CHF), and arrhythmias.  Finally, new technology provides us with rapid, accurate P and S measures critically needed to manage these patients much more successfully. Methods: Using the ANX 3.0 autonomic monitor, P&S activity was recorded in 4 studies:  163 heart failure patients in total, mean follow-up (f/u) 12-24.5 months; 109 orthostasis patients, f/u 2.28 years (yr), and 483 patients with risk factors or known HTN, CAD, or CHF, f/u 4.92 yrs.  All were on guideline-driven therapy. Results: Fifty-nine percent (59%) of CHF patients had dangerously high sympathovagal balance(SB) or cardiac autonomic neuropathy (CAN), and Ranolazine markedly improved 90% of these, improved left ventricular ejection fraction in 70% of patients on average 11.3 units, and reduced MACE (acute coronary syndromes, death, acute CHF, ventricular tachycardia/fibrillation[VT/VF]) 40%.  Sixty-six-percent (66%) of orthostatic patients corrected with (r) alpha lipoic acid ([r]ALA); non-responders had the lowest S-tone.  In the 483 patient study, SB>2.5 best predicted MACE when compared to nuclear stress and echocardiography (sensitivity 0.59, OR 7.03 [CI 4.59-10.78], specificity 0.83, positive predictive value 0.64, and negative predictive value 0.80).
25 ST-Segment– Elevation Myocardial Infarction for Pharmacoinvasive Strategy or Primary Percutaneous Coronary Intervention in Gaza (STEPP- PCI)   , ST-Segment– Elevation Myocardial Infarction for Pharmacoinvasive Strategy or Primary Percutaneous Coronary Intervention in Gaza (STEPP- PCI)  
Background A primary percutaneous coronary intervention (PCI) Primary PCI continues to be the optimal reperfusion therapy in patients with ST elevation myocardial infarction however, in areas where PCI centers are not readily available, a pharmacoinvasive strategy has been proposed. This study investigated the safety and efficacy of a pharmacoinvasive strategy compared with primary (PCI) strategy for ST-segment elevation myocardial infarction (STEMI) in Gaza. Methods: We randomized 145 patients presenting within 2 hours of symptom onset of acute ST elevation myocardial infarction to primary CPI (PCI) or for pharmaco-invasive PCI 2-24 hours after streptokinase, except in the event of failed reperfusion, in which case, emergency angiography was recommended. The primary endpoint a composite of death, shock and congestive heart failure at 30 days. Results: Total 145 patients with mean age 56.5+10.48 years. (The mean age of patients is) The primary endpoint in primary PCI (17%) and in pharmaco-invasive PCI (16.1%) p = 0.24.???? There was no difference in 30-day mortality (4.7 % in primary PCI and 4.9% in pharmacoinvasive strategy (P=0.94). Secondary endpoints:Emergency angiography was required in 39.5% of the patients in the pharmaco-invasive strategy and the median time for underwent angiography was 6 hours after randomization. TIMI major bleeding occurred among 4 patients ( 4.9 % ) in the pharmacoinvasive group and in 2 patients (3.1%) of  the primary PCI group (P = 0.59).The pharmacoinvasive group had 1.9  times the odds of having TIMI major bleed compared with the primary PCI group Conclusions In this randomized trial, early-presenting STEMI patients unable to undergo primary PCI within 1 hour (median, 75±20 minutes) were randomized to primary PCI or a pharmaco-invasive strategy with streptokinase followed by PCI. At 1 month follow-up, there was no statistical difference in all-cause mortality, heart failure or shock. This study suggests that, if primary PCI cannot be performed within 1 hour of presentation, a pharmaco-invasive strategy may be as good as primary PCI.
26 Update on Pediatric non-Postoperative Junctional Ectopic Tachycardia. , Maldonado Sebastian1*, Albaca Guadalupe1, Lafuente María Victoria1,  Benjamin Monica1, Lopez Jinete Darues1, Guerchicoff Marianna2, Sciegata Alberto1 1Garrahan Children Hospital, Buenos Aires, Argentina 2Buenos Aires Italian Hospital, Argentina *Corresponding author: Sebastián Maldonado, Garrahan Children Hospital, Buenos Aires, Argentina.  
Junctional ectopic tachycardia (JET) is a rare supraventricular tachycardia more frequently seen in pediatric patients which is associated with high morbidity and mortality without an adequate treatment. Its treatment often requires multiple drugs for arrhythmia control and, in some cases, a cryoablation is indicated.  Some patients may revert to sinus rhythm spontaneously after long periods on antiarrhythmic drug. Currently, the arrhythmia prognosis has improved significantly since cryoablation development and the implementation of a more aggressive pharmacological treatment strategy. The purpose of this review is to describe the natural history of idiopathic JET and treatment advances. 
27 Correlation of Coronary Artery Calcium and Invasive Coronary Angiographically in Patients with Atypical Angina Pectoris (CACICA - Trial)   , Majed Elshenat, MD1, Mohammed Balosha2, Mohammed Habib, MD, PhD1* 1Alshifa Hospital, Cardiology Department, Gaza, Palestine 2Alshifa Hospital, Radiology Department, Gaza, Palestine *Corresponding author: Mohammed Habib, Cardiology Department, Alshifa Hospital, Gaza, and Palestine.
OBJECTIVES This study correlated the multi - detector computed tomography (MDCT) calcium scores with the results of coronary angiography in diabatic and/or hypertensive patients with atypical angina pectoris in order to assess its value to predict or exclude significant coronary artery disease (CAD). BACKGROUND Muti-detector computed tomography is a sensitive method to detect coronary calcium. However, it is unclear whether it may play a role as a filter before invasive procedures in patients with atypical angina pectoris. METHODS A total of 150 patients (116 men and 34 women) with  diabetic and/or hypertension for at least 5 years and atypical angina pectoris  from a single center were included in our study. patients underwent calcium screening with MDCT and have calcium score more than 100 , then  all patient underwent invasive coronary angiography. RESULTS  The Mean age was 62±5.7  and  77.3% were male,  78% of men and 88.2 % of women revealed significant coronary stenoses (> 50% lumen narrowing of left main trunk stenosis and > 70% stenosis of any epicardial coronary artery). Significant correlation between calcium scoring and significant coronary artery stenosis was seen (P: 0001). A 70% were DM, 90% were hypertensive and 61.3% were HTN and DM. The LAD artery was the most stenotic artery by 53.3% followed by RCA (37.3%) and finally LCX (30.7%). one significant coronary artery  was 42% followed by two significant CAD (26.7%), while 9.3% included three-vessel disease. The significant coronary artery diseases was increased with age ( P: 0003). CONCLUSIONS Coronary calcium proved to have good diagnostic performance for significant coronary artery stenosis in patient with atypical angina pectoris.
28 Drug Coated Balloon Angioplasty in Peripheral Vasculature: Review of Literature   , Valerie F. Civelli*, Vincent Ngo, Mukul Anand, Ojas Sharma, Sarabjeet Singh, Sanjiv Sharma, Central Cardiology Medical Center Bakersfield Heart Hospital Touro University California Bakersfield, CA. USA *Corresponding author: Valerie F. Civelli MD, Central Cardiology Medical Center Bakersfield Heart Hospital Touro University California Bakersfield, CA. USA.
Drug-coated balloons (DCB) are commonly used to treat peripheral artery disease (PAD) and are often used in combination with or in place of a stent or rotational atherectomy. DCB’s are manufactured with the drug, Paclitaxel with the first-line indication of preventing restenosis of arteries following an intervention. Recent literature has suggested an increased mortality risk at years 2 and 5 post DCB angioplasty.  Inspired by Katsanos et al. and their important work in researching outcomes for DCBs in PAD, we conducted a thorough review of all literature to compile an informed conclusion.
29 Diabetes, Prediabetes and Cardivascular Diseases in the Light of Updated Guideline (2019) : Mini Review   , Cetin Sanlialp Sara Department of Cardiology, Servergazi State Hospital, Denizli, Turkey Corresponding Author: Sara Cetin Sanlialp, Department of Cardiology, Servergazi State Hospital, Denizli, Turkey. 
Diabetes mellitus(DM) is a major risk factor for cardiovascular diseases. Lifestyle changes, control of risk factors, and appropriate glucose-lowering therapy may prevent disease progression and the development of undesirable cardiovascular events. Therefore, current strategies and effective current therapies are needed to diagnose, treat and prevent complications of this disease. In this review we planned to discuss the newly updated guidelines for diabetes and cardiovascular disease  in 2019.  
30 The Cardiovascular Effects of Energy Drinks   , Cetin Sanlialp Sara Department of Cardiology, Servergazi State Hospital, Denizli, Turkey Corresponding Author: Sara Cetin Sanlialp, Department of Cardiology, Servergazi State Hospital, Denizli, Turkey. 
Energy drinks are generally consumed by young people to increase athletic performance and concentration. Energy drinks contain high concentrations of caffeine, sugar, vitamin B complex, taurine, ginseng and guarana. There are not enough studies on these stimulants but past case-reports and small studies about energy drinks have been associated with cardiovascular complications. Especially with the use of alcohol or abuse drugs increase their undesirable effects and it may lead to cardiac morbidity and mortality. In this review, we aimed to focus on the effects and complications of energy drinks on the cardiovascular system.  
31 Will The Innovations in Diabetes and Dyslipidemia Affect Our Practice in 2020?   , Cetin Sanlialp Sara Department of Cardiology, Servergazi State Hospital, Denizli, Turkey Corresponding Author: Sara Cetin Sanlialp, Department of Cardiology, Servergazi State Hospital, Denizli, Turkey.
In 2019, new guidelines on arrhythmia, coronary syndrome, diabetes mellitus, hyperlipidemia and pulmonary embolism were published. Innovations and changes in these areas will already affect the practice of cardiologists in 2020. In this article we aimed to focus on these changes and innovations with main lines in diabetes mellitus and hiperlipidemia.
32 Cocaine Cardiomyopathy, Physicians should be aware and Focused on Management , Naresh Sen Director- Cardiology, BYN Hospital, India Corresponding author: Naresh Sen, Director- Cardiology, BYN Hospital, India.
More than 14 million people worldwide, mostly within the age range of 15 to 64 years, consume cocaine. Men of 15–35 years represent the majority  
33 Cost-Effectiveness Analysis of Dapagliflozin in the Treatment of Heart Failure with Reduced Ejection Fraction   , Mohammed Habib, MD, PhD Cardiology Department- Al Shifa Hospital- Gaza – Palestine Corresponding author: Mohammed Habib, Cardiology Department, Alshifa Hospital, Gaza, and Palestine.
Bakground: The Dapagliflozin was associated with a reduction in cardiovascular mortality, all-cause mortality, and hospitalizations compared with enalapril. Objective: To estimate the cost-effectiveness of Dapagliflozin in Gaza Design, Setting, and Participants: Quality of life was based on trial EQ-5D scores. Hospital costs combined Medicare and private insurance reimbursement rates; medication costs included the wholesale acquisition cost for sacubitril/valsartan and Dapagliflozin. were performed on key inputs including: hospital costs, mortality benefit, hazard ratio for hospitalization reduction, drug costs, and quality-of-life estimates. Main Outcomes and Measures: Hospitalizations, quality-adjusted life-years (QALYs), costs, and incremental costs per QALY gained. Results: In DAPA HF trial: in patient with DM, the strategy of using dapagliflozin has an of $ 17287 per QALY gained and in patient without DM, the strategy of using dapagliflozin has an of $ 45192 per QALY gained. Indirect comparison between patients with dapagliflozin  but without DM  the strategy of using sacubitril/ valsartan has an ICER of $ 66000  per QALY gained  and in patient with DM, ICER of  94 000 $ per QALY gained. Conclusions: For eligible patients with HF and reduced ejection fraction, Dapagliflozin was cost effective than the sacubitril/valsartan in Gaza.
34 Role of Intracellular Ca2+-overload in Cardiac Dysfunction in Heart Disease   , Mohamad Nusier1, A Tanju Ozcelikay2, Anureet K Shah3, Naranjan S Dhalla4* 1Jordan University of Science and Technology, School of Medicine, Irbid, Jordan, 2Ankara University, Faculty of Pharmacy, Ankara, Turkey, 3Department of Kinesiology and Nutritional Sciences, California State University, Los Angeles, USA, 4Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre & Department of Physiology and Pathophysiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada *Corresponding Author: Naranjan S. Dhalla, Institute of Cardiovascular Sciences St. Boniface Hospital Albrecheston Hospital Research Centre Winnipeg, Manitoba, Canada R2H 2A6
Various heart diseases such as genetically-determined heart failure, acute myocardial infarction, ischemia-reperfusion injury and catecholamine-induced cardiomyopathies are associated with cardiac dysfunction, cellular damage, subcellular derangements and metabolic alterations. Since increase in myocardial Ca2+ is accompanied by these abnormalities, it is generally held that intracellular Ca2+-overload plays an important role in the pathogenesis of cardiac dysfunction as well as cellular and metabolic defects in different cardiovascular diseases. This view is supported by observations in hearts subjected to Ca2+-paradox, where reperfusion of Ca2+-free perfused hearts with Ca2+-containing medium was found to produce a marked increase in myocardial Ca2+-content, cellular damage and cardiac contracture. The intracellular Ca2+-overload in the heart has also been shown to produce mitochondrial Ca2+-overload, depress ATP production, release different toxic substances and induce cardiomyocyte apoptosis. By virtue of its ability to depress cardiac gene expression and increase proteolysis of sarcolemma (SL) sarcoplasmic reticulum (SR) and myofibrils (MF), the intracellular Ca2+-overload has been reported to reduce SL, SR and MF protein content and activities. Such remodeling of subcellular organelles is associated with dramatic alterations in Ca2+ -handling by SL and SR membranes as well as interaction of Ca2+ with MF for the impairment of cardiac function. Thus, it is evident that mitochondrial Ca2+-overload, and subcellular remodeling for Ca2+-handling defects are responsible for the occurrence of cardiac dysfunction, metabolic derangements and cellular damage during the development of heart disease.
35 Natural Course of Isolated Pulmonary Valve Stenosis in Pediatric Patients   , Güven Serçin1*, Öztarhan Kazım2 1Department of Pediadric Nephrology, Marmara University,İstanbul , Turkey 2Istanbul Kanuni Sultan Süleyman Research and Teaching Hospital, Istanbul, Turkey  *Corresponding Author: Güven Serçin, Department of Pediadric Nephrology, Marmara University,İstanbul , Turkey.
Aim: The aim of our study is to be able to predict the prognosis of patients with isolated pulmonary valvular stenosis on the basis of age and degree of stenosis. Identification of the course of pulmonary stenosis of different age groups will significantly contribute both to the physicians and the relatives of the patient. Material and Methods: 105 pediatric patients diagnosed with isolated pulmonary valvular stenosis were included in our study. We investigated the impact of the gradient of stenosis and the age at the time of diagnosis on the natural course of pulmonary stenosis. Mean follow-up time of the children was 19 months, 25.45±22.48 months. The patients were divided into four groups over their trans-valvular gradient degrees and<20 mmHg was defined as transient, 20-39 mmHg mild, 40-59 mmHg moderate, 60 mmHg and over as severe pulmonary stenosis. Results: Between two to five months, none of the moderate stenosis cases progressed unlike other patient groups. The decline in the final gradient versus initial gradient was significant in children between two to five months and six months to two years in our study, and yet there was no significant change of initial and final gradients in patients under one month, and at two years and over. Conclusion: It would be reasonable to conclude that the progression of pulmonary valvular stenosis is benign in patients with pulmonary valvular stenosis under 40 mmHg of systolic gradient diagnosed after 6th month of life.
