We in Pakistan are proud of all those who decided to return from overseas to serve their own country
Despite lucrative remuneration and good quality of life abroad, they came back which is indeed commendable, we just acted as a Bridge-Prof. Nadeem Qamar
KARACHI: We in Pakistan are proud of all those who decided to return to Pakistan to serve the country. Despite lucrative remuneration and good quality of life abroad, they came back is indeed commendable and we just acted as a Bridge. This was stated by Prof. Nadeem Qamar former Executive Director of National Institute of Cardiovascular Diseases who was the Guest of Honour while speaking in the Second Annual Heart Valve Summit organized by NICVD here on December 9th 2023.
When they came back, we took care of them and got them everything they wanted. Some of the toys(equipment) they asked for was very expensive but we managed to provide them. Their return and working in Pakistan will have an impact on image all over Pakistan. We got them MRI, CT and few other equipment they will get soon as Prof. Tahir Saghir the Director NICVD is dealing with the Finance Director. Now CT Scans have also been installed at Tando Muhammad Khan and Sukkur affiliates of NICVD and the entire province will start interventional procedures for acute stroke as well, Prof. Nadeem Qamar remarked.
Earlier Prof. Sabha Bhatti Programme Director of Advance Imaging Fellowship at NICVD and chief organizer of the Summit welcomed the faculty and participants of the Summit.
First Session
In the first scientific session which was chaired by Prof. Nadeem Qamar along with Prof.Abdul Hakeem and Prof. Sabha Bhatti, Dr. Nicolas Merke from Germany was the first speaker who made a presentation on” Echocardiography is still state of the art in valvular heart disease while CT and CMR are useful sidekicks”. State of the art evaluation, he opined, requires quantification as well. Mitral regurgitation is a daily routine with Echo. CT has big impact on planning. CMR has a role in a few patients with some acoustic window. CMR is unique in tissue characterization. He also talked about PISA pitfalls in grading SMR. Key to success, he said, was identification of correct PISA. He was of the view that one must make sure that the numbers must reflect reality. He also showed some informative slides of MR at rest and stress. One should use 3D to unmask mechanism. He then discussed in detail using fancy tools of valve quantification. What goes in must go out, he remarked. He also talked about blood pressure and Mitral Regurgitation. His presentation was supplemented with numerous informative ECHO slides. Quantification of severity, he stated, is like putting together pieces of puzzle. BP of regurgitation at different times of the day is different. He also spoke about etiology. Responding to a question he said that with two people they perform about forty ECHO a day. We cannot do 3D ECHO for every patient.
Dr. Marwan Saad from USA discussed “Cutting edge structural interventions. TEER: New hope for patients with mitral regurgitation”. He first descried the background, current commercial devices available and the clinical evidence. Trans catheter Edge to Edge Repair (TEER), he stated, was first performed in 1990 by Alfieri. Mitral Valve was first implanted in 2003. He discussed the birth of TEER, referred to G4 Mitraclip while PASCAL was yet another device available.
He then described management of a few cases. The first case was of seventy-eight year’s old lady who was suffering from Type2 diabetes, high risk for surgical repair for MR. He shared the findings of EVEREST Trial which included two hundred seventy-nine patients at thirty-seven sites. There was reduction in MR. In the second trial there were one hundred seventy-eight patients in mitral clips group and eighty in surgery group. There was a good outcome and mitral clip group had freedom from surgery. For five years there was a good survival as compared to surgery. He also talked about CLASP-II trial for PASCAL. Freedom from all-cause mortality was similar. In some patients three mitral clips were used.
His second case was a seventy-seven years old lady. In the COAPT trial there were three hundred five patients in Mitral Clip and three hundred five in GDMT group. Death and hospitalization due to heart failure was compared in both the groups. He then shared the details of ACC and AHA 2022 guidelines. Third case was ninety-three years old male who came with cardiogenic shock and his management was discussed in detail. He also talked about benefits of Mitral Clip. There was significant improvement in mortality in all patients who had successful mitral clip implantation. He also referred to the future of TMVR and showed some Mitral TEER slides.
