TAVR reduces risk of bleeding while stroke risk is equal to surgery-Dr. Osman Faheem


 AKU’s Health Sciences Research Symposium proceedings

TAVR reduces risk of bleeding while stroke risk
is equal to surgery-
Dr. Osman Faheem

TMVR has not improved survival but
it has improved quality of life

KARACHI: Trans catheter Aortic Valve Replacement (TAVR) has reduced the risk of bleeding and the risk of stroke is equal to surgery. Trans Catheter Mitral Valve Replacement (TMVR) has not improved survival but it has improved the quality of life. This was stated by Dr. Osman Faheem Consultant Cardiologist at AKU while speaking in the Plenary Session on the second day of the AKUH’s 20th National Health Sciences Research Symposium held from November 3-5, 2017. The topic of his presentation was Structural Heart Disease: Innovations in Treatment”.

Structural Heart Disease, he said, relates to non-coronary therapies in the heart, post Myocardial Infarction complications. It requires multidisciplinary approach and relies high on imaging.  During the past few years this specialty has grown tremendously. He then discussed in detail Trans Catheter Valve Therapy, aortic stenosis on which there is limited data in Pakistan and TAVI.  Survival in aortic stenosis goes down. Since the patients are getting older and complications are increasing, TAVI (Trans Catheter Aortic Valve Interventions) is needed. There is no difference in mortality as compared to surgery but TAVI ensures better survival. Surgical AVR has low risk. He also talked about different techniques, valves and valve in valve therapy.

Dr. Aamir Hameed Khan Associate Prof. of Medicine and Director of Cardiac Electrophysiology and Device therapy at AKU was the next speaker. Topic of his presentation was Innovations in the management of cardiac Electrophysiological disorders. He pointed out that it was Dr. Camer Vellani who did pioneering work in AKU in this field. Other pioneers include Lt. Gen. Imran Majeed who was working at AFIC previously and Dr. Azam Shafqat at AKU.  New pace makers, he stated, are more expensive. There are chances of heart perforations and there is a risk of dislodged devices. Multipoint pacing has a safety of 93.2% while device related adverse events account for 6-7%. These devices are placed in those patients who have already had optimal medical therapy. He also talked about scar within a scar, successful ablation of scar after MI. Patients, he stated, do not come in time. At present we are living in exciting times in cardiology and electrophysiology. Multipoint pacing will improve further. Scar VT ablation in CAD and complicated CAD are major moves in Pakistan, he added.

Dr. Zubair Luqman Cardiac Surgeon from St. Boniface General Hospital, Winnipeg, Canada was the next speaker who discussed Heart Failure Surgery: Innovations and latest research in management of Failing Hearts. Management of congestive heart failure, he sated, needs huge investment. We do not have good quality of life and longevity is not there. In United States there are over five million patients with heart failure and in Europe their number is 3.6 million. China has more than 4% population with heart failure and according to reports over two lac fifty thousand deaths occur only because of congestive heart failure annually. Heart Failure is known as the cardiac epidemic of the 21st century. Dr. De Bakey was the first one who did VAD in 1966. He then talked about various devices and new treatments for heart failure. New devices, he said, has improved survival rate and also offer better quality of life. Heart transplant he further stated was the ideal treatment but very few can get it because of paucity of donors. Ventricular Assist Device has become popular since there are not many heart transplants. He also referred to new surgical and intervention devices besides talking about different techniques for heart transplant. He further stated that now older age donors are being accepted for heart transplantation, bypass on transplanted heart is being performed. He also talked about changes in operative techniques and limitations of heart transplantation. Speaking about mechanical circulating support for heart failure he referred to Ventricular Assist Devices which offer three to five years survival though it should be improved to five to seven years. Cost effectiveness of these devices, he opined, was a major factor. Number of heart transplants are going down all over the world due to paucity of donors. He then talked about heart ware, potential device complications, immediate post-operative period and long term complications as well as thrombotic complications. He then discussed the progress being made towards biocompatibility. Stem cell therapy, he opined, could be a magic bullet or blind alley.

He concluded his presentation by stating that this epidemic of heart failure was increasing. Novel approaches are needed to manage this. Economic will be the major challenge as these devices are more expensive. One needs a heart failure team and we need to train more cardiologists in heart failure management. Taking care of these devices is much more important than acquiring or putting them in the patients.