36 Frequency and Antibiotic Susceptibility of Acinetobacter Baumannii in Surgical site Infections at Rawalpindi Institute of Cardiology   , Arif Maqsood Ali1*, Agha Babar Hussain2, Azhar Mehmood Kayani3 1Department of Pathology and Blood Bank, Rawalpindi Institute of Cardiology, Pakistan 2Executive Director, Professor of Medicine/ Cardiology Rawalpindi Institute of Cardiology, Pakistan 3Rawalpindi Institute of Cardiology, Pakistan *Corresponding Author: Arif Maqsood Ali, Assistant Professor of Microbiology, Department of Pathology & Blood Bank Rawalpindi Institute of Cardiology Rawalpindi, Punjab, Pakistan.
Acinetobacter is an important nosocomial pathogen to cause infections such as pneumonia, bloodstream infections, meningitis, wound and surgical site infections including flesh eating bacterium necrotizing fasciitis and urinary tract Infections. A. baumannii can be spread through direct contact with surfaces, objects and the skin of contaminated persons. Acinetobactter has acquired resistance to most of the antibiotics and can play havoc in hospital environment due to its ability to survive desiccation and in moist environment in the presence of disinfectants. Currently, there are 32 genospecies of Acinetobacter known. Among these, A. baumannii is the most important in the clinical context, since it is the most frequently isolated in nosocomial infections and the one associated with the highest mortality rate. Objective To find out the frequency of A. baumannii causing surgical site infections after cardiac surgery and best antibiotic options for its treatment in patients admitted in Rawalpindi Institute of Cardiology. Materials and Methods A retrospective study was carried out to find out bacterial cultures in admitted patients at Rawalpindi Institute of Cardiology with surgical site infections from July 2017 to August 2018. A total of 405 pus specimens collected from patients with suspected surgical site infections were tested for bacterial culture and antimicrobial susceptibility test. Patient profile was noted from centralized hospital data. Results Out of total 405 specimens 13 were culture positive for A. baumannii (3.2%). Ten isolates were Pan Drug Resistant (PDR). Conclusion A. baumannii infection although infrequent in our set up is mostly pan resistant. Infection control practices & surveillance are important to avoid its spread in hospitalized patients.
37 Ranolazine Improves Autonomic Balance in Heart Failure when added to Guideline-Driven Therapy   , Gary L. Murray1*, Joseph Colombo2,3 1The Heart and Vascular Institute, Germantown – USA 2Autonomic Laboratory, Department of Cardiology, Drexel University College of Medicine, Philadelphia – USA 3ANSAR Medical Technologies, Inc., Philadelphia – USA
Background: The effect of ranolazine (RAN) on cardiac autonomic balance in congestive heart failure (CHF) was studied. Methods: Fifty-four CHF patients were randomized to (1) open-label RAN (RANCHF) added to usual therapy vs. (2) usual therapy (NORANCHF). Parasympathetic and sympathetic (P&S) measurements were taken at baseline and at 12 months. Results: A total of 16/27 (59%) patients in both groups had initially abnormal P&S measures, including high sympathovagal balance (SB), cardiovascular autonomic neuropathy (CAN) or both. High SB normalized in 10/12 (83%) RANCHF patients vs. 2/11 (18%) NORANCHF patients. SB became high in 5/11 (45%) NORANCHF vs. 1/11 (9%) RANCHF patients. CAN improved in 4/6 (67%) RANCHF patients vs. 5/7 (45%) NORANCHF patients. CAN developed in 1/11 (9%) RANCHF vs. 4/11 (36%) NORANCHF patients. Since improved P&S in RANCHF patients seemed independent of improved brain natriuretic peptide and impedance cardiography (BioZ) measurements, 5 day RAN was given to 30 subjects without CHF but with high SB or CAN. P&S improved in 90% of these subjects. Conclusions: RAN improves unfavorable P&S activity in CHF possibly by a direct effect upon autonomic sodium channels.
38 Circadian Blood Pressure Variability in Hypertensive Patients with Coronary Heart Disease.   , Jorge Luis León Alvarez1*, Michel Curbelo López2, Tania Hidalgo Costa3, Miguel Ángel Yanes Quesada1, Raúl Orlando Calderín Bouza1, Andrew Sefenu Yao Dzebu4 1Doctor of Medicine. Professor in Internal Medicine. Hermanos Ameijeiras Hospital. Havana. Cuba.   2 Doctor of Medicine. Specialist in Internal Medicine. Hermanos Ameijeiras Hospital. Havana. Cuba.  3Doctor of Medicine. Specialist in Biostatistics. Hermanos Ameijeiras Hospital. Havana. Cuba.  4Doctor of Medicine. Resident of Cardiology.  Hermanos Ameijeiras Hospital. Havana. Cuba.  *Corresponding author: Jorge Luis León Alvarez, Hospital Ameijeiras. Address: San Lázaro 701, between Marques González and Belascoaín. Centro Habana, Habana. Cuba. ZIP: 10300. Phone: + 53-78761000. Fax: + 53-78735036.
Introduction and objectives: Coronary heart disease is one of the complications of hypertension. Ambulatory blood pressure monitoring allows studying the different circadian patterns of blood pressure, but there is not enough evidence linking coronary heart disease with different circadian patterns. This research was carried out with the purpose of characterizing the circadian patterns of blood pressure in patients with essential hypertension and coronary heart disease. Methods: Descriptive and transversal research in 68 hypertensive patients with coronary heart disease who underwent ambulatory blood pressure monitoring. The different circadian patterns of blood pressure were related to the different forms of coronary heart disease and to the control of blood pressure.  Results: In the sample, women (60.3%) predominated over men (39.7%). The ages were between 45 to 59 (63.3%) and those 60 and over (36.7%). 44.1% did not have their blood pressure under control, 45.6% were overweight and 38.2% were obese. The abnormal patterns were dipper 42.6%, non-dipper 41.2%, extreme dipper 7.4% and riser 8.8%. Morning surge was observed in 29 patients (42.6%), statistically significant in relation to the control of blood pressure (p = 0.033), but not with the different types of coronary heart disease studied. Conclusions: A statistically significant relationship was found between morning surge and control of blood pressure.
39 Ranolazine Preserves and Improves Left Ventricular Ejection Fraction and Autonomic Measures when wdded to Guideline-Driven Therapy in Chronic Heart Failure   , Gary L. Murray1*, Joseph Colombo2 1The Heart and Vascular Institute, Germantown, TN – USA 2Department of Cardiology, Drexel University College of Medicine, and ANSAR Medical Technologies, Inc., Philadelphia, PA - USA *Corresponding Author: Gary L. Murray, The Heart and Vascular Institute, Germantown  TN- USA.
Background: Ranolazine (RAN) reduces cardiac sodium channel 1.5’s late sodium current in congestive heart failure (CHF), reducing myocardial calcium overload, potentially improving left ventricular (LV) function. RAN blocks neuro- nal sodium channel 1.7, potentially altering parasympathetic and sympathetic (P&S) activity. The effects of RAN on LV ejection fraction (LVEF) and P&S function in CHF were studied. Methods: Matched CHF patients were given open-label RAN (1000 mg po-bid) added to guideline-driven therapy (RANCHF, 41 systolic, 13 diastolic) or no adjuvant therapy (control, NORANCHF, 43 systolic, 12 diastolic). Echocar- diographic LVEF and P&S measures were obtained at baseline and follow-up (mean 23.7 months). Results: LVEF increased in 70% of RANCHF patients, an average of 11.3 units. Mean LVEF remained unchanged in NORANCHF patients. P&S measures indicated cardiovascular autonomic neuropathy (P≤0.1 bpm2) in 20% of NORANCHF patients at baseline and in 29% at follow-up (increasing in both groups). At baseline, 28% of patients had high sympathovagal balance (SB), RAN normalized SB over 50% of these; in contrast, the NORANCHF group had a 20% increase in patients with high SB. Conclusions: RAN preserves or improves LVEF and decreases high SB in CHF.
40 Impact of Thrombus Aspiration one-year Cardiac Mortality During Primary PCI in STEMI Patients with total Occlusion; from Korea Acute Myocardial Infarction Registry National Institute of Health   , Kye Taek Ahn, MD, PhD1*, Seok-Woo Seong, MD1*, Mijoo Kim, MD1*, Jin-Ok Jeong, MD, PhD1, Seon-Ah Jin, MD, PhD1, Jun Hyung Kim, MD, PhD1, Jae-Hwan Lee, MD, PhD1, Si Wan Choi, MD, PhD1, Myung Ho Jeong, MD, PhD2, Shung Chull Chae, MD, PhD3, Young Jo Kim, MD, PhD4, Chong Jin Kim, MD, PhD5, Hyo-Soo Kim, MD, PhD6, Myeong Chan Cho, MD, PhD7, Hyeon Cheol Gwon, MD, PhD8, In-Whan Seong MD, PhD1 On behalf of the Korea Acute Myocardial Infarction Registry - National Institute of Health (KAMIR-NIH) Investigators 1Division of Cardiology, Department of Internal Medicine, Chungnam National University  Hospital, Chungnam National University, School of Medicine, Daejeon, Korea 2Chonnam National University Hospital, Chonnam National University, School of Medicine, Gwangju, Republic of Korea 3Kyungpook National University Hospital, Kyungpook National University, School of Medicine, Daegu, Republic of Korea 4Yeungnam University Hospital, Daegu, Republic of Korea 5Kyunghee University College of Medicine, Seoul, Republic of Korea 6Seoul National University Hospital, Seoul National University, School of Medicine, Seoul, Republic of Korea 7Chungbuk National University Hospital, Chungbuk National University, School of Medicine, Cheongju, Republic of Korea 8Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Republic of Korea *Corresponding Author: N, Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University, School of Medicine, Daejeon, Korea
Background: The clinical impact of intracoronary thrombus aspiration (TA) during primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) is unclear. We investigated to evaluate whether TA during primary PCI reduces one-year mortality. Methods: From the Korea Acute Myocardial Infarction Registry-National Institute of Health, 3749 patients with STEMI who were undergoing primary PCI within 12 hours (60.8±12.9 years, 18.7% women) and shown pre-procedural Thrombolysis In Myocardial Infarction (TIMI) flow 0, 1 in coronary angiography were enrolled between November 2011 and November 2015 during one-year follow up. The patients were divided into two groups according to TA during primary PCI: PCI with TA (n=1630) and PCI alone (n=2119). The primary end-point was major adverse cardiac events (MACE), defined as the composite of cardiovascular death (CVD), stroke or recurrent MI at one-year. The secondary efficacy end-point were all-cause of mortality and CVD at one-year. Results: PCI with TA did not reduce the risk of MACE (OR: 0.598, 95% CI: 0.737-1.160, p=0.499), all-cause mortality (OR: 0.898, 95% CI: 0.705-1.144, p=0.383) and CVD (OR: 0.893, 95% CI: 0.683-1.168, p=0.408) in all patients during one-year follow up. The trend did not change after propensity score matching. In subgroup analysis, there was no efficacy of clinical outcome during one-year follow up. Conclusions: Primary PCI with TA did not reduce MACE and all-cause mortality among patients with STEMI and pre-procedural TIMI flow 0,1 during one-year follow up.
41 Role of Inflammation on the Control of the Arterial Hypertension among Patients with Metabolic Syndrome.   , Ylber Jani MD,PhD 1, Atila Rexhepi  MD,PhD 2 , Bekim  Pocesta  MD 3, Ahmet  Kamberi  MD,PhD 4, Fatmir  Ferati MD,PhD5 , Sotiraq Xhunga MD,PhD 6 , Artur Serani  MD7 , Dali Lala MD8, Agim  Zeqiri MD9, Arben Mirto MD10. Lutfi Zylbeari11. 1Faculty of Medicine, Tetovo Republic of North Macedonia. 2Department of Internal Medicine Faculty of Medicine, Tetovo Republic of North Macedonia. 3Department of Cardiology Faculty of Medicine"Ss Kiril and Metodij" University Skopje Republic of North     Macedonia. 4Department of Cardiology Faculty of Medicine M. Teresa Tirana Republic of Albania. 5Department of Internal Medicine Faculty of Medicine, Tetovo Republic of North Macedonia. 6,7Department of Cardiology Medical Center Dures Republic of Albania. 8Private Health Institute of family medicine "Florenc "Tetovo Republic of North Macedonija. 9Department of Internal Medicine-General Hospital"DR Ferit Murat" Gostivar Republic of North Macedonia.  10Private Health Institute”Rostusha”Debar Republic of North Macedonia. 11Faculty of Medicine, Tetovo Republic of North Macedonia. *Corresponding Author: Ylber Jani, Faculty of Medicine,Tetovo Republic of North Macedonia.
BACKGROUND: It is widely accepted that hypertension is a pro-inflammatory disease and that the immune system plays a vital role in mediating hypertensive outcomes, end organ damages . and modulation of hypertensive pathology [2]. Patient with MetS usually present increased levels of C-reaktive protein (CRP) wich is a prototypic marker of inflammation [5], however the data of the influence of incresed levels of CRP on the control of the   aterial hypertension in patients with MetS, are scarce. OBJECTIVE: We sought to determine the incresed CRP levels influence on the control of the aterial hypertension in patients with MetS. METHODS: We conducted a multicenter observational cross-sectional study. The study population recruited from a coule of outpatient clinic between june 2018 and june 2019. The population study consisted of 420 patients with MetS aged ≥ 18 years, divided  in two groups:211 with level of CRP>3mg/l , and  209 participans with CRP level <3mg/l. RESULTS: Among those with  CRP level  > 3mg/l(N=211) controlled BP according to evidence and current guidelines, was  achieved  in 23.6%  of participans, whereas among those with  CRP level <3mg/l(N=209) controlled BP was achived in 48.3%; p=0.000). There was independent association of CRP levels >3mg/l with uncontrolled BP (OR=3.1, 95%CI 2.06 - 4.75). There were signifiacant association of uncontrolled BP with: uncontrolled glycemia (OR =1.4,95%CI 0.97-1.84); increased BMI (OR=4.4; 95%CI 3.02-4.05) and five  risk factors  for MetS.(OR=2.3, 95%CI 1.93 2.81).                                                                                                                                            CONCLUSIONS: We think,we brought some good evidence,in our present study ,that patients with MetS and higher  CRP level have a  higher prevalence of unconrolled BP.
42 Omega-3 Consumption Assessment in Vegetarian Diets.   , Carolina V. M. B. Pimentel1*, Viviane L. Simomura2 , Leticia Kitzinger3 1Faculty of Public Health of the University of São Paulo, São Paulo, SP - Brazil; Paulista    University, São Paulo,  SP – Brazil. 2Universidade Comunitária da Região de Chapecó – UNOCHAPECO, Chapecó, SC – Brazil. 3Universidade Paulista, São Paulo, SP – Brazil. *Corresponding author: Carolina Vieira de Mello Barros Pimentel, Faculty of Public Health of the University of São Paulo, São Paulo, SP - Brazil; Paulista University, São Paulo, SP – Brazil.