Commenting on the presentation Prof. Abdul Hakeem remarked that the first patient they managed went into cardiogenic shock and the clip had to be removed. While doing these procedures, it is difficult to predict as to what will happen.
Dr. Nasrien Ibrahim Heart Failure Transplant Cardiologist from Harvard Medical School USA was the next speaker who spoke on” Call Heart Failure before you call Heart Failure Team: The role of GDMT works in the contemporary management of mitral regurgitation”. Speaking about the global burden of heart failure, she said, there are over 2.8 million heart failure patients. She then discussed the tolerability of GDMT in mitral regurgitation. About 39% tolerated any dose of all three classes of GDMT simultaneously. MRAS was tolerated by 55% of patients while beta blockers were the most tolerated drugs. She also talked about heart failure with reduced Ejection Fraction. CRT, she said, reduced mitral regurgitation and then talked about cardiac resynchronization therapy. Later she shared the management of a few cases. Amlodipine offered no benefits in mortality in HFrEF. She then discussed the safety and efficacy of ARNI, Beta Blockers, MRA and SGLT2 inhibitors.
Speaking about the strategies of success, she advised that one must discuss the four drug strategy with the patient at the initial contact. Start with a small dose. Wet patients, she opined, are ideal. We need to back off diuretics when initiating ARNI and SGLT2 Inhibitors. If the therapy is initiated while the patient is admitted in hospital, they will remain on therapy. She also talked about multidisciplinary GDMT clinics and Telehealth besides patient self-titration. Beta blockers offer length of mortality reduction in patients with reduced EF, rapid reduction in hospitalization, health status also improves and it also improves LEEF but one must start treatment early. If there is a need for Inotropes, end organ dysfunction, recurrent HF hospitalization, escalating diuretic use, progressive intolerance of GDMT, at this stage the patient needs to be referred to advance heart center.
The take home messages from her presentation included that Mitral TEER is a viable alternative to mitral valve surgery in patients with degenerative MR and prohibitive risk of surgery. Mitral TEER is indicated in symptomatic patients with moderate, severe or severe functional MR whether degenerative or functional. The future of percutaneous transcatherer mitral valve replacement holds a lot of promise. During the discussion it was pointed out that GDMT plays an important role in MR and patients with HFrEF should be on beta blockers.
Dr. Jamal Khan from UK spoke about Mitral Regurgitation Imaging: What one actually has at our disposal in 2023: It is not just the ECHO.” He discussed in detail management of MR Imaging, MR assessment and management, MR imaging TEE and TOE, 3D in MR, anatomy, structure, severity, mechanism, left ventricle and management. These are the challenging cases but suitable for TEER. 3D, he said, is not just for TOE but get adjustment to TEE. He also talked about Exercise Stress Echo in MR and cardiovascular disease CT in MR.
Prof. Sabha Bhatti from NICVD was the last speaker in this session and she shared the data for the last one year of patients managed at Valve Center in NICVD. Establishment of a Valve center, she opined, is essential for medical objectives, education and training while long term objectives include making a multidisciplinary team. Heart Valve Centers of Excellence she said should annually report their mortality and success rate and the details needs to be shared. She described in detail the Heart Team components. The Centre offers individualized treatment services for the patients taking into consideration cultural factors, patient and family and the heart team. There are risks and benefits and the Heart Team after consultation decides what is best for the patient.
Continuing Prof. Sabha Bhatti said that it was in September 2022 that a dedicated Heart Valve Center was established at NICVD, there are three half days OPD clinic per week. All the patients are reviewed case by case. We review the previous tests, investigations, if need be additional tests are performed. We make sure that these tests are done the same day so that the patient don’t have to come again for investigations. We have started a Valvular Registry. So far we have registered one thousand two hundred thirty-six patients. These are not routine but most complex cases. Most of the patients come from the surgical clinics and majority of them were between the age of 31-40 years which is the most productive age. Common symptoms included dyspnea, and angina which were most common. About 56% of the patients had PEN G and the comorbids included diabetes, hypertension, smoking, dyslipidemias, about 1.2% had family history of heart disease and 6! % had normal LV functions and RV was normal in 66%. Speaking about the burden of vascular disease, she said, one hundred seventy-five had Myocardial Infarction, two hundred twenty-nine had MR, two hundred thirty seen had AS, five hundred eleven patients had mitral stress present, 99% were rheumatic patients, 76% 945 patients had MR while 291 (24%) had no MR, five hundred thirty-four cases were of AS while three hundred three patients were of severe aortic stenosis. Rheumatic Heart Disease and Mitral Valve Disease are more common. About 78% of these patients were referred for surgery, 13% were managed conservatively. Three hundred sixteen surgical procedures were performed. Of this 29% had MVR plus AVR, seventy-one patients were sent for PMBC, 31.5% had surgery in two weeks while 19.9% had surgery within three weeks. We had an overall mortality of 15.5%.
