The major goal of therapy is to prevent. Incidence of stroke. Increases stroke risk by 340 % Without this condition With this condition

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1 Honorary Editor : Dr. Milan Chag From the Desk of Hon. Editor: Dear Friends, Atrial Fibrillation (AF) is the most common arrhythmia in clinical practice affecting approximately 9 million people in US and Erope and may be an eqal nmber of patients in the rest of the world. AF increases the risk of stroke by 5 fold and to decrease this risk, sch patients need long-term Oral AntiCoaglant (OAC) therapy if stroke risk is intermediate or high as assessed by CHA2DS2- VASc score. For patients who cannot tolerate OAC or has sboptimal IN control or has contraindications for that, there is new ray of hope in form of perctaneosly insertable novel left atrial appendage occlding device which is now approved by US- FDA for sitable patients. - Dr. Milan Chag Dr. Ajay Naik (M) Dr. Satya Gpta (M) Dr. Vineet Sankhla (M) Dr.Jayaram Prajapati (M) Dr. Hemang Baxi (M) Dr. Gnvant Patel (M) Dr. Anish Chandarana (M) Congenital & Strctral Disease Specialist Healthy Volme-6 Isse-65 April 5, 2015 Price : ` 5/- Left Atrial Appendage Closre: A Novel, Approved Therapy for Atrial Fibrillation and Stroke isk edction Cardiologists Cardiothoracic & Vasclar Srgeons Cardiac Anaesthetists Dr. Keyr Parikh (M) Dr. Dhaval Naik (M) Dr. Hiren Dholakia (M) Dr. Milan Chag (M) Dr. Manan Desai (M) Dr. Chintan Sheth (M) Dr. Urmil Shah (M) Dr. Dhiren Shah (M) Dr. Niren Bhavsar (M) Pediatric & Strctral Srgeons Neonatologist and Pediatric Intensivist Dr. Kashyap Sheth (M) Dr. Milan Chag (M) Dr. Divyesh Sadadiwala (M) What is risk of stroke in patients with Atrial Fibrillation? Atrial fibrillation is the most common arrhythmia treated in clinical practice. Patients with AF have a 5 times increased risk of stroke and two fold increase risk of all-case mortality (Figre 1). AF-related strokes are more freqently fatal and disabling. Approximately half of acte stroke victims will die or live with a significant disability, which may reslt in instittional care. The major goal of therapy is to prevent Incidence of stroke Increases stroke risk by 340 % Withot this condition With this condition Increases stroke risk by 240 % thrombo-embolic complications sch as stroke. Warfarin is more effective than Aspirin to prevent this. However, despite its proven efficacy, long-term warfarin therapy is not well-tolerated by some patients and carries a significant risk for bleeding complications. Therefore, it is sefl to risk stratify patients with AF to identify appropriate c a n d i d a t e s f o r l o n g - t e r m o r a l anticoaglant therapy. Simple and most widely sed risk score is CHA2DS2-VASc score (Figre 2). If score is 2 or more, isk factors for stroke Increases stroke risk by 430 % Increases stroke risk by 480 % Dr. Shanak Shah (M) Dr. Amit Chitaliya (M) Cardiovasclar, Thoracic & Cardiac Electrophysiologist Thoracoscopic Srgeon Dr. Ajay Naik (M) Dr. Pranav Modi (M) Dr. Vineet Sankhla (M) Figre-1