Understanding feeding consumption and nutrient ingestion in vegetarian diet is essential to foster nutritional adequacy. The goal was assessing Omega-3 consumption in such diets. It is a transversal study, performed with 09 vegetarian adults. The ingestion was achieved by means of 24-Hour Reminder and the nutrients were defined by nutritional software. The results disclosed that the diet is rich in ALA (alpha-linolenic acid), however the functions are performed by EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid). ALA is capable of converting inefficiently in the other ones. In the present study, ALA consumption is above DRI’s (2.55g± 2.14), but when it is converted to EPA (326mg) and DHA (65.5mg) is below EFSA guidance and North American cardiovascular disease prevention and treatment guidelines. It was possible to conclude that this nutrient is essential to health, and in vegetarian diet, it is not achieved, a special care is required in diet planning.
43 Redo Resection of Residual Right Ventricular Outflow Tract Obstruction in a Postoperative Case of Tetralogy of Fallot under Moderately Hypothermic Extracorporeal Circulation and Cardioplegic Arrest: A   , Ujjwal K. Chowdhury*, Diplomate NB, Sukhjeet Singh, Niwin George, Lakshmi Kumari Sankhyan, Sushama Gayatri B, Parag Gharde, Prateek Vaswani, Priyanka Chowdhury, Cardiothoracic Sciences Centre All India Institute of Medical Sciences, New Delhi ​​​​​​​*Corresponding Author: Ujjwal Kumar Chowdhury, Professor Department of Cardiothoracic and Vascular Surgery All India Institute of Medical Sciences New Delhi-110029, INDIA.
Following the introduction of intracardiac repair of tetralogy of Fallot, early mortality in 1950s was as high as 25%. However, by the mid-1980s, this has reduced to 2% and currently ~ 0% even in neonates and young infants [1-11] despite the risk of reoperations, a large number of studies have documented satisfactory long-term survival rates in repaired tetralogy of Fallot, with a 30-year survival rate ranging from 86% to 91.7%. [8-22]  
44 Re-Print- (r) Alpha Lipoic Acid Is a Safe, Effective Pharmacologic Therapy of Chronic Orthostatic Hypotension Associated with Low Sympathetic Tone   , Gary L. Murray1*, Joseph Colombo2,3 1Cardiovascular Research, Heart-Vascular Institute, Germantown, Tennessee 2Autonomic Laboratory, Drexel University College of Medicine; Parasympathetic & Sympathetic Nervous System Consultant, Franklin Cardiovascular Associates, Pennsylvania 3ANSAR Medical Technologies, Inc., Philadelphia, Pennsylvania *Corresponding Author: Gary L. Murray, The Heart and Vascular Institute, Germantown  TN- USA
Chronic orthostatic hypotension (OH), affecting 10 to 30% of the elderly, is associated with falls, and increased morbidity and mortality. Current pharmacologic therapy can cause or worsen hypertension and fluid retention. (r) α lipoic acid (ALA), a powerful natural antioxidant, avoids those complications and may assist management ofchronic neurogenic orthostatic hypotension (NOH). The purpose of this study is to demonstrate improvement in the symptoms of orthostatic dysfunction with r-ALA, including improved sympathetic (S) and blood pressure (BP) responses to head-up postural change (standing).   A cohort of 109 patients with low S tone upon standing was detected using the ANX —3.0, Autonomic Monitor, ANSAR Medical Technologies, Inc., Philadelphia, PA. From the cohort, 29patients demonstrated NOH (change in (Δ) standing BP ≤ —20/–10 mm Hg) and 60 patients demonstrated orthostatic intolerance (OI, Δ standing systolic BP between –6 and –19 mm Hg). These 89 were given ALA orally: either 590 to 788 mg (r) ALA or 867 to 1,500 mg of the less expensive 50 to 50% mixture (r) ALA and inactive (s) ALA. Changes in their S- and P tone, and BPs, were compared with 20 control patients during mean follow-up of 2.28 years.   Nineteen of 29 (66%) NOH patients responded with a Δ standing BP from –28/–6 mm Hg to 0/þ2 mm Hg. Forty of 60 (67%) of patients with OI responded with a Δ standing  BP of –9/þ1 mm Hg to þ6/þ2 mm Hg. Although all patients treated with ALA increased S tone, the Δ BP depended upon the pretreatment of S tone.  Those with the lowest S tone responded the least well. The only treatment side effects were nausea, intolerable in only 5%. Nausea improved with routine gastrointestinal medica- tions. Glucose levels improved in the 28% of patients who were diabetic. Also, resting hypertension improved. Control patients had no Δ BP and no increase in S tone. (r)ALA improves S-, and BP, responses to head-up postural change, and thereby NOH/OI, in a majority of patients without causing harmful side effects.
45 I’m Glad we can add: Finally Accurate Measurement of Both Components of Heart Rate Variability Can be Applied Routinely Clinically   , Gary L. Murray Clinical Research The Heart and Vascular Institute Germantown, TN, USA Corresponding Author: Gary L. Murray, The Heart and Vascular Institute, Germantown - USA
One century ago, the critical role of the Autonomic Nervous System (ANS) in health and disease was prophesized. In 1990, Heart Rate Variability (HRV =Sympathetic-tone [S] + Parasympathetic-tone [P]) was 1st used in clinical cardiology.  Emphasizing the reduction in HRV was associated with a poor prognosis in all major cardiovascular illness. In 2000, HRV was included in Sudden Cardiac Death (SCD) risk stratification.
46 The Feasibility of Blood Pressure Control with Autonomic- Assisted Hypertension Therapy versus JNC 8 Therapy   , Gary L. Murray1*, Joseph Colombo2 1Director of Medical Research, the Heart and Vascular Institute, Germantown, USA 2CTO and Senior Medical Director, TMCAMS Inc., Atlanta, USA *Corresponding Author: Gary L Murray, The Heart and Vascular Institute, 7205 Wolf River Blvd, Germantown, TN, 38138, USA, Tel:+1 901-507-3100, Fax: +1 901-507-3101
Background: Over one billion people have Hypertension (HTN); mortality and morbidity are increasing. The Parasympathetic and Sympathetic (P&S) nervous systems prominently affect the onset and progression of HTN, yet P&S measures are not used to assist in management. Our objective was to determine the feasibility of HTN control using P&S-guided to JNC 8 HTN therapy. Methods: 46 uncontrolled HTN patients were randomized prospectively to P&S-assisted management, adjusting JNC 8 therapy using the ANX 3.0 Autonomic Monitor and adding (r) Alpha Lipoic Acid (Group 1) vs. JNC 8 (Group 2). Results: The two Groups were similar in: 1) age (mean 66 vs. 70 y/o for Groups 1 and 2, respectively; 2) initial resting home Blood Pressure (BP, Group 1 mean=162/90 mmHg vs. Group 2 mean=166/87 mmHg, 3) initial resting office BP Group 1 mean=151/75 mmHg vs. Group 2 mean=155/73 mmHg, and 4) ethnicity. Upon follow-up (mean=8.35 mo.): 1) mean resting home BPs were 145/77 mmHg (Group 1, 74% of patients at JNC 8 goal) vs. 155/83.5 mmHg (Group 2, 30.4% at JNC 8 goal), and 2) mean resting office BPs were 138/71 mmHg (Group 1) vs. 146/65 mmHg (Group 2). At the study’s conclusion, Group 1 Sympathetic tone was lower than that for Group 2 both at rest and upon standing, and Group 1 Parasympathetic tone was higher than that for Group 2 both at rest and upon standing. Conclusion: P&S-assisted HTN therapy is feasible, resulting in improved BP control, through healthier P&S tone on fewer prescription medications.
47 Posteroseptal Accessory Pathways Ablation: do not forget the Coronary Sinus Diverticulum   , Martín De La Ossa,1 Jhan Carlos Altamar2 1Electrophysiology department, Iberoamerica Clinic, Barranquilla, Colombia. 2 Electrophysiology department, Iberoamerica Clinic, Barranquilla, Colombia. *Corresponding Author: Jhan Carlos Altamar, MD, Carrera 42h #84-33, Barranquilla, Colombia, +573012420368
The posteroseptal accessory pathways often are associated with coronary sinus abnormalities. We report the case of a 15-year-old female, who had palpitations due to Wolff Parkinson White Syndrome and high risk posteroseptal accessory pathway associated with coronary sinus diverticulum. The accessory pathway was successfully ablated using radiofrequency catheter ablation into the diverticulum. These accessory pathways have a very short refractory period and are associated with a risk of sudden cardiac death during atrial fibrillation. Performing a coronary sinus venography and demonstrate diverticulum before ablation, substantially reduces failed ablation.  
48 Artery Biomineralization and its Dissolution   , Maciej Pawlikowski AGH - Univ. of Science and Technology, Dept. Mineralogy, Petrography and Geochemistry, al. Mickiewicza 30, 30-059 Cracow, Poland. Corresponding Author: Maciej Pawlikowski, AGH - Univ. of Science and Technology, Dept. Mineralogy, Petrography and Geochemistry, al. Mickiewicza 30, 30-059 Cracow, Poland.
This publication presents the results of studies on biomineralization of “atherosclerotic plaque” forming in the coronary arteries of the heart. Obtained results were compared to studies of an artery unaffected by the process of atherosclerosis. Different types of artery biomineralization were marked, in terms of both mineral and chemical composition. Theories on the formation of crystallization centers where “atherosclerotic plaque” develops were also presented.  Results of preliminary in vitro studies on dissolving cholesterol and phosphate mineralization in arteries were presented. The results were interpreted, and conclusions were offered.
49 Cystatin C in Patients with Coronary Artery Disease   , Mohamed Wasfy Mohamed1*. Said Shalaby Montaser2, Waleed Abdou Ibrahim2, 1Cardiology department, Shebin El-kom teaching hospital, Menoufia, Egypt 2Cardiology department, faculty of medicine, Menoufia University, Menoufia, Egypt *Corresponding Author: Mohamed Wasfy Mohamed, Cardiology department, Shebin El-kom teaching hospital, Menoufia, Egypt.
Background:    Cystatin C, a marker for early stage chronic kidney dysfunction, mediates the pathogenesis of cardiovascular diseases.   Objectives:   To assess the relation between level of serum Cystatin C and severity of coronary artery disease (CAD) in patients without chronic kidney disease (CKD).   Patients and Methods:   In this cross-sectional study, we included 80 patients with CAD divided in two groups (group I with acute coronary artery disease and group II with chronic stable coronary artery disease) 40 patients each and acquired their demographic characteristics, medical histories, and listings of the concurrent medications they were taking. All patients with CAD underwent ECG, echocardiography, coronary angiography, serum Cystatin C level, cardiac enzymes and other routine laboratory tests.   Results:   As regard demographic data and comorbidities there was no significant difference between the two groups as regard gender, diabetes mellitus, hypertension or smoking.   Also, As regard level of serum Cystatin C, the mean and SD in 1 vessel affection was 0.92±0.07 while in 2 vessels affection was 1.07±0.13 and 3 vessels affection was 1.41±0.05 with (P< 0.01).   Finally, there was a highly significant difference as regard Cystatin C level with mean and SD 1.21±0.18 in ST-segment elevation MI while mean and SD was 0.96±0.09 in Non ST-segment MI or unstable angina with (P< 0.01). There was a statistically significant correlation between level of Cystatin C and severity of CAD (p < 0.05).   Conclusion:   Serum cystatin C has a significant effect on the severity of coronary artery disease (CAD), being higher in patients with 3 vessels disease and severe CAD.    
50 The Lebanese Geitawi Hospital-University Medical Center Heart Failure Registry   , Youssef Boutros¹, Abi Rached Nagi2, Bassil George3, Ward Ricardo3, Faddoul Joelle4 , El Murr Tony5* ¹MD, Department of cardiovascular diseases, Faculty of Medical Sciences-LU, Beirut, Lebanon. 2MD, Department of cardiovascular diseases and Medical Director of LGH-UMC affiliated with the Faculty of Medical Sciences –LU, Ashrafieh, lebanon. 3Medical students, Faculty of Medical Sciences-LU, Beirut, Lebanon. 4MD, Department of Internal Medicine diseases, Faculty of Medical Sciences-LU, Beirut, Lebanon. 5MD, Department of Infectious Diseases, Head of Internal Medicine Department of MEIH affiliated with the Faculty of Medical Sciences-LU, Bsalim, Lebanon *Corresponding Author: El Murr Tony, MD, Department of Infectious Diseases, Head of Internal Medicine Department of MEIH affiliated with the Faculty of Medical Sciences-LU, Bsalim, Lebanon.
Heart Failure (HF) has become a major cause of death and hospitalization among people older than 60 year. Lack of available data and registries from different countries that may aid in understanding the burden of the disease does exist. The aim of the lebanese Geitawi Hospital-University Medical Center (LGH-UMC) heart failure registry is to point toward the incidence of heart failure, in patients with suspected dyspnea, during a 7 months period in a single university medical center based on Trans-thoracic echocardiography (TTE) findings with emphasis on its etiology. Study population The LGH-HFR includes inpatients and outpatients (≥18 years) presenting for further evaluation of possible HF by performing a TTE after suspicious clinical findings. Patients with clinical impression of possible heart failure were reported to LGH-HFR by their doctors. The final decision to register a patient in the LGH-HFR is made by a single cardiologist to ensure the validity of the clinical suspicion. Approximately 1422 patients with clinically suspicion HF were registered in the LGH-HFR between 1.1.2018 and 31.7.2018. Main variables and descriptive data Our study will be a retrospective cohort analysis of data collected from the LGH-HFR between 1.1.2018 and 31.7.2018. Our number of studied patients is about 1422. The main variables recorded in the LGH-HFR are related to the TTE findings: LVEDV, LVEF, presence of LVH, the presence of diastolic dysfunction, documentation of any valvulopathies, measurements of PAPs. Furthermore, pro-BNP level and basic patient characteristics (age and sex) will be recorded. The findings then will be pooled according to the documentation of heart failure, either systolic or diastolic. Furthermore, specific TTE findings will be mentioned in each case after correlation with the HF type pointing toward the possible etiology of the cardiac function degradation. Results of our study will be reported back to clinicians to promote awareness for HF and communicated with the HFRs of different hospitals and LSC in order to optimize the standards of care regarding HF and discussing the cost effectiveness issue if possible.  Conclusion The LGH-HFR is a valuable tool for continuous improvement of quality of care in patients and awareness regarding HF in Lebanon. Furthermore, it will be an important resource for the Lebanese registry-based HF research once available.
51 Evaluation of Systolic Function of the Right Ventricle in Patients with Chronic Obstructive Pulmonary Disease: A Cross Sectional Study about 30 Cases   , NGAIDE Aliou Alassane1, GAYE Ngoné Diaba2, SARR Simon Antoine3, AW Fatou3, DIOUM Momar4, SOW Maimouna3, BODIAN Malick3, NDIAYE Mouhamadou Bamba3, MBAYE Alassane1, KANE Abdoul2 1Cardiology Department of Grand Yoff General Hospital, Dakar, Senegal 2Cardiology Department of Dalal Djam Hospital, Dakar Senegal 3Cardiology Department of Aristide Le Dantec Teaching Hospital, Dakar, Senegal 4Cardiology Department of Fann Hospital, Dakar Senegal *Corresponding Author: NGAIDE Aliou Alassane, Cardiology Department of Grand Yoff General Hospital, Dakar, Senegal.