Post-operative ECHO was done of all cases. Fifteen patients had complications and all these patients had clinical follow up on phone. Reminders were also sent for follow up. One nineteen years old patient had left main disease. A thirty-two years old female with two children at home presented with family history of sudden cardiac death. She was five months pregnant. She was kept on medical therapy with follow up and then with the help of JPMC a cesarean section was performed, both the mother and the baby are fine and doing well. In addition, we also had screening of four hundred school children and identified four cases of RHD giving a prevalence rate of 1%. Survey of seven thousand five hundred patients at antenatal clinics also showed the prevalence of RHD as 1.1%.
Commenting on the presentation Prof. Nadeem Qamar remarked that Valve Clinic has done a commendable job. It has changed the lives of many. Such multidisciplinary clinics needs to be established in all the medical institutions. We should also conduct research to find out the real prevalence in the country.
Second Session
This was chaired by Prof. Jawaid Akbar Sial along with Dr. Asad Akbar Khan, Prof. Sabha Bhatti and Prof.Abdul Samad. Dr. Benoy Shah from UK spoke on “Secondary Tricuspid regurgitation- target for treatment or Bystander”. In management one should add diuretics. He then discussed a few case studies. Replacement, he said, should be offered to the patients. Now the number of papers on tricuspid regurgitation are increasing which is evident from the fact that in 2000 there were just fifteen papers and now in 2023 two hundred sixty two papers have been published though the years is not finished. Secondary TR, he said, is common. Optimal management of secondary TR remains challenging. Medical therapy is limited to diuretics. Surgery is infrequently performed for isolated intervention. Operative time for TV intervention is unknown.
Prof. Abdul Hakeem shared the Structural Heart Interventions at NICVD. He pointed out that IHD is on top in Pakistan as compared with other neighboring countries. TAVR and BAV are done in Pakistan. Other procedures performed include mitral valve intervention, PTMC, ACHD, ASD/PDA-VSD and valvuloplasty. About 77% of patients go for surgery and 15% for medical therapy. In 8% of cases Tran catheter therapy was reported. Weekly structural heart meeting is held at NICVD in which after detailed discussion patients for intervention are finalized. The first case of TAVR was done on August 19th 2005. In a study of one hundred cases, 94% had successful valve deployment. We have done forty-six cases last year, 40% were bicuspid and mean age of the patients was seventy-five years. Mean hospital stay was forty-eight hours.
Prof. Khan Shah Zaman did the first PTMC in 1993 and over the past few years over three hundred fifty patients had this procedure. Risk of tamponade was 0.8%. In severe MR the risk was 0.5%. Giving figures of the TAVR performed in the country Prof. Abdul Hakeem mentioned one hundred forty-nine at NICVD, Sixty at Tabba Heart Institute, AKUH seventy-six, Shifa Islamabad twenty-five, Baharia Hospital Islamabad twenty-three, GIMS fourteen and Punjab Institute of Cardiology fifty. All these centers, he said, have a dedicated heart team. Cost is the major problem, about 50-60% of the patients eventually get TAVR. At NICVD it is essential that the surgeon says no for surgery before TAVR is decided. At present the cost is between eight thousand to thirteen thousand US dollars. We can do five AVR for the cost of one TAVR. He also laid emphasis on having a robust registry. AT NICVD six hundred to seven hundred PCI procedures are done. Structural interventionist should have a good knowledge of imaging. We need to reduce the cost to implement this programme.
