Interventional Cardiology & Cardiac Surgery

The Department has a number of modern hemodynamic labs, treating - on a 24hour basis - all conditions related to coronary artery disease, peripheral vascular diseases, as well as structural and congenital heart diseases, both diagnostically and therapeutically.

Angiography is also included in the diagnostic procedures (imaging of the heart's arteries, for the evaluation of the severity of the coronary artery disease). Lately, this procedure is conducted through the upper arm and the radial artery (minimally invasive), with minimal risk of bleeding, enabling the patient to be discharged in a few hours.

full hemodynamic - imaging assessment of the heart's left and right cavities for the accurate diagnosis of valvular heart disease, aortic aneurysms, heart failure, congenital diseases and pulmonary hypertension can also be conducted.

The invasive procedures include angioplasty and the insertion of latest generation stents in the coronary arteries, in case of vascular stenoses with an occasional and simultaneous use of intracoronary ultrasound. The procedure usually takes place right after the coronary angiography, through the same incision in the leg or arm (radial access).

The basic commitment and mission of our Department is to conduct primary angioplasty, with the best door to balloon results complying with all International Standards. This method requires alertness and a highly experienced personnel, while it can only be conducted in very few medical clinics in our country on a 24hour basis.

Other procedures include angioplasty of peripheral arteries (carotid, renal arteries,subclavian arteries), treatment with special devices of structural congenital heart diseases, like septal defects, open foramen ovale, ductus arteriosus, valvuloplasty with stent insertion in case of aortic coarctationvalvuloplasty of the aortic and pulmonary valve and the percutaneous replacement of the aortic and pulmonary valve (TAVI).

The Heart Catheterization Lab is supported by a Heart Team (Cardiac Surgeons, Intensivists), special Intensive Care Unit (Coronary Care Unit) for emergencies, and specially equipped rooms, fully alert to accept patients, on a 24hour basis.

Interventional electrophysiology

The experienced and skilled team of the Electrophysiology and Pacing Lab in Athens Medical Center performs the whole spectrum of interventions with special emphasis on atrial fibrillation and ventricular arrhythmias ablation, as well as modern devices implantations, including leadless pacemakers.

Pacemaker implantations

The Lab is available 24 hours the day, 7 days the week for pacemaker implantation in emergency cases. Full body MRI compatible devices are implanted where indicated. Since October 2015, Athens Medical Center is one of the few centers worldwide that is certified for leadless pacemakers implantation by the specialized medical team. Micra pacemaker is the smallest pacemaker ever implanted in humans, 93% smaller compared to conventional devices. Up to October 2016, the largest number of leadless pacemaker implantations has been performed in Greece with great success. The procedure is performed through the right femoral vein and the microscopic device is implanted directly into the right ventricle avoiding the use of visible electrodes and a conventional pacemaker in the thorax. Duration of the procedure is around 1 hour and the patient is discharged the following day.

Defibrillators and Cardiac Resynchronization Therapy

Defibrillator implantation is a widely established therapy that prevents sudden cardiac death in heart failure patients as well as in certain patients with diverse types of cardiomyopathies. In Athens Medical Center, implanted devices are fully compatible with MRI and have a prolonged duration of battery life (>10-years). In certain cases, the medical team is also skilled in implanting completely subcutaneous defibrillators.

One out of three patients with heart failure are also eligible for cardiac resynchronization therapy, which improves significantly not only the quality of life but also survival.

Atrial fibrillation ablation

Ablation procedures of atrial fibrillation are being performed either by using cryoenergy or by means of the latest edition modern electroanatomic mapping systems. The head of the Electrophysiology and Pacing Lab is a proctor in European countries for cryoablation procedures. Efficacy of such procedures supervenes 80% in Athens Medical Center. Duration of the procedure is less than 2 hours and the patient is discharged the following day. Ablation of atrial flutter may be performed at the same time, if indicated.