Dr. Irfan Vaziri Consultant Hematologist from Callahan Cancer Center in North Platte, Nebraska, United States spoke on Innovations in Treatment Non-Small Cell Lung cancer. He discussed at  length lung cancer prevention and management of advanced diseases. He pointed out that lung cancer was the most deadly and most preventable cancer. Tobacco smoking is usually at its peak by the age of twenty five years. Hookah is another culprit which is becoming popular even in United States. He discussed the staging in lung cancer, efficacy of CT, PET scan and MRI besides principles of radiation therapy. For Stage-1 patient’s surgery is preferred for Stage-2 surgery is followed by chemotherapy. Patients in Stage-IIIa should be discussed in the Tumour Board meetings but Stage III B & C should not be operated but managed with chemotherapy and radiotherapy. He also talked about the role of immunotherapy in lung cancer which is a chronic but not lethal disease, he added.

Dr. Omar Minai Consultant Pulmonologist from USA discussed Innovations in Risk Stratification for Pulmonary Arterial Hypertension (PAH).This, he said, was a progressive disease. Its median survival used to be 2.8 years. While managing PAH, he suggested to be more aggressive in approach. He further stated that one cannot predict which patient is going to be better and which will need heart transplant, who will do poorly and who will do better? It is Syncope which predicts mortality. One should start with multiple medications so that clinical failure is reduced. Survival remains poor in PAH despite the use of many drugs. The reasons are delay in diagnosis, delay in starting therapy, inadequate therapy and poor understanding of the disease. He reminded the participants that there was no substitute for good clinical evaluation and PAH is much more than vasoconstriction.

Rozmeen Shivji Acute Care Nurse Practitioner and Critical Care specialist at University of Chicago Hospital United States highlighted the role of Advanced Practice Nurses in cardiac sciences. She pointed out that Advance Practice Nurses were playing a vital role in provision of healthcare in many developed countries. Their contributions to healthcare can be judged from the fact that   870 million patients have visited these Nurse Practitioners so far. He then traced the history of these Nurse Practitioners and said that at present in nineteen States in USA they have license to practice independently. The number of Nurse practitioners was 2, 34,000 in 2016 and over twenty three thousand new Nurse Practitioners were added during 2015-2016. In Nineteen States they can prescribe medicines independently. American Academy of Nurse Practitioners (AANP) she stated plan to increase the number of Nurse Practitioners to 2, 44,000 by the Year 2025. Because of them there has been reduction in re-admission rate in hospitals, it has increased access to health services. It has also improved working relationship and satisfaction rate among the patients. These Nurse Practitioners are also credited for reduced ICU mortality, reduction in overall healthcare costs. Over the years we have gained confidence and we are shouldering more and more responsibilities. Physician’s shortage is increasing which will lead to increased use of Acute Care Nurses.

Continuing Ms Rozmeen Shivji said that physicians feared that these Nurse Practitioners will take over their jobs. They also say that nurses are not as skillful as doctors, training of doctors is almost different and these Nurse Practitioners cannot act as Doctors.  It is true that we are not doctors and our training is different but we have job satisfaction. Of course there will be power struggle and growth opportunities but despite all these fears Nurse Practitioners Programme is functioning well in many countries. However there are challenges as to who will train them, where they will be trained and who is going to accredit these Nurse Practitioners. In China the disease burden is increasing, physician’s shortage is going up hence the need for these Acute Care Nurses. We consider ourselves as Champions but not competitors, she remarked.

On Day-III of the symposium in the morning session there were brief presentations related to posters and a few oral presentations. Those who spoke in the session included Hunaina Shahab who highlighted the importance of Post-Clinic Blood Pressure values which she stated were the closest to the gold standard Ambulatory Blood Pressure Monitoring. Dr. Muhammad Saad talked about post-operative cognitive dysfunction. Maj. Gen. Prof. M. Aslam Pro VC of National University of Medical Sciences Rawalpindi highlighted the cardiopulmonary aspects in Mountain Medicine.  He discussed in detail sudden ascent to high altitude which results in hyper ventilation, polycythemia, hypoxia and acute mountain sickness. High Altitude Medicine, it was pointed out has emerged as an important discipline of medicine but unfortunately not much work has been done in Pakistan in this field. This was followed by a panel discussion on the importance of Education and Awareness for Healthy Living. Dr. Anjum Halai moderated this session and the panelists included Dr. Batool Fatima, Yasmin Mehboob and Silpa Aziz. The importance of early childhood education and parent’s contribution to early education were some of the aspects which were highlighted in this discussion. 

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