2 Healthy Volme-6 Isse-65 April 5, 2015 : CHA 2 DS2 -VASc Score : HASBLED Score Total Score : CHA DS -VASc Score 2 2 Figre-2 Anticoaglation therapy options 0 (low stroke risk) No antithrombotic therapy (or aspirin mg daily) 1 (moderate) Either DOAC or warfarin at an international normalized ratio (IN) of ³2 (high) Either DOAC or warfarin at IN Figre-3 patient is at high risk and needs oral anti- In non-valvlar AF, over 90% of therapy with left atrial appendage coaglant. Patients with score 0 (Low stroke-casing clots that come from c l o s r e b y p e r c t a n e o s risk) may be kept on Aspirin alone while the left atrim are formed in the left i m p l a n t a b l e d e v i c e l i k e those with score 1 (Intermediate risk) atrial appendage (LAA). WATCHMAN or Amplatzer vasclar may be given Aspirin or OAC. Bleeding 50% of AF-related strokes occr plg is an option to redce the risk risk may be assessed by HASBLED score nder the age of 75. of stroke in patients with non- ( F i g r e 3 ) b t p r e v e n t i o n o f <50% of patients eligible for valvlar atrial fibrillation. It is thromboembolism has more priority warfarin are NOT being treated designed to avoid the embolization than bleeding risk. (tolerance/compliance). of thrombi that may form in the left Lifestyle limitations when taking atrial appendage (LAA). AF related Stroke isk Treatment warfarin inclde high risk of Option (Figre-4 & 5): bleeding, negative interactions with Indications: Who shold have LAA AF is projected to increase as poplation ages. Prevalence is estimated to at least doble in the next 50 years as poplation ages. food and drgs, serios side effects that are often difficlt to tolerate, and reqires freqent and ongoing monitoring. Left atrial appendage closre is an alternative to medication. Local device closre? (Figres : 6-9) L eft At r i a l A p p e n d a g e C l o s re Technology is intended to prevent thrombs embolization from the left atrial appendage and redce the risk of life-threatening bleeding events in 2

3 Volme-6 Isse-65 April 5, 2015 Healthy patients with non valvlar atrial fibrillation who are eligible for anticoaglation therapy or who have a contraindication to anti-coaglation therapy (Figre 4). Benefits of LAA Closre: Stroke risk redction Long term anticoaglation therapy cessation Better qality of life Figre-4 endothelialisation. A follow-p transoesophageal echocardiography will be performed at 45 days. At this stage, physician may decide to discontine Warfarin therapy and prescribe Clopidogrel (75mg) and Aspirin (81-325mg) ntil completion of the 6 months Figre-5 visit, from which point aspirin alone shold be contined. Physicians may prescribe clopidogrel and aspirin daily dose for p to six months to the patients contraindicated to anticoaglation therapy. These patients shold remain on aspirin indefinitely. Post-procedre: As the procedre is minimally invasive patient recovery takes abot 24 hors. After the device has been implanted, patient shold receive Warfarin (or other OACs) for 45 days, to facilitate device Figre-6 Figre-7 3

4 Healthy Volme-6 Isse-65 April 5, 2015 Figre-8 Safety, Efficacy and Mortality Data (Figre 6-11) Proven implant safety profile demonstrating a 95% implant sccess in the hands of both new and experienced operators, as well as a declining procedral complications rate to less than 5% in later trials. 40% redction of stroke, systemic e m b o l i s m, c a r d i o v a s c l a r / nexplained death at 4 years in POTECT-AF stdy 4 Figre-9 Figre-10 Figre % re d c t i o n i n C V - d e ath compared to Warfarin at 4 years in POTECT-AF stdy 34% redction in All Case Death compared to Warfarin at 4 years in POTECT-AF stdy F DA h a s re c e n t l y a p p ro ved Watchman device for LAA closre Cortesy : Some of figres, charts and information are taken from Boston Scientific Inc. TECHNOLOGICAL BEAKTHOUGH VALVE SUGEY AT On April 3, 2015 Trans Aortic TAV ( T r a n s c a t h e t e r A o r t i c V a l v e eplacement) was done for the first time in India on a 81 year old male patient with severe aortic stenosis, LVEF 25%, COPD, mild renal dysfnction and severe peripheral arterial disease. It was a very high risk case for an open heart procedre: so TAV was decided pon. TAV IS A HYBID POCEDUE where in cardiology catheter based techniqe and cardiac srgery beating heart techniqe are combined to give mortality and morbidity benefit to the patient. Becase this patient had severe peripheral artery stenosis, throgh a small right thoracotomy a direct aortic pnctre access was sed and stent monted aortic tisse valve was implanted on beating heart. Post op recovery is good and LVEF has improved. This procedre was performed by Dr Dhiren Shah (Cardiac Srgeon) Dr Milan Chag (Cardiologist), Dr Chintan Seth and Dr Hiren Dholakia (Cardiac Anesthetists). FFF (Flattening Filter- Free) for adiotherapy at A recent milestone achieved by Cancer Center in adiotherapy is the AEB approval to se FFF (Flattening Filter- Free) for clinical se. By removing the flattening filter from the linear accelerator, greater dose rate can be achieved de to the physiologic property of flat beam. Advanced treatment like SS (Stereotactic adio Srgery) ST (Stereotactic adio Therapy) and SBT (Stereotactic Body adiation Therapy for Lngs and Prostate) with se of state of art planning system can now be sed to modlate non-flat, high dose rate beams to achieve highly conformal dose distribtions with a redced treatment time.