In cases of patients with bleeding disorders and increased thromboembolic risk, transcatheter left atrium appendage occlusion is performed by the certified medical team of Athens Medical Center.

Ventricular tachycardia ablation

The medical team of the Electrophysiology and Pacing Lab is also highly experienced in the management of patients with ventricular arrhythmias. Based on the use of the latest edition software of electroanatomic mapping systems, ablation procedures are performed with safety and outstanding efficacy.

Conventional ablation procedures

Conventional ablation procedures are also being performed by the medical team of the Electrophysiology and Pacing Lab, ensuring definitive treatment in cases of patients with supraventricular tachycardias and life-threatening accessory pathways, additionally avoiding unnecessary drug treatment.

Heart Surgery

Heart Surgeons of Athens Medical Group use the most up to date surgical equipment covering the entire range of Cardiac Surgery.

The application of all known methods leading to innovative operations is guaranteed by the professional and scientific expertise of our surgeons. Most of them have been trained and have worked for more than two decades in world-class University Clinics, where they held leading positions.

The Department in Athens Medical Center is supported by 4 hemodynamic laboratories, 5 special operating theaters, 22 Intensive Care Unit beds, special chamber for postoperative treatment and all related clinical and ancillary structures.

Specifically within the Athens Medical Group the following are performed:

  • Coronary Artery bypass Surgery (On pump or off pump-beating heart).  At our special Beating Heart Center all the Coronary Cases are performed on beating heart. 
  • Heart valve replacement
  • Heart valve repairs (valvuloplasty).
  • Combined procedures.
  • Centre for the treatment of Aortic Diseases such as aneurysms, dissections, Marfan Syndrome Patients including all operations of the aortic arch and descending aorta.
  • Adult congenital heart surgery
  • Transcatheter Aortic Valve Implantation (TAVI) in collaboration with other Cath-lab Cardiologists (Heart Team)
  • Surgical ablation for atrial fibrillation
  • ECMO placement
  • Surgical Rx of Pericardial disease
  • Complex coronary artery disease cases (e.g. endarterectomy)
  • Use of arterial grafts

Related Videos

Α.Tzikas - Interventional cardiologist

L. Karagounis - Interventional cardiologist

ПАЦИЕНТ ИЗ РОССИИ - КОРОНАРНОЕ ШУНТИРОВАНИЕ 4-Х СОСУДОВ

Athens Medical Center

Dr. Petros Altsitzoglou

  • Director of the Cardiac Catheterization Laboratory
  • Specialized in Cardiology and Interventional Cardiology in Germany
  • Member of the German Cardiac Society

Dr. Michael Kantartzis

  • Professor (apl.) at the University of Dusseldorf Medical School
  • More than 4000 heart operations
  • Specialized and licensed to practice in Germany

Dr. Vassilios Kotsis, MD

  • Director of Cardiac Surgery Department and Beating Heart Center
  • Specialized in the UK

Dr. Dimitris Nikas, MD, ABS ,ABTS, FACS, FCCP, FACC

  • Former Associate Professor and Chief of Cardiothoracic Department of University of South Alabama
  • Graduated from Yale University · Has performed over 8000 open heart surgeries

Dr. George Papaioannou, MD MPH

  • Director of Cardiac Catheterization Department
  • Chief Cardiovascular Fellow, Hartford Hospital
  • Pyrtec Research Paper Distinction Award “Magna Cum Laude”, University of Connecticut

 

European Interbalkan Medical Center

Dr. Labros A. Karagounis, MD

  • Director of Cardiac Catheterization and Interventional Cardiology
  • Associate Professor, University of Utah
  • Ex Director of Cardiology Division VAMC, Salt Lake City, Utah​

Related Articles

05.09.16
Valve Replacement in the heart without a scalpel - New implantation method replacing open-heart surgery

Written by Dimitris Avgerinos, MD, PhD, Director of Cardiology of Athens Medical Center, Assistant Professor of Heart Surgery Department in the Cornell University of New York

One in 20 adults has a problem in one of the main valves of the heart, the aortic or mitral, which require surgical treatment. Until a few years ago, patients were undergone an open heart surgery, requiring a connection to an extracorporeal circulation device and interruption of the heart with strong drugs. Today, however, in selected patients a noninvasive percutaneous method is used.