Introduction: Chronic pulmonary heart is the main cardiovascular complication of chronic obstructive pulmonary disease. The aims of our study were to evaluate the right ventricular systolic function in patients with chronic obstructive pulmonary disease and to investigate the relationship between parameters of right ventricular function and pulmonary function testing data. Methodology: A multicenter cross-sectional study was conducted between January 2013 and July 2013 in cardiology and pulmonology department in Dakar. Was included all in or outpatient diagnosed for chronic obstructive pulmonary disease. Results: 30 patients were evaluated in this cohort. The mean age was 62.4 years. Male predominance was noted (sex ratio of 9). Right heart failure was found in 7 patients (23.3%) had. Right ventricule enlargement was noted in 12 patients (40%). Mean sPAP was 58.58 ± 23.59 mmHg. Pulmonary arterial hypertension was found in 16 (53.3%) patients. TAPSE was impaired in 7 patients (23.3%). Reduction of right ventricule fractional area change was present in 14 (46.6%) patients. S’ of the tricuspid annulus velocity was reduced in 11 (33%) patients. Parameters correlated with the severity of chronic obstructive pulmonary disease were: TAPSE (p= 0.0099), right ventricule fractional area change (p = 0.0095), S’ of the annular tricuspid (p= 0.0173) TEI index (p= 0.038) and Pulmonary arterial hypertension (p= 0,023). Conclusion: Evaluation of right ventricular systolic function in chronic obstructive pulmonary disease is fundamental and must use multiple parameters.
52 Shocking the Racing Heart   , Kirstin U. Mosley1, MD¶ Shabih Manzar2, MD* 1Pediatric Resident, Department of Pediatrics 2Attending, Division of Neonatology, Louisiana State University of Health Sciences (LSUHSC)    Shreveport, LA *Correspondence: Shabih Manzar, MD 1501 Kings Highway Shreveport, LA 71130 Telephone: 318-626- 1620 Fax: 318-698-4305
We present a case of a term infant who developed refractory supraventricular tachycardia (SVT) that responded to a high dose of electrical shock. The exact cause for SVT remained obscure.
53 Patient Satisfaction Questionnaire After Transcatheter Aortic Valve Replacement   , Shikhar Agarwal MD MPH1, Imran Baig, MD1, Amir Eslami, DO2, Tanawan Riangwiwat, MD1* 1Cardiology Department, Geisinger Medical Center, Danville, PA 2Internal Medicine Department, Geisinger Medical Center, Danville, PA *Corresponding Author: Tanawan Riangwiwat, Cardiology Department, Geisinger Medical Center, Danville, PA
Health-related quality of life (HRQoL) is a multi-dimensional concept that includes domains related to physical, mental, emotional, and social functioning. Kansas City Cardiomyopathy Questionnaire (KCCQ) is typically utilized to assess the HRQoL after TAVR
54 Usefulness of the Turnpike Gold Catheter in Balloon Uncrossable Coronary Lesions   , Matthew Jackson1, Mohaned Egred1-2* 1Cardiac Department, Freeman Hospital, Newcastle-upon-Tyne, UK 2Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK *Corresponding author: Mohaned Egred, Cardiac Department, Freeman Hospital, Newcastle-upon-Tyne, UK.
Balloon-uncrossable lesions present a particularly challenging situation to the interventional cardiologist. They are increasingly encountered with the more complex cases performed and the aging population undergoing coronary intervention. Method All procedures where a Turnpike Gold micro-catheter was used to cross a balloon-uncrossable lesion (defined as any lesion uncrossable by a balloon < 1.5mm in diameter or an alternative micro-catheter with adequate guide catheter and guidewire support) between September 2016 and September 2018 were included. Clinical demographics, procedural details and peri-procedural complications were recorded. Results Twenty one cases were included.  The average age was 77 +/- 9.6 years (61 – 93) and 13 (62 %) were male.  Fourteen (67%) lesions were mildly to moderately calcified, six (32%) were severely tortuous and all coronary arteries were involved, LAD (8 cases), CX or OM (8 cases), RCA (5 cases).  The Turnpike Gold successfully crossed 14 (67%) lesions that other devices failed to cross (low profile balloons (7 cases), Corsair micro-catheter (9 cases), Turnpike Spiral (3 cases), CrossBoss (1 case).  In three cases, multiple devices had failed to cross the lesion and a Guideliner extension catheter was used in 4 cases. Conclusion The Turnpike Gold can be safely and effectively used to cross lesions that low-profile balloons and other micro-catheters have failed to cross, and would help in achieving a successful procedural outcome.
55 Extreme Bradycardia with Variable Block in Severe Hyperkalemia: A Forgotten Culprit in Brady-arrhythmia   , Han Naung Tun1,2,*,  Syed Haseeb Raza3 1Coronary Care Unit, Heart and Vascular Centre, Victoria Hospital, Yangon, Myanmar 2National Representative of Heart Failure Specialist of Tomorrow (HoT) for Myanmar in European Heart Failure Association  and Clinical & Research Working Group of Cardiac Cellular Electrophysiology, European Society of Cardiology, Sophia Antipolis, France  3Department of Cardiac Electrophysiology, National Institute of Cardiovascular Diseases, Karachi, Pakistan *Corresponding Author: Han Naung Tun, Coronary Care Unit, Heart and Vascular Centre, Victoria Hospital, Yangon, Myanmar
Bradycardia is commonly encountered in emergency department. Hyperkalemia may sometime cause bradycardia with block and also synergize with AV node blockers to cause bradycardia and   hypoperfusion.   We report a 53 years old male with history of hypertension, congestive heart failure and coronary artery disease was admitted to hospital for sudden onset of breathlessness. He underwent percutaneous coronary intervention (PCI) to left anterior descending (LAD) artery and left circumflex (LCx) artery one year ago and taking Aspilet 80 mg for daily, Clopidogrel 75 mg daily, Ramipril 5 mg daily, Atorvastatin 20 mg daily, Metoprolol 25 mg daily, Spironolactone 25 mg daily and Frusemide 40 mg daily.  Significant physical examination was remarkable for a temperature 97.5’F, blood pressure of 110/70 mmHg, heart rate of 40 beats per minute, oxygen saturation was 99% on air and both lung were full with audible crepitation by auscultation. He was given atropine 0.6 mg bolus and transcutanaeous pacing with unimproved heart rate and then a transvenous pacing was immediately placed before the blood investigation results were returned.  His relevant laboratory values were significant  for a potassium of 7.99 mmol/L( ref range : 3.5-5.2 mmo/l) , creatinine of 458 micmol/L ( ref range : 59-104 micmol/L) , Urea of 33.9 mmol/L ( ref range : 2.7 – 8.0 mmol/l), random blood glucose of  233mg/dl , sodium 126.8 mmol/L ( ref range 135-145 mmol/L ) , anion gap of 13.5 mmol/? (ref range : 3.6 -11.0 mmo/L) and bicarbonate of 15.6 mmil/L ( ref range: 22-29 mmol/L). He was given calcium glucoronate , insulin with dextrose , kaexylate , nebulizer salbutamol with significant improvement in his potassium levels to 4.6 in 24 hours  . In Cardiac intensive care unit his heart rate was improved and the transvenous pacemaker was turned off the next day.
56 Long-term Home use of Dobutamine in end-stage Heart Failure in Nigeria: a case report and Review of literatures.   , Edafe Emmanuel Auchi1*, Odia .O. James2 1Department of Internal Medicine, Niger Delta University, Amassoma. 2University of Port Harcourt Teaching Hospital, Port Harcourt *Corresponding Author: Edafe Emmanuel Auchi.  Department of Internal Medicine, Niger Delta University, Amassoma.
Introduction: Dobutamine increases cardiac contractility and causes vasodilation with little change in heart rate. It has been used in management of acute heart failure. It has also been document for use in management of chronic heart failure.  We reported 86 year old man with refractory heart on long term dobutamine. Case Summary: A 86-year-old retired civil servant living with hypertension for 26 years, type 2 Diabetes Mellitus (T2DM) for 14 years and hyperlipidemia for 10 years. He was diagnosed with biventricular failure 4 ago and had cardiac resynchronization therapy (CRT-D) implanted 3 years ago.  He presented to the emergency department with 3 weeks history of bilateral leg swelling, dyspnea, orthopnea, paroxysmal nocturnal dyspnea and oliguria.  He has more than 12 repeated hospital admission for heart failure in the past 4 years despites CRT-D.  He was noted to be anxious and diaphoretic with a respiratory rate of 36 breaths/minute, blood pressure of 84/52 mm Hg, heart rate 80 beats/minute. Peripheral pulses were threated and diminished in amplitude, and his hands and feet were cool and moist.  A summation gallop was noted over the precordium. Fine crepitations were heard over the posterobasal regions of both lungs.  The electrocardiogram showed a pacemaker rhythms. He was treated for NYHA class IV heart failure with digoxin, and dobutamine. He was discharged home on long term dobutamine infusion. CONCLUSION: Home dobutamine is a simple and effective in term treatment for end-stage heart failure. Its widespread use may be restricted by cost and expertise considerations in Nigeria
57 Partial Fracture of a Subcutaneous ICD Lead from Mechanical Trauma   , Hieu Huynh1* D.O., Gregory Siroky2 M.D., Devendra Bisht3 M.D., Patrick Lam4 M.D., Asad Mohammad D.O., Davendra Mehta6 M.D. 1Internal Medicine New York, NY Physician 2Cardiology New Brunswick, NJ Physician 3Cardiology New York, NY Cardiac Electrophysiology Physician 4General Cardiology, Cardiac Electrophysiology, Interventional Cardiology 5Clinical Cardiac Electrophysiology Mount Sinai Health System New York, NY 6cardiac Electrophysiology *Corresponding author: Hieu T. Huynh, Mount Sinai Morningside Hospital Al-Sabah Arrhythmia Institute 440 W 114th St, New York, NY 10025
Transvenous implantable cardioverter-defibrillators (TV-ICD) have electrode failure rates as high as 20% over a 10 year followup with 12% as a result of lead fractures. [1] The development of the Boston Scientific subcutaneous ICD (S-ICD) promoted the benefit of significantly reduced post-implant complication rates. [4] We present the first reported case of a S-ICD electrode failure secondary to partial fracture as a result of mechanical trauma.  
58 Main cardiovascular manifestations induced by coronaviruses: about the new virus 2019-CoV.   , Maria Luz Gunturiz A. BsC, PhD Specialized professional, Public Health Research Division, National Institute of Health.  Avenue Street 26 No 51-20 CAN, Bogotá, D.C., Colombia, Telephone: +57(1) 2207700 Ext 1629, Cell phone: 3123600581, Email: mgunturiz@ins.gov.co Corresponding author: Maria Luz Gunturiz A., Public Health Research Division, National Institute of Health.  Avenue Street 26 No 51-20 CAN, Bogotá, D.C., Colombia.
Chronic diseases are the cause of the highest mortality worldwide. Its prevalence is increasing, especially in middle- and low-income countries, in populations with a longer life expectancy that have adopted, among others, healthier lifestyles and diets. On the other hand, there are no therapeutic strategies focused exclusively on this population when they occur. respiratory virus epidemics such as coronaviruses. This review presents evidence that shows the main cardiovascular manifestations associated with infection by respiratory viruses and especially by coronaviruses.
59 A Review of Surgical Aortic Valve Repair. Indications and techniques for the General Cardiologist   , Jeremy W. Docekal, Landstuhl Regional Military Medical Center Department of Cardiology Corresponding Author: Jeremy William Docekal, Staff cardiologist Landstuhl Regional Military medical Center
The management of surgical aortic valve disease is particularly challenging among young patients and patient’s employed in high risk occupations such as the military.  Longer life expectancy predicts an increased probability for prosthetic-valve-related complications.  Consequently, there is a recognized need for alternative therapies, and surgical aortic valve repair may offer an attractive option for selected patients.  Furthermore, aortic valve repair surgical techniques have evolved, and data from contemporary studies show consistent, successful, and durable outcomes; particularly when performed in high volume centers.  The purpose of this review is to discuss the indications for aortic valve repair, review basic operative techniques, and illustrate how pre-procedural echocardiographic imaging is contributing to surgical planning.    
60 Case Report: The Novel Use of an Esophageal Deviator System to Displace the Phrenic Nerve during Ablation of a Focal Right Atrial Tachycardia , Asad Mohammad DO Mount Sinai Morningside Hospital Al-Sabah Arrhythmia Institute 440 W 114th St, New York, Corresponding Author: Asad Mohammad DO, Mount Sinai Morningside Hospital Al-Sabah Arrhythmia Institute 440 W 114th St, New York, NY 10025 212-523-2400
Atrial tachycardia is a sub-type of supraventricular tachycardia (SVT) that can be seen in patients with both structurally normal and abnormal hearts. In contrast to other types of SVTs, an atrial tachycardia does not require an accessory pathway or the atrioventricular node for maintenance. It typically arises from any ectopic site within atrial myocardium and typically the atrial rate ranges between 150-250 beats per minute; in addition P waves may appear either similar or dissimilar to sinus P wave morphology.
61 Patent Ductus Arteriosus, Hypotension, and Fluid Bolus in a Preterm Infant   , Hilary A. Smith* Shabih Manzar, MD Department of Pediatrics School of Medicine Louisiana State University Health Sciences Center 1501 Kings Highway Shreveport, LA 71103 *Corresponding Author: Shabih Manzar, MD, 1501 Kings Highway Shreveport, LA 71103 Telephone: 318-626-1623 Fax: 318-698-4305
The incidence of patent ductus arteriosus (PDA) is about 50-55% in term neonates while it varies in preterm infants, depending upon the gestational age and associated respiratory pathology. Hypotension in preterm infants is common. When it occurs with a PDA, it is often difficult to treat. The minute to minute changes in the hemodynamic status is difficult to monitor clinically, therefore the dilemma is restricting versus liberalizing fluids. We present a case in brief, followed by the discussion on how one should approach such a situation.  
62 Influence of COVID -19 pandemic on acute coronary syndrome and management of ST segment elevation myocardial infarction in a single cardiac intervention center in Kingdom of Bahrain A glimpse from the   , Fawaz Bardooli*, MD, Jasim Hasan, MD, Abdulkarim Abdulrahman, MD Shereen Alshaikh, MD Mohamed bin Khalifa bin Salman Al Khalifa Cardiac Center, Riffa Bahrain *Corresponding Author: Fawaz Bardooli, Interventional cardiologist Riffa- Bahrain
The Coronavirus disease 2019 (COVID-19) pandemic has significantly affected the global health care system worldwide. The first COVID 19 case in Bahrain was detected on 24 February for a citizen travelling from Iran. The magnitude of the effect of COVID on the health care systems is unpredictable. However, the COVID national team task force made significant preparations to limit the spread of this virus and flatten the curve of the pandemic locally.  