5 Volme-6 Isse-65 April 5, 2015 Healthy At... we care NABL American College of Cardiology (ACC) (Leading Institte of the World) certifies Hospital as a ACC - Center of Excellence Amongst the first in World and only one in India for high-standards of medical practice and dedication in providing qality cardiovasclar care Express (Cardiology) - Same day appointment for new patient / second opinion Call on , (9 am to 5 pm) (24 x 7) Hospital : Nr. Shkan Mall, Off Science City oad, Sola, Ahmedabad info@cims.me /cimshospitals ENAL TANSPLANT now at Hospital with the backing of world class technology A highly experienced and skilled renal transplant team with experience of over more than 1000 cases welcomes the following as a part of their team Interventional Cardiologist Dr. Jayaram B. Prajapati (M) DNB (Medicine), DNB (Cardiology) Interventional Paediatric Cardiologist Dr. Divyesh Sadadiwala (M) MD (Peds.), FPC Consltant Paediatrician & Neonatologist Dr. Snehal H. Patel (M) MBBS, DNB (Paediatrics) Consltant Obstetrician & Gynaecologists Dr. Sneha Baxi (M) M. D. (Obst. & Gynec) For appointment call: , (M) Dr. Nita Thakre Endoscopic Gynaecology (M) High isk Pregnancy, Urogynaecology 5

6 Healthy Volme-6 Isse-65 April 5, 2015 Management of pregnant patients coming for open heart srgery Introdction: The incidence of heart disease in pregnant women is reported to vary from 1% to 4%. In low-income contries, 60-80% of the pregnant women with heart disease sffer from rhematic heart disease and it is a major case of death related to pregnancy. Indications for srgery sing Cardio Plmonary Bypass (CPB) dring pregnancy inclde cardiac valve disease, prosthetic valve malfnction, cardiac myxoma, congenital heart disease, plmonary embolism, anerysm and coronary artery disease. ecent data sggests a maternal mortality rate similar (1.47%) to that associated with CPB in non-pregnant women, nless the srgery is emergent while fetal mortality is as high as 16-33%. Cardiac srgery in pregnant patients, as a reslt, mst be limited to cases where medical management fails. ecently, we have sccessflly managed a case of 26years old primigravida with 5.5 months of amenorrhea with twins fets with rptred sins of valsalva into right ventricle and Ventriclar Septal Defects (VSD). Patient has been operated sccessflly with repair of rptred sins of valsalva with VSD repair on CPB. Mother discharged with stable condition with live healthy twin fets. Sccess of srgery depend pon the timing (trimester) of srgery, pertrbation of maternal cardiovasclar system by the heart disease, concomitant maternal and fetal morbidities. Table 1 shows the predictors of maternal and fetal otcome according to the heart disease. Why it's a real challenge? Dring pregnancy physiologically cardiac otpt increases by 40-50% with increase in plasma volme by 45% and heart rate Table 1. Predictors of maternal and fetal otcome by 15-25%. The presence of maternal heart disease with these circlatory changes of pregnancy can reslt in decompensation and in death of the mother or fets. Management: There is no difference in srgical approach and management of a pregnant verss non pregnant patient coming for heart srgery. Anaesthesia and cardioplmonary bypass management is the real challenge as at any given point of time teroplacental insfficiency can reslt in fetal demise. So proper planning with mlti disciplinary team approach inclding cardiologist, cardiac srgeon, cardiac anaesthesiologist, gynecologist and perfsionologist is pmost important Goals of anaesthesia and CPB management n Infective endocarditis prophylaxis n Avoid feto toxic drgs n Be prepared for difficlt intbation as airway edema with high vasclarity n Antiaspiration prophylaxis n Avoid inferior ven caval compression by gravid ters by left lateral tilt of degree n Fetal heart rate and terine contraction monitoring (fig. 1) n Maintain tero placental circlation n On CPB maternal hematocrit >25%, High maternal oxygen satration, Normothermia, High perfsion flow rates (>2.5 L/min/m2), High perfsion pressre (>70 mm of Hg), Minimize CPB time with Plsatile flow (preferred bt not mandatory) n Adeqate analgesia post operatively n CP in pregnancy is different than non pregnant patient n At any given point of time maternal well being is given priority over fets Low isk Moderate isk High isk Most commonly repaired lesions Single ventricle NYHA fnctional class >III Uncomplicated left-to-right shnt Systemic right ventricle History of peripartm cardiomyopathy Plmonary stenosis Uncorrected coarctation Plmonary hypertension Plmonary regrgitation Unrepaired cyanotic lesions Marfan syndrome with aortic size >4 mm Aortic regrgitation Use of anticoaglants Severe left ventriclar dysfnction Mitral regrgitation, mitral valve prolapse Mitral stenosis Aortic stenosis Left ventriclar dysfnction NYHA = New York Association *Adopted from a table in Dob and Yentis.* 6