As an individual gets older, calcium is deposited in the aortic valve, causing gradual narrowing, subsequently impeding the free flow of blood and developing symptoms such as chest pain, shortness of breath and fainting.

When should a surgery be performed?

When the patient develops symptoms (especially breathlessness, chest pain or loss of consciousness) or when a valve is very narrow or failure occurs.

How did the need for non-invasive treatment occur?

The open surgery has increased risks and complications for the high-risk patients: very elderly population, patients with previous history of open heart surgery, and patients with renal or hepatic impairment.

Actually, for these specific groups of patients a percutaneous aortic access technique has developed in recent years.

How is the surgery performed?

Through the femoral artery or a small incision in the chest. During surgery, usually no more than one-hour duration, although the patient is under anesthesia, his heart does not need to stop and he is not connected with extracorporeal circulation device.

What are the advantages of the method?

Short-duration surgery, relatively a non-invasive operation, without postoperative pain and complications of an open- heart operations and significantly reduced mortality compared to open heart surgery. The patient goes home in 3-4 days and is ready to return to daily activities.

The new method is now available for special patient groups who can not undergo the traditional surgery, while the patient selection is done under strict rules established by the American and European heart surgery and cardiology companies.

Numbers

·       4-5% of the population will develop eventually valve disease requiring surgery

·       Patients aged50 years and more  require surgical reconstruction or replacement of the heart valve

·       The mean survival of patients treated without surgery is 2-3 years , when the aortic valve causes symptoms

Suspected signs of severe valvular heart disease

·       Dyspnea

·       Angina Pectoris

·       Loss of consciousness (fainting)

Eligible patients for percutaneous intervention

Those who can not undergo an open heart surgery because they:

·       Are old age

·       Have multiple health problems (especially respiratory problems, and hepatic or renal failure)

·       Previous history of open heart surgery

12.08.16
The latest advances in the surgical treatment of Cardiovascular Disease (BYPASS)

Written by Vasilios N. Kotsis MD, Cardiothoracic Surgeon, Director of Cardiac Surgery Clinic and Beating- Heart Surgery Center in Athens Medical Center

In 2002-2012, there was a rapid spread of the use of stents to treat coronary heart disease, despite the improvement in mortality and morbidity of the surgical method, known as Bypass.

In the initial stages of implementation, there was enthusiasm for their prevailance in the treatment of coronary artery disease. The studies that followed demonstrated that despite the technological revolution in the manufacture of the stents, the results fell short of the surgery.

We had fewer deaths, fewer heart attacks, fewer strokes and less need for reoperation to surgical repair than with the stents, in the long run. In very severe cases, the difference was even greater for the surgical method.

The results of these studies were included in the guidelines for the treatment of coronary artery disease (instructions for myocardial reperfusion), issued in 2014 by the European Society of Cardiology and the European Association of Cardiothoracic Surgery (the largest scientific societies in Cardiology and Cardiac Surgery in Europe). In these instructions, surgery is recommended (known Bypass) as the most appropriate treatment in myocardial reperfusion, except for cases of one or two stenosed coronary vessels, which can be repaired by angioplasty.

 

It is even more interesting, however, that bypass surgery is performed in much the same way in the last thirty years. In various centers abroad, many innovative methods are applied but to be established, studies are required to prove their utility. In this context, approved and applied innovations refer to both how the surgery is performed and the implants used. Such development in the way the operation is performed, was the surgery of coronary arteries in beating heart. This is an important tool in the hands of the surgeon, improving morbidity and mortality of surgery. This technique does not use an extracorporeal circulation device replacing the heart and lungs during surgery. By using this device, the surgeon can perform his practice in unbeating heart and clean field. However, this device, while helping the surgeon, is the cause of complications such as strokes, bleeding, inflammation, etc., that increase the mortality of surgery.