63 Statin therapy Prescribing patterns for primary prevention of Cardiovascular disease in patients with type 2 Diabetes Mellitus receiving primary care at the Tamale Teaching Hospital (TTH) in Northern   , Martin Mumuni Danaah Malick 1,2, Stephen Adjei 3   1Tamale Teaching Hospital, Department of Pharmacy; 2University for Development Studies, Department of Pharmacy; 3Tamale Teaching Hospital, Department of Pharmacy. *Corresponding Author: Martin Mumuni Danaah Malick, Tamale Teaching Hospital, Department of Pharmacy,Gana
Background: One of the leading causes of morbidity and mortality amongst type 2 diabetic (T2DM) patients is Cardiovascular disease (CVD). Patients with T2DM are at a higher risk of developing CVD than non-diabetic patients. Statin therapy has been proven to be effective for the primary prevention of CVD amongst T2DM patients. The objective of this study was to determine the extent of statin therapy use for primary prevention of CVD in T2DM patients at TTH. Methods:  A retrospective review of prescription records of T2DM patients who attended the Diabetes Clinic between January 1 2019 to March 31 2019 was conducted. Patient-specific data, evidence of T2DM Diagnosis and prescribed statin therapy were retrieved. Data was collected using a pre-structured tool and analyzed with STATA 15.0. Results: A total of 171 patients were included in this study. Of these, only 49% (84) patients received a statin. Atorvastatin 20mg was prescribed for 76% (64) patients, followed by atorvastatin 10mg for 22% (19) patients. Atorvastatin 40mg and simvastatin 20mg was the least prescribed at 1% (1) patient each. A total of 76% of statin therapies were of moderate-intensity dose, 23% were of low-intensity dose and only 1% was of high-intensity dose. Conclusion: Despite the overwhelming evidence supporting the cardiovascular benefits of statins in T2DM patients, these therapeutic agents are under-prescribed for T2DM patients at TTH with atorvastatin being the most frequently prescribed statin therapy
64 Adjustable Vertical Vein Ligation in Supracardiac Totally Anomalous Pulmonary Venous Connection: A Clinical Report of 99 Patients   , Ujjwal K. Chowdhury*, Diplomate NB ,Sukhjeet Singh, Niwin George, Suruchi Hasija, Lakshmikumari Sankhyan, Srikant Sharma, Diplomate NB, Niraj Nirmal Pandey, Mani Kalaivani, Cardiothoracic Sciences Centre All India Institute of Medical Sciences, New Delhi, India. *Corresponding author: Ujjwal Kumar Chowdhury, M.Ch., Diplomate NB Professor Department of Cardiothoracic and Vascular Surgery AIIMS, New Delhi-110029, INDIA.
Background: Unligated vertical vein in repaired obstructive totally anomalous pulmonary venous connection (TAPVC) with pulmonary hypertension reduces perioperative pulmonary artery pressure, pulmonary hypertensive crises and improves survival. Our aim was to assess the long-term results of delayed ligation of the vertical vein using an adjustable ligature on survival and reoperations. Method: A series of 99 consecutive patients (62 males), aged 24.8±55.3 months (range 1 day-25 years; median 4 months) underwent rechanneling of isolated, obstructive and non-obstructive TAPVC with left atrial augmentation, atrial septal fenestration and an unligated vertical vein. An adjustable vertical vein ligature was employed in all patients for later interruption. Results: Hospital mortality was 5.0% (n=5) with 2 (2%) late deaths. At a mean follow-up of 218.8 (sE± 209.9) months, the actuarial survival was 93.7% (SE± 0.02%; 95% CI: 86.5, 97.1). Postoperatively, all ligatures were tightened gradually over a period of 24-144 hours. Computed-tomographic angiograms during follow-up revealed absence of flow through the vertical vein and ruled out distortion of the left superior pulmonary vein and left brachiocephalic vein. Conclusions: A patent vertical vein, augmented left atrium and atrial septal fenestration in repaired obstructive and non-obstructive TAPVC with pulmonary hypertension decreased postoperative pulmonary hypertensive crises and improved survival by providing superior hemodynamics. Percutaneously adjustable vertical vein ligature is an expedient, safe and effective technique in these patients in a setting where transcatheter solutions are not available. Use of a percutaneously adjustable ligature around the vertical vein allows gradual tightening of the ligature under optimal physiological conditions, without multiple reoperations (Figure 1).
65 A Coronary computed Tomography Angiography assisted CHIP-PCI: large Ectasia, multiple Narrowings and Chronic total Occlusion   , Alfredo Marchese 1,2,*, Antonio Tito2, Fabrizio Resta2, Giuseppe Speziale3 1Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy 2Ospedale Santa Maria, GVM Care & Research, Bari, Italy 3Anthea Hospital, GVM Care & Research, Bari, Italy. *Corresponding Author: Alfredo Marchese, Chief of Interventional Cardiology Ospedale Santa Maria, Bari, Italy
Background - Complex higher-risk and indicated patients (CHIP) percutaneous coronary interventions (PCI) still challenge interventionalists. Coexistence of coronary atherosclerotic ectasia, narrowings and chronic total occlusion (CTO), represents a unique complex scenario where no evidence could support a standard treatment. Case summary - A 67-year-old man, hypertensive, diabetic, and with recent kidney transplantation with ongoing anti-rejection therapies, presented a complex three-vessel disease, in which the triad of ectasia, stenosis and chronical total occlusion became linked in a continuous pathological arterial remodelling process. The patient was successfully treated with CHIP-PCI integrating endovascular devices, drugs and imaging modalities. Discussion - If revascularization is clinically warranted, procedural challenges and thrombotic issues could be overcome with advanced devices and effective antithrombotic therapies. Moreover, coronary computed tomography angiography (CCTA) represents one of the most promising procedures to predict the likelihood of success during CTOs recanalization and to overcome the absence of some objective means on invasive angiography. If narrowings, CTO and lesion-containing thrombus coexist, coronary imaging combined with modern technical devices and new antithrombotic drugs need to be combined in a tailored complex procedure.
66 COVID-19: Deciphering the cardiology riddle   , Tania Muñoz Critical Patients Unit. Metropolitan Hospital of Providencia. Santiago; Chile Corresponding Author: Tania Muñoz, Critical Patients Unit. Metropolitan Hospital of Providencia. Santiago; Chile
In this writing I propose pathophysiological mechanisms that could be altering the regulatory control of blood pressure and heart rate of patients hospitalized in ICU for COVID-19, through clinical observation, monitoring and measurements of non-invasive hemodynamic variables, in a series of patients.
67 High Dose Loop-Diuretic Treatment Results in Higher Mortality Rate in Elderly Heart Failure Patients (>80 years) versus Standardized Neuroendocrine Treatment   , Isak Lindstedt1*, Lars Edvinsson2, Marie-Louise Edvinsson2 1Department of Emergency and Internal medicine, Lund University Hospital of Skåne, Sweden 2Department of Medicine, Institute of Clinical Sciences in Lund, Lund University, Sweden. *Corresponding Author: Isak Lindstedt, Department of Medicine Institute of Clinical Sciences in Lund Lund University,  S22185 Lund, Sweden, Phone: + 46 734 386425
Introduction Most chronic heart failure (HF) patients receive therapy with non-potassium-sparing diuretics (loop diuretics), which are fundamental drugs used to prevent multi-organ failure and improve symptoms. The use of diuretics in HF is also associated with neuroendocrine activation, organ damage and increased mortality. However, there is a lack of studies in the very elderly over the age of eighty. Methods The study included 99 elderly patients with HF, mean age 81 years, which represented a cohort of patients gathered during recent years. They had been admitted to the internal medicine ward at Lund University Hospital and had been given the primary diagnosis of HF. The patients were divided into two groups based upon the dose of furosemide they had at discharge. Patients receiving less than 80 mg daily were allocated to the low-dose furosemide group (LD-group), 65 patients, and patients receiving 80 mg or more of furosemide, 34 patients, were allocated to the high-dose furosemide group (HD-group). Results The HD-group received a mean of 118 mg/day of furosemide and the LD-group received a mean of 39 mg/day of furosemide (p < 0.01). The main finding was that the HD-group had an increased 6 month mortality compared to the LD-group (p = 0.03). Also, both groups demonstrated significant decreases in mean NT-proBNP values from enrollment into the hospital compared to follow up (p < 0.01). Conclusions Elderly patients (>80 years of age) were enrolled into the hospital with the diagnosis of severe HF. During treatment they showed higher 6-month mortality when therapy was focused on high doses of furosemide as compared to low doses combined with neuroendocrine therapy. The use of non-potassium-sparing diuretics in the elderly is not unproblematic and this group of patients respond favourable to neuroendocrine treatment.
68 High Dose Loop-Diuretic Treatment Results in Higher Mortality Rate in Elderly Heart Failure Patients (>80 years) versus Standardized Neuroendocrine Treatment   , Isak Lindstedt1*, Lars Edvinsson2, Marie-Louise Edvinsson2 1Department of Emergency and Internal medicine, Lund University Hospital of Skåne, Sweden 2Department of Medicine, Institute of Clinical Sciences in Lund, Lund University, Sweden. *Corresponding Author: Isak Lindstedt, Department of Medicine Institute of Clinical Sciences in Lund Lund University,  S22185 Lund, Sweden, Phone: + 46 734 386425
Introduction Most chronic heart failure (HF) patients receive therapy with non-potassium-sparing diuretics (loop diuretics), which are fundamental drugs used to prevent multi-organ failure and improve symptoms. The use of diuretics in HF is also associated with neuroendocrine activation, organ damage and increased mortality. However, there is a lack of studies in the very elderly over the age of eighty. Methods The study included 99 elderly patients with HF, mean age 81 years, which represented a cohort of patients gathered during recent years. They had been admitted to the internal medicine ward at Lund University Hospital and had been given the primary diagnosis of HF. The patients were divided into two groups based upon the dose of furosemide they had at discharge. Patients receiving less than 80 mg daily were allocated to the low-dose furosemide group (LD-group), 65 patients, and patients receiving 80 mg or more of furosemide, 34 patients, were allocated to the high-dose furosemide group (HD-group). Results The HD-group received a mean of 118 mg/day of furosemide and the LD-group received a mean of 39 mg/day of furosemide (p < 0.01). The main finding was that the HD-group had an increased 6 month mortality compared to the LD-group (p = 0.03). Also, both groups demonstrated significant decreases in mean NT-proBNP values from enrollment into the hospital compared to follow up (p < 0.01). Conclusions Elderly patients (>80 years of age) were enrolled into the hospital with the diagnosis of severe HF. During treatment they showed higher 6-month mortality when therapy was focused on high doses of furosemide as compared to low doses combined with neuroendocrine therapy. The use of non-potassium-sparing diuretics in the elderly is not unproblematic and this group of patients respond favourable to neuroendocrine treatment.
69 Elevated Lipoprotein (a) in Cardiac Outcomes: A Review   , Sahoo Alor 1, Strong Laura 1, Jensen Alexander 2, Flaherty Daniel 2, Anand Mukul 1, Alromheen Hassan 1, Singh, Sarabjeet 3* 1Central Cardiology Medical Center, Bakersfield, CA. 2Touro University California, Vallejo, CA. 3Central Cardiology Medical Center, Cedars-Sinai, College of Osteopathic Medicine, Touro University California, Vallejo, CA. *Corresponding Author: Singh Sarabjeet, Central Cardiology Medical Center, 2901 Sillect Avenue Suite 100, Bakersfield, CA 93308, USA
Context Elevated lipoprotein (a) [Lp(a)] levels is an often-ignored risk factor for major adverse cardiac events (MACEs) in humans. Even after accounting for established risk factors (discussed in the text), some residual risk can still be independently attributed to elevated Lp(a) levels. Current guidelines dictating normal and elevated Lp(a) levels and subsequent treatment have proven haphazard due to unstandardized studies. Many studies offer cutoff values in units mg/dL, which do not account for the heterogeneity of Lp(a). Interpretation of elevated Lp(a) necessitates consideration of ethnicity necessary for proper predictions. Numerous studies detail the effects of elevated Lp(a) in relation to myocardial infarction, aortic valve stenosis, and atherosclerosis, among other conditions. This article aims to clarify the numerous cutoffs and guidelines presented. Methods Searches were primarily conducted through Google, PubMed.gov, and cochrane.org. Results Elevated Lp(a) seems to correlate with the incidence of MACEs and should be considered when assessing risk. Specific cutoff values remain quite unclear. Conclusions We urge for further detailed investigation on the effects of elevated Lp(a) on cardiac outcomes with the use of isoform independent assays. Particular attention should be given to ethnicity when assigning risk cutoffs for cardiac conditions. Proprotein convertase subtilisin/kexin type 9 (PCSK-9) inhibitors can lower Lp(a) levels significantly and should be investigated.
70 Prevalence of different type of valvular heart disease and other cardiac pathologies of the heart in high risk patients with suspicion of heart failure. A retrospective cohort study.   , Madeeha Subhan Waleed1 and Waleed Sadiq2 1Ayub Medical College. 2Staten Island University Hospital. *Corresponding Author: Madeeha Subhan Waleed, Ayub Medical College.
Background: Valvular heart disease and other cardiac pathologies are associated with impending heart failure. An early diagnosis of these can help prevent the disabling ad disastrous effects and improve the prognosis. Aim: The prevalence of various pathologies associated with heart failure is not known. This study helps in recognizing various pathologies that can lead to heart failure, which if diagnosed early can improve the patient’s outcome. Materials and Methods: A total of 4560 patients were included in the study. All the patients were aged greater than 15 years. Patients with suspicion of heart failure on symptoms were ordered echocardiography. Transthoracic echo was done using echocardiography ultrasound machine using the British Society of Echocardiography guidelines. Echocardiography was done by registered sonologists. Echocardiograph were later read by cardiologists. Data was collected on Excel sheet. Echocardiographic results Of 9 690 patients, were admitted to the hospital during the year 2013 to year 2017 with the suspicion of heart failure based on symptoms echocardiogram was ordered. Among these 2448 patients had normal echocardiographic findings were as 4560 had valvular disease. Among the valvular disease patients 2951(64.71%) were females and 1609(35.2%) were males. Among these 2950(64.6%) had mild valvular disease 959(21.0%) had moderate valvular disease and 651(14.2) patients had severe valvular disease. Mitral stenosis occurred in 1200(26.3%) patients, mitral regurgitation in 2953(64.7%) patients, tricuspid stenosis in 40 (0.008%)patients ,tricuspid regurgitation in 1592(34.8%) patients, aortic stenosis in 81 (0.017%) patients and aortic regurgitation in 1957(42.9%) patients. Ischemic cardiomyopathy was present in 24 patients, dilated cardiomyopathy in 14 patients, rheumatic heart disease in 23 patients, ventricular septum defect in 5 patients ,Atrial septum defect in 2 patients , Apical aneurysm formation in 4 patients, Uremic cardiomyopathy on 3 patients, Grade 1 diastolic dysfunction in 2200 patients, Grade 3 diastolic dysfunction in 400 patients, Bicuspid aortic valve in 5 patients and restrictive cardiomyopathy in two patients, 1100 patients had a thin rim of pericardial effusion and were ordered Thyroid function tests. Conclusion: In the community heart failure is a common cause of death. Various pathologies of the heart are predictors of the outcome and hence early diagnosis can help in proper treatment and increased survival
71 Modern Treatment Methods of Heart Failure   , UA Eyubova, Azerbaijan Medical University, Azerbaijan Corresponding Author: UA Eyubova, Azerbaijan Medical University, Azerbaijan
Modern methods of treatment of heart include, first of all, pathogenetic therapy and modern methods of treatment. Complete pathogenetic treatment has been achieved after the use of sacubitril / valsartan which is neprilysin inhibitor, whose use has been initiated in recent years.             According to data provided in 2017, 26 million people worldwide suffer from heart failure. [1,2] These reasons include especially malnutrition and obesity, diabetes mellitus that is increasing every year, increase in smoking, hypertension, and an increase of alcohol consumption. In recent years, it is revealed that brain natriuretic peptide has been crucial in the pathogenesis of heart disease.  B-type natriuretic peptide has a significant role in the diagnosis of heart failure and in the evaluation of its prognosis. [3] The device treatment methods also play a significant role in the treatment of chronic heart failure.