Dr. Asad remarked that we get the valves at a very economical price which are available in other countries at a much higher cost. In the days to come the situation can be worse. If someone buys them in bulk and then provide it to various centers, it could be one option to reduce the cost. Medtronic’s has helped us a lot, he remarked.
Participating in the discussion Prof. Abdus Samad referred to an Editorial published in BMJ about fifteen years ago which had the title “Why we are afraid of thoracotomy”. In the past many TB patients used to have it successfully which improved their quality of life. American companies he said, will never reduce the cost. Either we should start manufacturing these valves locally or the Chinese can help improving production and reducing the cost. He also remarked that once members of the Pakistan Cardiac Society had a meeting with late Dr. Abdul Qadeer Khan. He offered that they can start indigenous production of valves and stents provided the cardiologist promise to use them. Now NUST has produced stents but I do not what happened to the Valves project. Good surgeons, he remarked should not be afraid of thoracotomy.
Dr. Babar S. Hasan from SIUT made a presentation on Use of Artificial Intelligence in Valvular Heart Disease and discussed the use of AI in healthcare in Low and Middle Income Countries. AI, he remarked, is a complementary tool and it will not at all replace the physicians. He was of the view that we should think smart, look at the problems, ensure patient centrist care and plan for continuum oriented care. We have inadequate resources and the burden of disease is very high. We need to plan intervention in school children who are between the age of five to fifteen years of age. AI can be a value addition. AI is being increasingly used in developed countries. If we do not act wisely, we will continue to publish prevalence studies. AI can be successfully used for screening in schools. He then showed studies in which digital stethoscope was used wit machine learning, AI was being used to read ECG. He was of the view that unsupervised learning can do a lot of useful work. Case selection can be done using AI. We at SIUT are working on fetal and maternal Echo. AI Dr. Babar Hasan said is here to stay and now Healthcare is not being done by physicians and surgeons alone.
Prof. Abdus Samad remarked that AI physicians are not scientists. One becomes a doctor because one does not need job, is respected in the society and can serve the ailing humanity. AI is being used to make money. One should never underestimate the importance of human touch which plays an important role in delivery of healthcare. AI can be used with caution.
Concurrent sessions
There were three concurrent sessions held in the afternoon. One of the sessions was chaired by Dr. Tasnim Naqvi along with Prof. Zainab Samad and Dr. Shahbaz Sarwar. Prof.Zainab Samad was the first speaker who discussed Mitral Regurgitation Assessment. She suggested one should determine the type of severity of MR and its comprehensive assessment should be made. American Society of Echocardiography recommends that 3D Echo is good for assessment. Selection for intervention is important and the same operators should be assessing the mitral valve.
Dr. Saira Bokhari from AKUH discussed repair and replacement for mitral regurgitation. She pointed out that in some cases repair may not work but repair should be tried as far as possible but if not, then it should be replaced. Guiding principles are that complex mitral disease repair should be done by experts. One should not push for repair. Operative mortality she stated is less than 1% and it offers good quality of life. She concluded that Echo guidance and patient selection is very important for best outcome. She also discussed when one should not push for repair. Prof. Zainab Samad remarked that we must publish from Pakistan the results of repair and replacement.
Dr. Tasnim Naqvi in her concluding remarks said that functional MR is very important on right side. One should not forget atrial fibrillation. 3D Echo is very important. One should not go for replacement although replacement is done in almost 40% of cases in non-academic institutions in USA. 3D remains a gold standard for assessment. Surgeons should be trained in replacement. Dr. Shahbaz Sarwar remarked that we have young rheumatic patients who come from lower socio economic class and their follow up is also very poor.
Dr. Gurmani Sukoon from NCVD talked about Aortic Valve Imaging and opined that one must be aware of associated findings. She presented a few case studies. While scanning one should always think of sideways, take help of multimodality imaging. Commenting on the presentation Dr. Tasnim Naqvi remarked that one does not see such advanced pathology in USA. One should be careful of early intervention.