The coronary artery surgery in beating heart allows us to avoid the complications arising from the use of extracorporeal circulation device in order to operate patients, for example, whose aorta has hardened over the years (porcelain aorta), patients over 80 years with fragile tissues, diabetics at higher risk of contamination, renal patients bleeding easily, patients with respiratory failure and COPD having an increased risk of infections, women who have sensitive tissues, patients receiving antiplatelet medications and must be operated immediately (less bleeding tendency), even patients who avoid blood sampling for religious reasons (minimize the need for blood). Patients with peripheral vascular disease (e.g., a carotid disease) can also be operated without the need for concomitant endarterectomy. Finally, this technique is important in patients with poor heart function, i.e., heart failure. In these cases, maintaining heart function, we can improve the blood circulation in the periphery of the vessel, without ischemia time, while maintaining heart function. In any case, a remarkable decrease in recovery time has been achieved, both in the ICU and the simple treatment room. The patient is mobilized quickly and leaves the hospital one to two days earlier.

In recent years, great change has been also seen in the grafts used. The new guidelines of the Society of Thoracic Surgeons (The Annals Of Thoracic Surgery, Volume 101, Number 2, February 2016) include the use of both mammary arteries (the arteries behind the breastbone) for anterior cation revascularization (the main vessel to the heart), instead of the left mammary artery alone and the use of 2 arterial grafts instead of one, which is generally used today. The second arterial graft may be either the right mammary artery or the radial artery. The guidelines state that age is not prohibitive for the use of arterial grafts and if they are placed with beating heart, the risk of stroke is reduced. Now, we do not see patients with large incisions on both feet for graft harvesting, since the use of venous grafts is reduced, which are inferior to the arterial ones. Of course, there are also major technological advances in surgery, such as the use of robot, automatic staplers, endoscopic graft harvesting, synthetic grafts, etc., which though are not widely used and we will have to deal with in the future.

In Athens Medical Center and specifically in the Beating- Heart Surgery Center, we follow these principles for many years, which now form the official guidelines of the Cardiothoracic community.

26.12.15
Syncope: What you should know and how to manage it

Written by Tsiachris Dimitrios MD, PhD Cardiologist - Electrophysiologist,  Director of Pacing and Electrophysiology Lab, Athens Medical Center , Athens Medical Group

Syncope is a medical term used to describe what is commonly called fainting. It refers to the sudden transient loss of consciousness of a person due to decreased blood supply to the brain.

Before syncope or a fainting episode, there are often the so-called "prodromal" symptoms, such as dizziness, nausea, pale and cold skin and what makes it different from a stroke, seizures and coma is the immediate recovery of consciousness without confusion or other recessive disorders

How common is syncope and how is classified?

Syncope is a common medical problem which accounts for 3% of patient visits to emergency rooms. The syncopal episodes are classified in:

  • vasovagal (vagotonic) syncope (after emotional stress, trauma, pain, prolonged standing or blood view)
  • Hypersensitive carotid sinus syncope
  • situational syncope (urination, defecation or severe cough)
  • Cardiac syncope (due to bradyarrhythmia or tachyarrhythmia or structural heart defect such as aortic valve stenosis)
  • postural syncope when standing.

What is the prognosis of patients with syncope? 

Cases of situational or vasovagal syncope have very good prognosis, whereas cardiac syncope can be life-threatening.