72 Major Findings of the Angioplasty Procedure in Cohort of the Patients: A Epidemiological/Observational Study   , Rodrigo Bottura Nuevo Viveiros de Araújo1, Wilson Pedro Guimarães Neto1, Júlio Cesar Queiroz de França1, Moacir Fernandes de Godoy2, Márcio Antônio dos Santos1, Flávio Corrêa Pivatelli1, Márcio Rogério de Souza Braite1, Ana Valéria Garcia Ramirez3,4, Jair Baron Junior1, Idiberto José Zotarelli Filho3,5,6 Marcella Castro Torres7* 1 Department of Hemodynamics and Interventional Cardiology, Base Hospital, Medicine School of São Jose do Rio Preto/SP –  FAMERP, Brazil. 2 Department of Cardiology and Cardiovascular Surgery, Medicine School of São Jose do Rio Preto/SP - FAMERP, Brazil. 3Associação Brasileira de Nutrologia (ABRAN)/Brazilian Association of Nutrology, Catanduva/SP, Rua Belo Horizonte, 909 - Centro, Catanduva SP Brazil 15801-150. 4Clinic Ana Valeria Ramirez (CAVR)- Clinical of Nutrition and Health Science, Street Antônio José Martins Filho, 300, 10o floor, room 103, São José do Rio Preto SP, 15092-230, Brazil. 5FACERES – Faculty of Medicine of Sao Jose do Rio Preto/SP, Brazil. 6Zotarelli-Filho Scientific Work, Sao Jose do Rio Preto/SP, Brazil. 7Ambulatório Médico de Especialidades (AME)/Outpatient Specialty Clinics, Jales and Santa Fé do Sul, São Paulo, Brazil. *Corresponding Author: Idiberto José Zotarelli Filho, Ambulatório Médico de Especialidades (AME)/Outpatient Specialty Clinics, Jales and Santa Fé do Sul, São Paulo, Brazil..
Introduction: According to data from the World Health Organization of 2017, of the 21.7 million deaths from these diseases, more than ten million occur due to atherosclerotic coronary disease. Objective: Therefore, the present study aimed to analyze the main clinical data in terms of coronary angiography findings, as well as to know if the types of lesions found are related to acute myocardial infarction and whether gender and age predictors influence these events. Methods: A total of 502 participants (Female: n=174; Male: n=328) were submitted to eligibility analysis, followed by the rules STROBE. The present study followed a retrospective longitudinal with epidemiological/observational profile study on the analysis of the profile of patients who underwent angioplasty at Brazil. As there were continuous and categorical predictors and the response predictors, linear regression and was applied. For all linear regression tests, alpha level lower than 0.05 was adopted as significant.   Results and Conclusion: According to the results in the evaluated cohort of the present study, it can be known that the presence of lesions above 50.0% in the LCT, P. Descendant, Circumflex, Right Coronary, Saphenous Bridge did not imply the occurrence of Stable, AMI – ST events. (NOT), AMI-ST and Complications, with a significant statistical difference, p <0.05, not finding any relationship between them. Moreover, it was observed that the Gender and Age predictors statistically influenced the response of the P. Descendant, Circumflex, Right Coronary and Complications predictors, with p <0.05.
73 Re-print: Maintenance (r) Alpha Lipoic Acid Reduces Sudden Cardiac Death in Geriatric Diabetes Mellitus II Patients   , Gary L Murray1* and Joseph Colombo2 1Director of Clinical Research, The Heart and Vascular Institute, Germantown, TN-USA. 2Parasympathetic & Sympathetic Nervous System Consultant, Franklin Cardiovascular Associates, Sewell, New Jersey – USA 3Physio PS, Inc., Atlanta, Georgia – USA *Corresponding author: Gary L Murray, The Heart and Vascular Institute, 7205 Wolf River Blvd, Germantown.
Background: Diabetes carries a two-fold risk of Sudden Cardiac Death (SCD). Diabetic Autonomic Neuropathy (DAN), often progressing to Cardiovascular Autonomic Neuropathy (CAN, critically low parasympathetic tone [P]), increases death 3.5-fold over 5 years, half sudden or non- renal. Oxidative stress is a major cause of DAN. Also, increased sympathetic tone (S), High Sympathovagal Balance [SB>2.5] increases SCD risk. Objective: Dysautonomic diabetic II patients were treated with the antioxidant (r) Alpha Lipoic Acid (ALA), autonomic function followed, and Sudden Death (SD) compared to untreated patients. Methods: 133 patients (mean age 66y/o) with DAN or CAN, diagnosed using the ANX 3.0 Autonomic Monitor (Physio PS, Inc., Atlanta, GA) was offered (r)-ALA: 83 agreed (Group 1), and 50 refused (Group 2). P and S were re- measured up to 3 times/yr (mean f/u 6.31 yrs); SCDs were recorded. Results: A 43% Relative Risk Reduction (RRR) in SCD occurred with (r)- ALA (25% SCD Group 1 vs. 44% SCD Group 2, p=0.0076). Initial to final patients with high SB or CAN were 21.7%-12% (p=0.010), 10.8%- 15.7% (p=0.045), Group 1 vs. 24%-22% (p=ns), 6%-12% (p=0.083), Group 2. Only Group 1 survivors increased mean resting P. The progressive increase in P’s decline, increasing CAN risk, in the other patients correlated with mortality (p<0.001) and (r) ALA dose. Initially, Group 1 had insignificantly less high SB (p=0.449) and significantly more CAN (p=0.013) vs. Group 2. Finally, Group 1 had significantly less high SB (p=0.0967) vs. Group 2, also improving to insignificantly more CAN (p=0.261). Conclusion: (r)-ALA was associated with a 43% RRR of SCD and favorable P and S changes.
74 The first Case of Circulatory Arrest in deep Hypothermia in Cardiac Surgery in Mali   , Modibo Doumbia1*, Baba Ibrahima Diarra1, Thierry Langanay4 Bréhima Coulibaly1,2, Asmaou keita1,2, Mahamadoun Coulibaly1,2, Siriman Koita1, Sanoussy Daffe1, Mamadou K Toure1, Seydina Alioune Beye2,3, Erwan Flecher4, Mamadou B Diarra1,2,3 1Center cardio-pédiatric André Festoc de Bamako- Mali 2Faculty Médicine and Odonto-stomatologist of Mali 3University sciences technic and technologist of Bamako- Mali 4Faculty Médicine and Odonto-stomatologist of Reine and France *Corresponding Author: Modibo Doumbia, surgeon cardiovascular and thoracic, MALI  
The authors report the case of circulatory arrest in deep hypothermia during the closure of an arterial duct associated with significant mitral insufficiency for mitral replacement in an underdeveloped country such as Mali. This circulatory arrest technique used in major European and American heart surgery centers for the management of complex heart disease. It constitutes a real challenge for us to report the first case of circulatory arrest in the management of the persistent arterial canal associated with mitral insufficiency including simple operative consequences.
75 Dual-Energy Computed Tomography in the Diagnosis of Intracranial Hemorrhage after Interventional Therapy   , Guoqiang Chen1*, Xiaolin Liu1, Haoyun Pan1, Ning Su1, Yuechun Li1*, Guorong Liu1, Kai Sun1,2* 1Department of Radiology, Baotou Central Hospital, Baotou, 014000, China  2Department of Radiology, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, 518000, China *Corresponding Author: Kai Sun: Department of Radiology, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, 518000, China, and Guorong Liu: Department of Radiology, Baotou Central Hospital, Baotou, 014000, China and Yuechun Li: Department of Radiology, Baotou Central Hospital, Baotou, 014000, China.
Background: This study aimed to assess the feasibility of dual-energy computed tomography (DECT) in distinguishing intracerebral hemorrhage (ICH) from iodinated contrast in patients with acute ischemic stroke following endovascular treatment. Methods: This study included 20 patients with acute ischemic stroke who underwent intravascular interventional therapy. Immediately after the intervention, they underwent dual-energy CT scans of the head using the 140-kV and 80-kV dual-energy scanning technologies to obtain virtual non-contrast (VNC) images through image post-processing and iodine overlay images (IOMs). Moreover, after 48 h, common head CT or MRI images were clinically reviewed as the gold standard to evaluate the accuracy and specificity of the plain dual-energy CT scanning technique in identifying intracranial hemorrhage (ICH) and contrast agent extravasation. Results: A total of 27 foci of intracranial hyperattenuation within parenchymal and subarachnoid areas were shown in SE images, whereas both VNC and IOM showed an area of hypoattenuation, suggesting hemorrhage in 8/27. Follow-up CT demonstrated bleeding in7/8. The sensitivity of DECT in the diagnosis of cerebral hemorrhage and contrast agent extravasation was 100%, specificity was 95%, positive predictive value was 87.5% and negative predictive value was 100%. Conclusion: Dual-energy CT can quickly and accurately distinguish between intracranial hemorrhage and contrast agent extravasation after endovascular intervention in patients with acute ischemic stroke. Running Head: Dual-Energy CT Detects Extravasation of Iodine Contrast Agents
76 Cannabis Induced Vasospasm Complicated By Iatrogenic Coronary Artery Dissection   , Marina Santos1*, Nuno Santos1, Ricardo Rodrigues1, Bruno Silva1, António Drumond1 1Department of Cardiology, Dr. Nélio Mendonça Hospital, Avenida Luís de Camões, Funchal, Portugal *Corresponding author: Marina Santos., Nélio Mendonça Hospital, Avenida Luís de Camões, nº 57 – 9004-514 Funchal, Portugal.
Cannabis is the most abused psychoactive drug in the world. Delta 9-tetrahydrocannibol, the main psychoactive compound in marijuana, acts via the endocannabinoid system to elicit various cardiovascular physiological effects, and has been associated with many adverse cardiovascular effects such as acute coronary syndrome, arrhythmias, and sudden cardiac death. It is important to consider cannabis use as a significant risk factor of myocardial infarction, particularly in individuals with no cardiac risk factors, as delay in management can result in fatal outcomes. Coronary angiography as the main exam to definitively diagnose or rule out coronary artery disease is usually safe, but complications also occur. Coronary dissection, despite rare, can be extremely difficult to manage and even be fatal. Iatrogenic causes of coronary dissection include catheter tip or guidewire trauma, vigorous contrast injection and angioplasty balloon overinflation. We present the case of a 41 years old Caucasian woman admitted to cardiology department after an episode of myocardial infarction due to cannabis induced vasospasm. However, the angiography was complicated by iatrogenic coronary artery dissection.
77 A valve-in-valve transcatheter aortic valve implantation with commissural alignment using advanced imaging reconstruction: a case report   , Marco Angelillis1*, Andrea Christou1, Marco De Carlo1, Cristina Giannini1, Laura Stazzoni1, Paolo Spontoni1, Anna S. Petronio1. 1Catheterization Laboratory, Cardio-Thoracic and Vascular Department, University of Pisa *Corresponding author: Marco Angelillis, MD, PhD Catheterization laboratory, Cardio-Thoracic and Vascular Department, University of Pisa.   
Transcatheter valve in valve (ViV) implantation actually represents a valid alternative to surgical reinterventions in patients with previous surgical aortic valve replacement (AVR). In patients less than 80 years old, it is crucial to correctly position the new valve leaving a feasible and easy access to coronary ostia, both for future percutaneous coronary intervention (PCI) than for a future possible TAVinTAV procedure. We report a 71 year old man with prior AVR presented with structural valve deterioration (SVD) leading to severe aortic stenosis. In order to guarantee comfortable coronary access we aligned, the commissures of the new percutaneous valve with the ones of the surgical bioprothesis by reconstructing the headframes of the surgical bioprosthesis with computer tomography (CT) and fluoro-CT.  
78 Re-Print- The effect of cost and reimbursement on treatment choice   , Victor Gurewich, MD Vascular Research Lab, Mount Auburn Hospital, Cambridge, MA, USA Professor of Medicine, Harvard Medical School Corresponding Author: Victor Gurewich, Vascular Research Lab, Mount Auburn Hospital, Cambridge, MA, USA Professor of Medicine, Harvard Medical School
Treatment of acute myocardial infarction (AMI) has been with tissue plasminogen activator (tPA) alone since 1987, at an original cost of $2,000 which has risen to $5,000. Over the past decade tPA has been replaced by percutaneous coronary intervention (PCI), an invasive, more time-consuming hospital procedure. The mortality results of the two treatments were similar, but the PCI cost and reimbursement are at least 5-fold higher.  At the time, another fibrinolytic regimen was developed which is more effective, but it was ignored, and PCI continued to be the treatment choice and major source of revenue.   
79 Use of Transtracheal Oxygen following Decannulation of Pediatric Tracheostomy   , Ujjwal Kumar Chowdhury*, MCh, Diplomate NB , Ramesh Menon, DM, Niwin George, MCh ,Lakshmi Kumari Sankhyan, MCh , Nikhil Bansal, MCh , Srikant Sharma, Diplomate NB , Suryalok Angadi, MS , Vishwas Malik, DM Cardiothoracic Sciences Centre All India Institute of Medical Sciences, New Delhi *Corresponding author: Ujjwal Kumar Chowdhury, M.Ch., Diplomate NB Professor Department of Cardiothoracic and Vascular Surgery AIIMS, New Delhi-110029, INDIA.
Purpose: Uninterrupted sustained oxygenation is paramount in neonates and infants with cyanotic/acyanotic congenital heart diseases (CHD) undergoing closed or open heart surgeries and tracheostomy tube decannulation to avoid hypoxic events. Description: We describe here-in a new device, permitting uninterrupted delivery of oxygen through the tracheostomy stoma, allowing continuation of enteral feeds and suctioning of the endotracheal secretions through the tracheostomy stoma. Evaluation: Eighty-four neonates and infants with a median age of four months (IQR:23 days-9 months) undergoing different closed and open heart surgeries for cyanotic/acyanotic CHD with or without pulmonary arterial hypertension were treated with a device permitting uninterrupted oxygenation following tracheostomy tube decannulation. There were 11 (13.1%) deaths due to multifactorial etiologies, and one was lost to follow-up. Seventy-two children were successfully decannulated using this protocol. At a median follow-up of 166(IQR:82.5-216) months, the actuarial survival was 86.61% (SE±0.04%; 95% CI: 77.1-92.3). Conclusions: Transtracheal oxygenation through the tracheostomy stoma via a thin catheter allows uninterrupted oxygenation following tracheostomy tube decannulation, continuation of enteral feeds, and allows intermittent endotracheal suctioning, thus avoiding post decannulation hypoxic events. Running title: Transtracheal oxygenation
80 Simple Provisional Stenting or two-stent Strategies to Treat Anomalous Right Coronary Originating from the mid of left Anterior Descending Coronary Artery   , Xuguang Qin1*, Weiguo Xiong2, Chunpeng Lu2, Lin Yang3, 1Department of Cardiology, Beijing North Asia Orthopedics Hospital. Beijing 102445, People's Republic of China, 2Department of Cardiology, the First Affiliated Hospital of Tsinghua University. Beijing 100016, People's Republic of China; 3Department of Cardiology, Linshu County People's Hospital of Shandong Province. Linshu 276700, People's Republic of China; *Corresponding Author: Xuguang Qin, Department of Cardiology, Beijing North Asia Orthopedics Hospital. Beijing 102445, People's Republic of China,
Congenital anomalies of coronary arteries (CAAS) are very rare and usually documented as an incidental finding during routine catheter or CT angiograms performed for other reasons. Their prevalence ranges from 0.2% to 1.3% based published series. The most common coronary artery anomaly is origination of the left circumflex coronary (LCX) artery from the proximal of right coronary artery (RCA) or right sinus of Valsalva. The second is separate origination of the left anterior descending coronary artery (LAD) and LCX artery from the left sinus of Valsalva. Herein, we present three cases that the anomalous RCA arises from the mid of left anterior descending coronary artery (LAD). The bifurcation lesions of first case was treated using two-stent strategies of DK culotte, excellent angiography results was observed. The last two cases were treated using simple provisional stenting strategy: one stent was deployed crossover the ostium of the anomalous coronary artery, final angiographic results were excellent. These cases are extremely rare. We bring forth them in an attempt to highlight their significance, and make cardiologist to understand what important the anomalies are, and the strategy how to treatment these bifurcation lesions.