7 Volme-6 Isse-65 April 5, 2015 Healthy Conseling of women with heart disease n The conselling of cardiac patients abot the risk of pregnancy shold commence as soon as they become sexally active. n Adeqate advice concerning contraception shold be offered. n T h e r e i s a significant risk of maternal cardiac decompensation and death dring pregnancy and in the first month post partm in w o m e n w i t h E i s e n m e n ger's syndrome, severe Figre1: fetal heart rate and terine contraction monitoring p l m o n a r y h y p e r t e n s i o n, severe aortic stenosis or left ventriclar otflow tract obstrction, Marfan's syndrome with aortic dilation greater than 4 cm or symptomatic systemic ventriclar dysfnction with an ejection fraction < 40%. These patients shold be conseled against pregnancy. n In general regrgitant and volme overloaded conditions are better tolerated than stenotic and pressre overloaded conditions. n When a woman wants to get pregnant, clinical assessment inclding echocardiography, exercise testing and sometimes 24-hor ECG and MI is indicated. Based on these data, risk assessment can be performed. n When it is decided that the woman can carry on and attempt to get pregnant, each medicine that she is sing n n n shold be reviewed: is it necessary to contine this medication throghot pregnancy, or can it be safely discontined, or shold it be replaced by a safer alternative? A plan for cardiology and obstetric spervision dring pregnancy mst be made If pregnant patient reqires cardiac srgeries, it shold be performed dring second trimester as first trimester is associated with organogenesis and third trimester is associated with risk of prematre delivery. Many women with heart disease can go throgh pregnancy with few or no complications if managed by mltidisciplinary team at tertiary care center. Dr. Kashyap Sheth Dr. Hiren Dholakia Ulhas Padiyar Pediatric & Strctral Srgeon Dr. Shanak Shah Pediatric Cardiologists Dr. Divyesh Sadadiwala Cardiac Anaesthetists Team Dr. Chintan Sheth Pediatric Intensivists Dr. Amit Chitaliya Cardiac Perfsionist Team Dhanyata Dholakia Dr. Snehal Patel Obstetrics and Gynecologist Dr. Sneha Baxi Dr. Milan Chag Dr. Niren Bhavsar Prashant Nair Once again, we are prod to be the official medical partner of ajasthan oyals - IPL Team #Hospital #ajasthanoyals #AlwaysAoyal #IPL2015 #IPL8 7

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