How we investigate patients with syncope

As in any patient who has suffered syncope, a targeted full history is received, we examine the heart, measure the blood pressure in supine and upright position and perform electrocardiogram and echocardiogram, thus achieving a diagnosis in half the cases. In patients aged more than 40 years with syncope, we will also massage the carotid sinus. Trying to correlate symptoms with the underlying heart rate, we will place a 24-hour or 48-hour Holter. If we suspect situational or vagotonic syncope, our patient will undergo a tilt-table test while in the case of underlying brady- or tachyarrhythmia, the value of electrophysiological study is prominent. Finally, continuous monitoring of heart rate with implantable Holter is beneficial in patients with arrhythmic syncope, often as a last step in the diagnostic algorithm.

Treating people with syncope

The treatment of patients who have suffered syncope is personalized based on the underlying disorder. In case of bradycardia or hypersensitive carotid sinus, pacemaker is implanted. In case of tachycardia and structural heart disease, we place a defibrillator and perform ablation in cases of idiopathic tachycardias.

In case of vasovagal, situational or postural syncope, which are the most common causes of syncope, we reassure patients (often of young age) for benign prognosis and train them to apply simple methods to prevent recurrent episodes. 

03.12.15
The first surgery to treat atrial fibrillation with the newest third generation cryoablation system from Athens Heart Center of Athens Medical Center

Last November, the interventional electrophysiologists,Dimitrios Tsiachris and Sotiria Stambola performed the first successful surgeries in Greece for the treatment of atrial fibrillation with the novel cryoablation system of 3th generation in the special unit of Atrial Fibrillation of the Athens Heart Center in the Athens Medical Center.

Atrial fibrillation is an abnormality in heart rate and the most often reported heart arrhythmia, whereas chronic atrial fibrillation may result in heart failure and stroke. In Greece, patients are estimated at 100,000. In this context, the Atrial Fibrillation Unit of Athens Heart Center, the first standard unit in Greece, aims at the holistic management of the disease, covering the entire range of pharmaceutical and interventional methods.

Thanks to the new cryoablation technology of pulmonary veins, the operations carried out at the Athens Medical Center have very good results, they are safer and shorter. Patients stay in the hospital overnight and return home the next day and the day after to their work. Indicatively, it is noted that the success of these operations exceeds 80%.

Ablation of atrial fibrillation is performed when drugs fail, and in some cases are even the first treatment option, particularly in young patients.

"In Atrial Fibrillation Unit, patients can undergo these procedures are selected based on the appropriate initial laboratory examinations. The sooner we operate, the more efficient ablation of the disease. “Especially in young patients, we can provide a complete cure,"says Dimitrios Tsiachris, Director of the Laboratory of Electrophysiology and Pacing of Athens Heart Center in Athens Medical Center and Instructor of these contemporary interventions in Greece and internationally.

10.11.15
Innovative Bypass surgery in beating heart at Athens Medical Centre

A large number of successful operations has been already carried out one year after the opening of the Cardiac Surgery Clinic and Beating- Heart Surgery Center in Athens Medical Center, among these more than 120 mere coronary bypass surgeries. The clinic operates as a standard center, under the direction of the cardiothoracic surgeon Mr. Vasilios N. Kotsi, MD, where all heart surgical operations are performed with particular emphasis in beating-heart coronary artery surgery (bypass). At international level, these operations are carried out only by specialized cardiothoracic surgeons and at selected centers.

The specificity of this technique is that the use of extracorporeal circulation device (device simulating the heart and lungs) is prevented and the complications arising from its use. This means that the continuous function of the heart and lungs is kept, similarly to any other non-cardiac surgery. Advanced technological mechanisms stabilize parts of the heart,enabling the surgeon to operate, while the rest heart is still beating. In addition, special attention is given to the use of arterial grafts, which, according to the latest studies, provide better long-term outcomes. The grafts of choice, especially for the reperfusion of the left heart vascular network are the two pedicled mammary arteries and the radial artery. 