81 Micra Transcatheter Pacing System Implant under Direct Visualization During Minimally Invasive Tricuspid Valve Surgery   , Mohamad C. Sinno 1*, and Mario Castillo-Sang 2, 1Department of Cardiac Electrophysiology. 2Department of Cardiothoracic Surgery Heart and Vascular Institute St Elizabeth Healthcare, Edgewood, KY *Corresponding Author: Mohamad C. Sinno, St Elizabeth Hospital Medical Village Drive Edgewood KY.
Atrioventricular nodal conduction abnormalities are common after open heart surgery and more so during or after valve surgery. The incidence of atrioventricular (AV) block after tricuspid valve (TV) surgery is higher than what is observed following coronary artery bypass surgery or left sided valve interventions due to the proximity of the TV annulus to the AV node and hence requirements for cardiac pacing are high. However, the mechanical interference between pacing leads and TV leaflet mobility and coaptation can result in regurgitation rendering such an approach counterintuitive. We report a case of Micra Transcatheter pacing system (TPS) implant under direct visualization at the time of tricuspid valve surgery performed via a right mini-thoracotomy approach.  
82 Congenital heart disease   , Cristiane Martins Diretora Científica do Departamento de cardiologia Pediátrica Corresponding author: Cristiane Martins, Diretora Científica do Departamento de cardiologia Pediátrica
Congenital heart disease (CHD) is the most common cause of major congenital anomalies, and is the group of malformations that contributes the most for perinatal mortality  
83 MMED PROJECT The Clinical Profile of Takayasu Disease at Tygerberg Academic Hospital – a retrospective study   , Amani Kaawan1*, Mou Manie1, Adel M Aboshakwa2, Razeen Davids3 1Division of Rheumatology, Tygerberg Academic Hospital, National Health Laboratory Services. Faculty of Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa 2Department of Medicine, Stellenbosch University and Tygerberg hospital 3Division of Nephrology, Department of Medicine, Stellenbosch University and Tygerberg Hospital *Corresponding Author: Amani Kaawan, Division of Rheumatology, Tygerberg Academic Hospital, National Health Laboratory Services. Faculty of Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa.
Takayasu’s arteritis (TA) is a disease of unknown etiology that causes chronic inflammation of the large blood vessels and usually involves the aorta and its branches. The inflammatory process initially leads to thickening of the arterial wall and may result in stenosis, occlusion, dilatation or aneurysm formation. Although TA occurs more commonly in certain regions such as Asia, it is a global disease. Currently, there is a dearth of information on this condition in African countries, including South Africa. Results: We have identified 50 patients meeting the ACR criteria for the diagnosis of TA.  Data was drawn from the records of the Division of Rheumatology as well as the angiographic records of TA. This included patient demographics, mode of presentation, classification, co-morbidities, complications, clinical and laboratory features, radiological findings, drug therapy as well as outcomes. The cohort comprised 34 of mixed race, 12 black and 4 white patients. The mean age at diagnosis was 16-56 (28.2) years. The most common presention was hypertension, followed by CVA, heart failure, and syncope. Angiography revealed Type V (most of aorta) and Type I (aortic arch branches) lesions to be the most common and that stenosis was much more common than aneurysm formation. Two patients had concomitant antiphospholipid syndrome. Another two had concomitant internal jugular vein thrombosis. Six patients had significant mediastinal lymphadenopathy, only one of whom had TB. Corticosteroids and additional immunosuppressive therapy were used to control disease activity in most patients. Biological treatment was used in two patients. Surgical intervention consisted mainly of renal auto transplantation. Twelve percent of patients had repeated admissions, which included planned surgical intervention. We had two mortalities, both as a result of massive strokes. The mortality rate was 6%. Only 3 patients had active TB. Conclusion: The study revealed gender and age characteristics similar to previous studies, confirming that TA affects mainly young females. The mortality rate of 6% in this cohort is significantly lower than that of previous series. The unusual findings in this study were: Significant chest lymphadenopathy in 12% of the cases,the significantly lower percentage of active TB of only 6%, two cases of a rare finding of venous thrombosis as well as 2 cases of an uncommon finding in TA of  antiphospholipid syndrome.
84 Angiosarcoma of the Heart: Case Report   , Sofie Dhaeyer1, Chirik Wah Lau1, Vanessa Meert2, Jan Leeman1, Martin Penicka1, Marc Vanderheyden1* 1Heart Failure Unit, Cardiovascular Research Centre, OLV Hospital Aalst, Moorselbaan 164, B-9300 Aalst, Belgium, 2Department of Pathology, OLV Hospital Aalst, Moorselbaan 164, B-9300 Aalst, Belgium, *Corresponding Author: Marc Vanderheyden, Heart Failure Unit, Cardiovascular Research Centre, OLV Hospital Aalst, Moorselbaan 164, B-9300 Aalst, Belgium.
Cardiac angiosarcomas are rare malignant tumors, predominantly affecting the right heart with poor survival outcomes. The current mainstay of treatment consists of surgery with or without chemotherapy, but often yields limited results with local relapse or metastatic recurrence. This case report describes 2 patients with primary angiosarcoma located in the right atrium. One patient received neo-adjuvant and adjuvant chemotherapy; both were scheduled for surgical resection. The course of disease is described followed by a comprehensive review of the literature.
85 Pharmaco-Invasive Therapy for Acute ST-Elevation Myocardial Infarction. - A Viable Alternative to Primary Percutaneous Coronary Intervention   , Lairikyengbam SKS1*, Ramdeo Yadave2, Moirangthem Vidyathoi Devi3 1Chief Cardiologist, SKY Hospital & Research Centre, Imphal, India. 2Senior Consultant, Interventional Cardiologist and Electrophysiologist, Batra Hospital and Medical Research Centre, Delhi; visiting Consultant at SKY Hospital & Research Centre, Imphal, India. 3Academic Executive, SKY Hospital & Research Centre, Imphal, Indi. *Corresponding Author: Lairikyengbam SKS, Chief Cardiologist, SKY Hospital & Research Centre, Imphal, India.
Primary percutaneous coronary intervention (pPCI) is considered as the preferred treatment for acute ST-Elevation myocardial infarction (STEMI). However, its availability is limited to less than 10% in rural and sub urban population in India (1). Therefore, Pharmaco-Invasive Therapy (PIT) (Thrombolysis first followed by planned coronary stenting) as an alternative to pPCI for acute STEMI has more recently been explored. A retrospective observational study of 60 patients with acute STEMI treated at the Dedicated Heart Attack Treatment Centre of SKY Hospital & Research Centre, Imphal, India over a period of 2 years has shown that Pharmaco-Invasive Therapy improved survival of patients with acute STEMI to 100% and increased Left Ventricular Ejection Fraction (LVEF) by 5.08% at the time of discharge and may be used as a viable alternative to pPCI in the treatment of patients with acute STEMI when pPCI cannot be  performed within recommended time.  
86 The Impact of Murmur’s Severity on the Cardiac Variability   , F.Mokeddem1, F.Meziani 2, L.Hamza Cherif 3, S.M Debbal4* Genie-Biomedical Laboratory (GBM), Department of Genie-Biomedical, Faculty of Technology, University of Aboubekr Belkaid – Tlemcen, BP 119, Tlemcen (Algeria) *Corresponding Author: S.M Debbal, Genie-Biomedical Laboratory (GBM), Department of Genie-Biomedical, Faculty of Technology, University of Aboubekr Belkaid – Tlemcen, BP 119, Tlemcen (Algeria).
Phonocardiogram (PCG) signal is one of the useful approach to explore cardiac activity, and extract many features to help researchers to develop technic that may serve medical stuff to the diagnosis of several cardiac diseases. For people when it comes to a heart activity problem it is a serious health matter that need special care. In this paper, the importance is given to heart murmurs to highlight their impact. Heart murmurs are very common disease in world and depend on their severity they could be life-threatening point; therefore, the purpose of this paper is focused on three essential steps: first is to design an algorithm to extract only heart murmurs from a pathological phonocardiogram signal (PCG) as a basic background to the whole work. Than calculate their severity based on energy ratio (ER) which is recommended by recent studies as an effective factor, in order to classify them to mild, medium and severe murmurs. In other hand, this classification will served to study the impact of severity of systolic and diastolic murmurs on cardiac variability, which is very important indicator on general health of human body. This study is done on consider number of patients and its reveal on very interesting results.  
87 Kissing Intravascular Balloon Lithoplasty and Endovascular Aortic Repair as a Treatment of Severe Distal Aorto-Iliac Occlusive Disease to Ensure a Safe Conduit to Facilitate Thoracic Endovascular Aort   , Pankaj Khullar1*, Joshua Berookhim2,  Justin Ratcliffe1, Reid Ravin3, Gabriele Di Luozzo4, Naveed Rajper1, Joseph Puma1 1Cardiovascular Department at Mount Sinai Morningside Hospital, New York, NY, USA 2Department of Medicine at Mount Sinai Morningside and Mount Sinai West, New York, NY, USA 3Department of Vascular Surgery at Mount Sinai Morningside Hospital, New York, NY, USA 4Department of Cardiothoracic Surgery at Mount Sinai Morningside Hospital, New York, NY, USA *Corresponding Author: Pankaj Khullar., Cardiovascular Department at Mount Sinai Morningside Hospital, New York, NY, USA
Background: We describe a novel case of treating severe distal aorto-illiac occlusive disease and endovascular aortic repair with kissing endoluminal lithoplasty balloons. This ensured a safe conduit to facilitate thoracic endovascular aortic repair. Case Presentation: A patient with multiple comorbidities including coronary artery disease and peripheral artery disease (Rutherford 4 symptoms bilaterally) presented to the emergency room with chest pain and dyspnea on exertion. The patient was found to have a 3.5 cm descending thoracic aortic aneurysm, multiple penetrating aortic ulcers (PAU’s) within the descending thoracic aorta which was felt to be the cause of her chest pain along with heavily calcified occlusive aorto-iliac disease.  The patient was deemed high surgical risk for open repair and the patient’s severe calcific distal aortic stenosis and bilateral severe ostial iliac stenosis was deemed a barrier for endovascular repair. Therefore, the patient was successfully treated with kissing balloon lithoplasty for lesion preparation of the heavy calcification and placement of an endovascular stent graft (EVAR) in the distal aorta, which ensured a safe conduit for thoracic endovascular aortic repair (TEVAR) procedure. Conclusion: As patients become more and more complex it is important to explore endovascular treatment options especially when surgical risk is high. Balloon lithoplasty and graft placement of calcified aorto-iliac bifurcation is a safe approach to develop a clear conduit for TEVAR. 
88 Kissing Intravascular Balloon Lithoplasty and Endovascular Aortic Repair as a Treatment of Severe Distal Aorto-Iliac Occlusive Disease to Ensure a Safe Conduit to Facilitate Thoracic Endovascular Aort   , Pankaj Khullar1*, Joshua Berookhim2,  Justin Ratcliffe1, Reid Ravin3, Gabriele Di Luozzo4, Naveed Rajper1, Joseph Puma1 1Cardiovascular Department at Mount Sinai Morningside Hospital, New York, NY, USA 2Department of Medicine at Mount Sinai Morningside and Mount Sinai West, New York, NY, USA 3Department of Vascular Surgery at Mount Sinai Morningside Hospital, New York, NY, USA 4Department of Cardiothoracic Surgery at Mount Sinai Morningside Hospital, New York, NY, USA *Corresponding Author: Pankaj Khullar., Cardiovascular Department at Mount Sinai Morningside Hospital, New York, NY, USA
Background: We describe a novel case of treating severe distal aorto-illiac occlusive disease and endovascular aortic repair with kissing endoluminal lithoplasty balloons. This ensured a safe conduit to facilitate thoracic endovascular aortic repair. Case Presentation: A patient with multiple comorbidities including coronary artery disease and peripheral artery disease (Rutherford 4 symptoms bilaterally) presented to the emergency room with chest pain and dyspnea on exertion. The patient was found to have a 3.5 cm descending thoracic aortic aneurysm, multiple penetrating aortic ulcers (PAU’s) within the descending thoracic aorta which was felt to be the cause of her chest pain along with heavily calcified occlusive aorto-iliac disease.  The patient was deemed high surgical risk for open repair and the patient’s severe calcific distal aortic stenosis and bilateral severe ostial iliac stenosis was deemed a barrier for endovascular repair. Therefore, the patient was successfully treated with kissing balloon lithoplasty for lesion preparation of the heavy calcification and placement of an endovascular stent graft (EVAR) in the distal aorta, which ensured a safe conduit for thoracic endovascular aortic repair (TEVAR) procedure. Conclusion: As patients become more and more complex it is important to explore endovascular treatment options especially when surgical risk is high. Balloon lithoplasty and graft placement of calcified aorto-iliac bifurcation is a safe approach to develop a clear conduit for TEVAR. 
89 Lyme Carditis Presenting as Sinus Node Dysfunction and Accelerated Junctional Rhythm   , Saima Karim1*, Roy Arjoon2, B. Julie He2, Lynda Rosenfeld2, Paras Bhatt2 1Heart and Vascular Institute, Case Western Reserve University/MetroHealth Medical Center Campus, 2500 Metrohealth Medical Center, Cleveland, Ohio 2Section of Cardiovascular Medicine, Yale University School of Medicine, 789 Howard Avenue, Dana 3, New Haven, CT 06510 *Corresponding Author: Saima Karim, DO Metro Health Medical Center 2500 Metro Health Drive Cleveland, OH 44109
Lyme disease can have cardiac involvement and can subsequently present with various types of atrio ventricular (AV) block. Sinus node dysfunction (SND) and accelerated junctional rhythm are highlighted in this case as an uncommon presentation for Lyme Carditis.  This case highlights the importance of having a high index of suspicion for cardiac involvement with Lyme disease when atypical arrhythmias are present.  