Prof. Shaharyar Sheikh from Lahore shared the highlights from World Congress on Rheumatic Diseases recently held at Abu Dhabi in the session chaired by Prof. Babar Hasan and Dr. Najma Patel. He recalled that at the conference held in 2013 it was decided that we will try for 25% reduction by 2025. There is an increase in rheumatic heart diseases and studies shows that the most patients are in the most productive period of age. Vaccine development is difficult because the pharmaceutical industry is not interested since there is not much money in this. Studies in Africa has noted the role of skin infections in acute rheumatic fever. A Biomarker project is now underway in which Pakistan is also participating. He also talked about molecular epidemiology and said that some proteins have been identified for rheumatic heart disease. Anti-inflammatory drugs are being used to reduce the disease. REMEDY study is underway in fourteen countries which will have two years follow up. Global Rheumatic Heart Disease Registry has been created. High mortality is at the age of 28.7 years. Two years’ fatality rate has been estimated to be 16.9%. In Africa antibiotic treatment has been initiated for latent rheumatic heart disease. One of the studies reported that 85% of the patients present with heart failure or cardiac complications. We need to pick up these cases. He became very emotional and tears came to his eyes when he commended all those who have returned from overseas to serve the country.(This has a very sad and tragic history). Prof. Shaharyar Sheikh remarked that when we decided to comeback there was no Echo and we all practiced with clinical skills taking good history and comprehensive physical examination.
Dr. Shahbaz Sarwar said that Prof. Shaharyar Sheikh is my mentor and he is pioneer in the field of heart failure and Rheumatic Heart Diseases. We are all extremely grateful to him. Dr. Najma Patel said that even if Echo is normal, repeat it after three months and even till one year. Prof. Babar Hasan said that people like Prof. Shahryar Sheikh inspire all of us to do more. His advice to his colleagues was to become thought leaders and don’t become data gatherers.
Dr. Shazia Mohsin from SIUT discussed the management of a few cases of pediatric valvular heart disease. She showed some images which are helpful in diagnosis and also discussed aortic valve classification. She opined that we must adopt new technology, collaborate which improves outcome. She suggested collaboration between different centers in the region.
Dr. Abdul Sattar Sheikh from NICVD talked about the pulmonary valve interventions. Pulmonary valve, he said, is as important as other valves but unfortunately it is least addressed in literature. Congenital heart disease accounts for 23% and it is the most common birth defect. Pulmonary regurgitation is very important and it is also progressive. Almost 75% most common cases are of pulmonary regurgitation. Significant pulmonary valve regurgitation will lead to sudden death. Different sizes are available for trans catheter valve replacement. Early mortality is reported to be 1%. Intervention results in significant improvement in functional class. VT risk is lower about 23%. PR, he opined, needs close monitoring, cost remains the biggest problem. Dilated RVOT is also a problem. We want to look at future and plan accordingly. Dr. Shazia Mohsin emphasized the importance of audit, regular monitoring and learning from our mistakes on diagnosis. Prof. Babar Hasan remarked that Echo will be used for pulmonary regurgitation. People must know right heart management. Dr. Tasnim said that we can train nurses to do Echo using AI. Studies have shown that they were as good at assessment. We need to pick up cases early. Babar Hassan said we need to create care pathways as well because screening alone will not help.
In the other session Dr. Osman Fahim from AKUH disused the Evolving role of surgical aortic valve replacement in the era of Trans catheter Valve procedures. Other topics in this session discussed included Case assessment for TAVR, TAVR in patients with a small aortic annulus and PMBC. In the other concurrent session, the topics which were discussed by various presenters included minimally invasive cardiac surgery, Rheumatic Mitral Valve: Repair or Replacement, and benefits of aortic root enlargement during aortic valve replacement.
In the concluding session Prof. Tahir Saghir Executive Director of NICVD said that there was lot of learning during the day long sessions. He wished there were more students, postgraduates and we must find out how we can engage them in future. He hoped that next year the programme will be much more informative and we will take it to the next higher level.Prof. Sabha Bhatti thanked all the speakers, participants and all those who extended valuable help and assistance in organizing the conference. She specially thanked PharmEvo for sponsoring the meeting.