With this technique high- risk patients, such as diabetics renal patients, patients older than 75 years with atheromatous aorta, with left ventricular dysfunction, chronic obstructive pulmonary disease, with peripheral vascular disease, women and those on antiplatelet treatment after an acute coronary event, those who do not accept blood for religious reasons or require reoperation (Redo).

The results of operations, with this technique in Athens Medical Center, is comparable and in some cases better than the results of the respective large centers abroad. Patients who undergo the specific procedures remain six days in the hospital in total, ie 2-3 days less compared to international standards. Patients are electronically monitored using Telemetry, i.e with small portable devices with continuous electronic recording of ECG, arrhythmias, beats and oxygenation whether the patient is in decubitus or in move.

It should be noted that so far the results have not shown major complications such as myocardial infarction, respiratory infections, surgical wound infections and strokes, while internationally, the complication rate is 3-6%. On average, it has reduced the blood transfusion in less than one unit per patient, while the mortality rate was 1% and was due to non-cardiac causes, while abroad this figure ranges between 1.5% and 3%.

"The well-trained staff, the modern facilities of Athens Medical Center in the operating rooms , the intensive care unit and on the floor, with continuous telemetry and patient monitoring, ensure that there will be continuity in the excellent results of beating-heart surgery center" said Mr. Vasilios N. Kotsis, Director of Cardiothoracic Surgery Clinic of Beating-Heart Surgery Center.

26.09.15
Non-Surgical Invasive treatment of Aortic valvular disease: Everything you want to know about the Transcatheter Aortic Valve Replacement

Written by George I. Papaioannou, MD, MPH, FACC, FSCAI Director of Interventional Cardiology, Catheterization Laboratory, Athens Medical Center

What severe stenosis of the aortic valve is

The aortic valve allows smooth passage of the oxygenated blood from the heart to the circulation of the whole body. Normally, the passage is made effortlessly with the contraction of the heart, while the closure of the valve prevents the retrograde flow of blood to the heart. Severe aortic valve stenosis occurs when, for various reasons, the aortic valve can not open and close properly. This causes a "thickening" of the heart muscle in order to "push" the blood in the circulation, and over time the "thinning" of the heart.Causes of aortic valve stenosis

Severe aortic valve typically correlates with the age and the deposition of calcium in the valve or in the annulus. Other causes are the history of rheumatic fever at an early age, congenital valve defect, previous chest radiation to the chest, medicines, rare metabolic or autoimmune diseases, hereditary hypercholesterolemia, end-stage renal failure.

Symptoms of severe aortic valve stenosis

The symptoms of severe aortic stenosis are associated with the inability of the heart to pump blood to the coronary vessels and the circulation, especially in cases of increased requirements such as in some physical effort.

These are:

·       Chest pain (angina)

·       Dizziness, feeling faint or fainting

·       Dyspnea

·       Palpitations

·       Weakness and fatigue

Incidence of aortic valve stenosis in population

Epidemiological studies have shown that the incidence of aortic stenosis increases with age. At the age of 75 years or more, one in eight people have moderate or severe aortic stenosis, and 4% of the population suffers from symptoms due to severe aortic stenosis. Especially as life expectancy increases, the incidence of the disease increases too. This is a major and growing public health problem.

When the aortic valve stenosis should be treated

Aortic valve stenosis is progressive and life threatening. Once the symptoms of heart failure occur, shortness of breath, chest pain or fainting, the life expectancy is reduced dramatically. Essentially, with the onset of symptoms, and if there is no treatment, one in two patients lives for two years and only one in five for five years.

Management of aortic valve stenosis

There is no drug therapy to reverse or slow the progression of aortic stenosis. Surgical aortic valve replacement is the treatment of choice today for its treatment. However, several patients either due to age or due to other medical conditions, are at high to prohibitive risk (usually higher than 20%) to surgical treatment. These patients can be treated with an alternative method: Transcatheter Aortic Valve Replacement (TAVI or TAVR).