90 Intracoronary Thrombolysis in no Flow after Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction   , Goutam Datta Associate professor Department of cardiology Burdwan medical college and Hospital West Bengal, India Corresponding author: Goutam Datta, Associate professor Department of cardiology Burdwan medical college and Hospital West Bengal, India
Introduction: Mechanical revascularization of the infarct-related artery (IRA) is the most effective treatment modality in ST-segment elevation myocardial infarction (STEMI).No-reflow occurs in ∼8.8-10% of cases of primary percutaneous coronary intervention(PCI) in STEMI patients. Intracoronary tenectaplase was used when there was huge thrombus causing no flow in coronary artery following primary PCI in STEMI patients. Methods: Five hundred and eighty primary PCI patients were studied over a period of two years i.e. January 2016 to December 2017. Drug eluting stents were used in all cases. Majority of our patients (>90%) came 6 hours after onset of chest pain. There were many patients where there was no flow even after mechanical thrombus aspiration and pharmacological vasodilator therapy. We have given 20 mg of tenectaplase through microcatheter in those cases. Results: There were 44 cases of no flow in our series (7.75%). TIMI 3 Flow was reestablished in thirty two patients after intracoronary tenectaplase (72%). Amongst twelve failure cases LAD involvement was most common eight cases. RCA was involved in four patients. One month mortality rate in no flow group was 50% and 6.25% in successful recanalization group. One year mortality was 12.5% in successful recanalization group and 66% in no flow group. Both were statistically significant. Conclusion: Refractory no reflow during primary PCI in STEMI is associated with high mortality and morbidity. There is no established strategy to solve this phenomenon. Intracoronary thrombolysis is an option to salvage these patients.
91 Total Pericardiectomy via Modified Left Anterolateral Thoracotomy without Cardiopulmonary Bypass (UKC’s Modification): A Video Presentation   , Lakshmi Kumari Sankhyan1, Niwin George1, Sushamagayatri B1, Abhinavsingh Chauhan1, Sheil Avneesh1, Andrei Jha1, Vishwas Malik1, Ujjwal K. Chowdhury1*, 1Cardiothoracic Sciences Centre All India Institute of Medical Sciences, New Delhi *Corresponding Author: Ujjwal Kumar Chowdhury, Department of Cardiothoracic and Vascular Surgery  All India Institute of Medical Sciences
We report one male patient aged 28-years undergoing total pericardiectomy for chronic calcific pericarditis with an uneventful postoperative course. The step-by-step surgical procedure of total pericardiectomy via modified left anterolateral thoracotomy without utilizing cardiopulmonary bypass has been detailed.  
92 Coronary Artery Embolism and Antiphospholipid Syndrome: A Case Report and Review of the Literature   , Tianbao Xu1#, Esmayilaji Patiway1#, Gulistan Alim1, Chenghui Tong1, Jinghe Zhao1, Patigul Rozi1, Eslamgul Hayrilla1, Zemu Wang2, Dianfu Li2*, Yanrong Liu1,2*. 1Department of Cardiovascular Medicine, Kizilisu Krighiz, The People’s Hospital of Kizilisu Kirghiz Autonomous Prefecture, Xinjiang, China. 2Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University. *Corresponding Author: Yanrong Liu and Dianfu Li, Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University.
Coronary artery embolism is an uncommon cause of acute myocardial infarction (AMI), while antiphospholipid syndrome (APS) is one of the rare reasons due to premature AMI. Coronary angiography can diagnose coronary artery embolism, and the positive serum of aPLs may infirm APS. We report a 32 years old man with ST-elevation AMI, without any high-risk factors of coronary artery disease. Coronary thrombosis was founded in the M1 sub-coronary of Left Anterior Descending (LAD), and the coronary artery was recanalized, the artery was not obstructive, Thrombolysis in Myocardial Infarction (TIMI) grade was III. He became shortness after exercise, the echocardiography showed his left ventricular was enlarged and LVEF was decreased. High titers of an anticardiolipin antibody (aCL) IgG of 46U (positive >20.0U), and it was positive at two dosages with an interval greater than 12 weeks. But there was no evidence of any other serum markers suggesting other associated pathologies such as SLE, so the primary APS was diagnosed. We gave him anticoagulation with warfarin and a single antiplatelet with Aspirin, the target INR was 2.5-3.0. Meanwhile, statins and hydroxychloroquine (HCQ) were all prescribed. After 6-months follow-up, his heart failure symptoms were disappeared, the LVDd and LVEF were all normal, the titer was decreased to nearly normal. In clinical background, young AMI without traditional high-risk factors of CAD, we should suspect APS. Therefore, we believed that HCQ may low thrombotic rate, down-trending aPLs titer, and prevent thrombotic recurrences in patients with primary antiphospholipid syndrome.
93 Myocardial infarction in the absence of obstructive coronary artery disease (MINOCA): A Challenge to Diagnose and Manage   , Meera D Kondapaneni1*, Ahmad Jabri2*, Aisha Siraj* and Saima Karim* Heart and Vascular Institute, MetroHealth Medical Center / Case Western Reserve University, 2500 MetroHealth Dr, Cleveland, OH, USA, 44109 *Corresponding Author: Meera D Kondapaneni, Heart and Vascular Institute, MetroHealth Medical Center / Case Western Reserve University, 2500 MetroHealth Dr, Cleveland, OH, USA, 44109
Myocardial Infarction in the absence of obstructive coronary artery disease [MINOCA] is seen in 5-6% of the patients presenting with myocardial infarction. While patients with MINOCA can present with either ST segment elevation or non-ST segment elevation myocardial infarction, they are less likely to have ST segment deviation on electrocardiography and have less of cardiac biomarker elevation compared to their obstructive coronary artery disease counterparts. Patients with MINOCA are usually younger and with lower prevalence of traditional cardiovascular risk factors compared with patients presenting with obstructive coronary artery disease. A variety of atherosclerotic and non-atherosclerotic mechanisms can lead to MINOCA. A diagnosis of MINOCA can only be made in patients whose clinical presentation is attributed to an ischemic event after excluding obstructive coronary artery disease and alternate causes for troponin elevation. A systematic approach to diagnosing the underlying causes is warranted to optimally treat patients presenting with MINOCA.
94 Re-Print- COVID-19 Cardiac Complications: Is an Easy, Safe treatment Strategy Right under Our Noses?   , Gary L Murray Director of research, The Heart and Vascular Institute, Germantown, TN USA. Corresponding author: Gary L Murray, The Heart and Vascular Institute, 7205 Wolf River Blvd, Germantown, USA.
Background: Many chronic conditions, as Diabetes Mellitus (DM) and cardiovascular Diseases, suffer Major Adverse Cardiac Events (MACE): congestive heart failure (CHF), Ventricular Tachycardia (VT), Ventricular Fibrillation (VF), Acute Coronary Syndromes [ACSs], and Sudden Cardiac Death (SCD). Acute infections, like COVID-19, also involve oxidative stress, leading to increased Sympathetic tone (S) and decreased Parasympathetic tone (P), increasing Sympathovagal Balance (SB) and MACE. The antioxidant (r) Alpha Lipoic Acid (ALA) improves SB. The antianginal Ranolazine (RAN), also an antioxidant, is an antiarrhythmic. Our studies of their effects on MACE, in DM, and non-DM patients with CHF, ventricular arrhythmias and SCD are reviewed herein, as our findings may apply to acute diseases, such as COVID-19. Methods: (1) In a case-control study, 109 CHF patients, 54 were given adjunctive off-label RAN added to ACC/AHA Guideline therapy (RANCHF). MACE and SB were compared with 55 NORANCHF patients; mean f/u 23.7 mo. (2) 59 adults with triggered premature ventricular contractions (PVCs), bigeminy, and VT were given off-label RAN. Pre- and post-RAN Holters were compared; mean f/u 3.1 mo. (3) 133 DM II with cardiac diabetic autonomic neuropathy were offered (r) ALA; 83 accepted; 50 refused. P&S were followed a mean of 6.31 years, and SCDs recorded. Results: (1) 70% of RANCHF patients increased LVEF 11.3 EFUs (p ≤ 0.003), SCD reduced 56%; VT/VF therapies decreased 53%. (2) 95% of patients responded: VT decreased 91% (p<0.001). (3) SCD was reduced 43% in DM II patients taking (r) ALA (p=0.0076). Conclusion: RAN, (r) ALA treat CHF, VT, and prevent SCD. Trials in COVID-19 are needed.
95 Can the health care system be effective? - The research results   , Joanna Jasińska Warsaw Medical University named Tadeusz Kozluk, – Poland *dr hab. MBA, prof. Warsaw Medical University named Tadeusz Kozluk, Vice-Rector for Education and Development, Warsaw. Poland *Corresponding Author: Joanna Jasińska., Warsaw Medical University named Tadeusz Kozluk, – Poland dr hab. MBA, prof. Warsaw Medical University named Tadeusz Kozluk, Vice-Rector for Education and Development, Warsaw. Poland
The different definitions of efficiency (in their medical meanings) are presented as the result of meta-reviews found in scientific databases. Efficacy and efficiency are often mismatched with effectiveness in the research of healthcare systems in different countries. In addition to the classic Bismarck’s and Beveridge’s models the modern concepts of health systems include personalized medicine, recognition of health as economic value. However, the basic problem in the Polish healthcare system is the low quality of overly specific and often changed legislation.
96 Out of the Blue Acute May-Thurner Syndrome   , Siddharth Agarwal1*, Christopher Sosnofsky2*, Jamie Saum RN3, Brian Taylor4, Sandeep M. Patel3* 1Vardhman Mahavir Medical College and Safdarjung Hospital. New Delhi, India 2Heritage College of Osteopathic Medicine, Athens, Ohio 3Structural Heart and Intervention Center, St. Rita’s Medical Center, Lima, OH 4Department of Internal Medicine, St. Rita’s Medical Center, Lima, OH *Corresponding Author: Sandeep M Patel, Director, Structural Heart and Intervention Center St. Rita's Medical Center (Mercy) 730 West Market Street, 2K Tower Lima, Ohio 45801
May-Thurner syndrome (MTS) is defined as extrinsic ilio-femoral venous compression by the aorto-iliac arterial system against vertebral bodies and has been associated with many abnormalities involving the arterial system as well as bony structures around the ilio-caval region. We present an unusual case of a patient who came with phlegmasia cerulea dolens in the setting of acute onset MTS after chiropractic vertebral manipulation and was treated with a multimodal interventional approach, combining pharmaco-mechanical catheter directed thrombectomy along with venoplasty with stenting and subsequent post-procedure anticoagulation and antiplatelet prophylaxis.  
97 A Case of Extrinsic Compression of the Left Main Coronary Artery by Dilated Pulmonary Artery in Eisenmengers Syndrome   , Nagamani Alur Chikkabasavaiah, Beeresh Puttegowda, Yeriswamy, Ramesh Basavappa, Varshit Hathi*, Manjunath Cholenally Nanjappa, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research *Corresponding Author: Varshit Hathi, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research.
The extrinsic compression of the left main coronary artery secondary to pulmonary artery trunk dilatation is a relatively rare syndrome. [1,2] It is mostly associated with congenital acyanotic heart disease, idiopathic pulmonary arterial dilatation or primary pulmonary hypertension. [3,4] Most cases of pulmonary artery hypertension with no atherosclerotic risk factors rarely undergo coronary angiography, and hence, diagnoses are seldom made  and proper management is delayed.We describe a patient with Ostium secundum atrial septal defect with severe pulmonary hypertension who presented with clinical angina ,diagnosed to have left main coronary artery compression  by CT angiography ,underwent successful percutaneous coronary intervention with good symptomatic relief.  
98 Basilar Artery Occlusion. Clinical Evaluation and Contemporary Methods of Treatment   , Ivo Petrov1, Zoran Stankov1, Damyan Boychev1*, Valentin Balabanski1, Marko Klissurski2 1Clinic of Cardiology and Angiology, Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria 2Clinic of Neurology, Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria *Corresponding Author: Damyan B Boychev, Acibadem City Clinic Cardiovascular center, Sofia
Acute occlusion of the basilar artery and its branches is a frequent cause of posterior circulation strokes. Although it accounts for only 1 to 3 % of ischemic strokes, it is a potentially life-threatening condition associated with high mortality rates. Exact clinical diagnosis is still challenging because symptoms such as vertigo, dizziness followed by headache, and neck pain are nonspecific and usually attributed to many other neurological diseases. The onset of symptoms can be abrupt or gradual and progressive. Establishing the time of symptoms onset and making a timely diagnosis is highly important. In case the diagnosis is made promptly, ideally with the help of an advanced neuroimaging, intravenous thrombolysis, or catheter-based endovascular treatment can be performed immediately to improve prognosis and reduce mortality.  
99 Acute Arterial Occlusions in Patients with COVID-19: Results and Outcomes , Rafael de Athayde Soares*, Celso Zafani Nunes Hospital Regional Sul – São Paulo, Brazil *Corresponding Author: Rafael de Athayde Soares, Hospital Regional Sul – São Paulo, Brazil
In this paper, we aimed to describe a case series report of four patients that were admitted in the emergency room of our vascular and endovascular surgery department with acute arterial occlusion after a diagnosis of Covid-19 infection. The first patient was a male, 50 years, tobacco user, with arterial systemic hypertension and COVID-19 positive that was admitted with an acute arterial occlusion Rutherford IIb in the left lower limb. He was submitted to an arterial thromboembolectomy with Fogarty catheter and had a satisfactory evolution. CASE 2 was a female, 63 years, with arterial systemic hypertension, diabetes, esquizophrenia, that was admitted with acute limb ischemia (ALI) Rutherford III in the upper left limb. Despite attempts do revascularize the upper limb, the patient evolved with a hand amputation. CASE 3 was a Male patient, 49 years, HIV positive, diabetic with previous debridement in both feet due to diabetic foot infection, tobacco user and Rutherford IIb ALI in the right lower limb..The patient was submitted to an arterial thromboembolectomy with Fogarty catheter, however presented with fasciotomy infection and another post-operative complications that led him to die. Finally, CASE 4 was a female patient, 49 years, diabetic, admitted with COVID-19 infection that presented ALI during hospitalization on the right lower limb. She was submitted to proper thromboembolectomy, with a satisfactory evolution and limb salvage. COVID-19 pandemic crisis is a challenging situation that has increased the number of acute arterial thrombosis and embolism urgencies and emergencies surgeries in the vascular world. The four patients related in this paper bring valuable information regarding the impact of COVID-19 on micro and macrovascular system.
100 Addressing Stroke Risk in a Patient with CREST Syndrome and Atrial Fibrillation with Left Atrial appendage Occluder Device (WATCHMAN)   , Ali Alkhayru1*, Adria Madera-Acosta2, Bassman Tappuni3, Belal Kaseer4, Kamal Shemisa5 1Institutions: University of Iowa Health Care 2Institutions: Augusta University 3Institutions: Cincinnati Good Samaritan Hospital. 4Institutions: Cincinnati Good Samaritan Hospital. 5Institutions: Cincinnati Good Samaritan Hospital and Trihealth health system. *Corresponding Author: Ali Alkhayru, MD Adult Hospitalist Program. Department of Internal Medicine University of Iowa Health Care
CREST syndrome is rare autoimmune disease causing calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly and telangiectasias. We present a case of an eighty-two year old female with CREST syndrome who presented to our clinic with atrial fibrillation and prohibitive bleeding risk.  Managing stroke risk in atrial fibrillation is essential to minimize the morbidity and mortality of the condition. Those with CREST syndrome presenting with recurrent gastrointestinal bleeding may require alternatives to anticoagulation. Recently, the left atrial appendage occluder device became widely used to manage patients at increased risk for bleeding. The device provides a safe and efficacious alternative in lowering atrial fibrillation associated stroke risk. Our patient underwent uncomplicated implantation of the left atrial appendage occluder device. She was closely monitored for one year where she remained stroke free and had one minor episode of gastrointestinal hemorrhage.