What Transcatheter Aortic Valve Replacement (TAVI or TAVR) is

This is a surgery where the new tissue valve replaces the old one through a catheter (tube) via the femoral artery or the subclavian artery. The valve consists of a biological material attached to a stent made of steel. During valve implantation the stent is deployed in the wall between the heart and aorta. The new valve, attached onto the stent, is placed over the old one, which is compressed, allowing the normal passage of blood from the heart to the rest bloodstream.

Preparation

Before determining whether you qualify for Transcatheter Aortic Valve Replacement, the following tests are required and performed after admission and hospital stay for 1 day:

·       Electrocardiogram

·       Blood tests

·       Heart Ultrasound (Triplex)

·       Coronary angiography (Imaging of the heart arteries)

·       CT angiography of aorta and peripheral vessels

Upon these tests, the overall risk of the patient is assessed, while all data are given to the Heart Team for the indication of surgery and how the valve should be replaced.

Operation

The surgery is usually performed in the Catheterization laboratory, which is equipped with all necessary radiological equipment and supplies for the Transcatheter Aortic Valve Replacement. Exposure to radiation and contrast material is less than twenty minutes, while the total duration of surgery is one to two hours. When the access to the valve placement is the femoral artery, the patient is awake or in a light sedation. The Interventional Cardiologist performs a femoral artery puncture (local anesthesia in the area) and inserts a tube into it. Initially, the old valve is dilated with a balloon (valvuloplasty), and then, through a larger tube the valve is placed under fluoroscopy. When the access for the valve placement is the subclavian artery, the same operation is performed under general anesthesia.

Risks

It is important to remember that the percutaneous placement (replacement) of the aortic valve has clearly lower risks than the typical surgical treatment of aortic stenosis. For this reason, after all, this is the treatment of choice in patients at high surgical risk. Especially as the technique is improved, this will be also indicated in patients with lower risk. However, there are some risks during surgery, some more and others less serious. Based on the study data (2014) up to the present, the most common complications are of vascular origin (bleeding or "tearing" of the vessel used as a passage for inserting the valve), placement of a permanent pacemaker, atrial fibrillation, and rarely, stroke and/or death.

Recovery

After surgery, the patient is initially in the ICU for 24 hours and the total duration depends on the degree of recovery (usually 3-8 days). During hospitalization, the patient undergoes additional blood tests, chest X-ray, electrocardiogram and echocardiography. In the next 4-6 weeks retesting is performed and if all is well, examinations are performed every 6-12 months.

What will I gain from the surgery?

Treatment with the placement of the new valve immediately reduces the symptoms to the extent that they were due to aortic stenosis. It restores the normal operation of the valve and improves the overall function of the heart muscle. This potentially enhances the quality of life and life expectancy of the patient.

16.09.15
Athens Medical Centre: The first implantation of a totally subcutaneous defibrillator in a patient with an inherited disease in Greece

The first implantation of the novel, totally subcutaneous defibrillator system in patient with inherited disease was performed in Greece in Athens Medical Center by the Electrophysiologists of the Athens Heart Center, Dimitrios Tsiachris and Sotiria Stambola.

The surgery was performed in a 16- years-old patient and for the first time, total subcutaneous defibrillator was used to treat a congenital disease. The patient suffered from the gene-inherited “long QT syndrome”(electrical heart rhythm disorder) and had recovered from sudden cardiac death.

The defibrillation generator is placed on the distal left axillary region and the subcutaneous defibrillation electrode, on the sternum. This prevents direct contact of the total subcutaneous defibrillator with the circulatory system and the heart and reduces the severe complications of typical transvenous systems, thus ensuring faster recovery.

Sudden cardiac death is the most negative outcome of congenital cardiovascular diseases and is mainly responsible for the death of young and otherwise healthy people. Since the overall control of the population is not possible, the specialized team of the Cardiomyopathy Unit of Athens Heart Center, under the direction of Mr. Ari Anastasaki, focuses on a thorough testing of high-risk groups, which consist of:

  • Individuals who develop cardiac symptoms
  • Families affected by sudden cardiac death of their members
  • Families who have members diagnosed with hereditary cardiovascular disease
  • Athletes at high-level competitive sports diagnosed with cardiomyopathy

"Sudden cardiac death manifests by a sudden loss of consciousness and occurs within one hour of the onset of symptoms in individuals with or without known cardiovascular disease. According to the American Heart Association, it is estimated that 1,000 people/day die from sudden cardiac death worldwide, making prevention and early diagnosis of cardiovascular disease, particularly in people at high risk, the best treatment approach of syndrome. The totally subcutaneous defibrillator is our most important ally in cases such as the 16-year -old patient, giving patients a better quality of life, "said Professor Christodoulos Stefanadis, Professor of Cardiology, Director of the Athens Heart Center.

19.08.15
Athens Heart Center

Written by Christodoulos Stefanadis, Professor of Cardiology University of Athens, Professor of Cardiology Yale School of Medicine, Director of Athens Heart Center, Athens Medical Center

Cardiology is a modern specialty rapidly developed and shifted regarding its methods and scope. Standard "Athens Heart Center" in Athens Medical Center aims at covering the entire spectrum of modern developments in cardiology while aiming at producing and promoting research and educational work.

The main features of Athens Heart Center is the Department of Cardiology, the Catheterization Laboratory, The Electrophysiology Laboratory - Pacing and the improved innovative Diagnostic Laboratories and Units, which cover the entire spectrum of cardiology with the most modern approach.

The Interventional Cardiology Laboratory has two modern rooms of Catheterization Laboratory. The contemporary approach to invasive treatment of coronary artery disease requires performing both angiography and angioplasty with stent placement, by accessing the arm and the radial artery, achieving patient’s mobilization and discharge on the same day.The Cardiology Clinic is a fully equipped and organized cardiology clinic, with excellent medical and nursing personnel, who are at the disposal of patients at any time, ready to manage any acute or chronic cardiac incident. The excellent patient monitoring is facilitated by the telemetry systems and the ongoing education of nursing staff.

Main commitment and mission of the Laboratory is to conduct primary angioplasty any time and day, ie, direct stenting of the occluded artery in case of acute myocardial infarction with excellent results. The method is internationally established as the best treatment of acute myocardial infarction, it requires readiness and experienced staff and is carried out in very few centers in our country in a 24-hour basis.

High priority is to promote the transcatheter aortic valve implantation program (TAVI), where recent studies demonstrate the efficacy of percutaneous approach of structural heart disease, often superior to the open-heart surgical approach. In the Laboratory of Electrophysiology and Pacing of Athens Heart Center,

entire range of electrophysiology and pacing procedures is performed. The laboratory is available all days and hours of the week, throughout the year, for permanent pacemaker implantation systems in patients, where the pacemaker implantation is urgent.

Since October 2015, Athens Heart Center is the first center in Attica, and Athens Medical Center the only private hospital, where implants without leads of the most advanced pacing technology of Micra pacemakers will be performed, in the largest international clinical study. The innovative device is implanted through the femoral vein, it is 93% smaller than existing pacemakers and minimizes complications as it has no leads or does not require the creation of a "pocket" on the chest, making it the epitome of nanotechnology.

The implanted defibrillator is now an established treatment that prevents sudden death in patients with heart failure and in patients with myocardial infarction, dilated cardiomyopathy, hypertrophic cardiomyopathy and electrical heart diseases. At the same time, one in three patients with heart failure also require biventricular implant systems with the defibrillator. The defibrillator prevents the occurrence of sudden cardiac death, while the biventricular pacemaker, to appropriately selected patients, re- synchronizes significantly the cardiac contraction, improving cardiac function and the clinical condition of the patient.

Atrial fibrillation that needs a holistic medical approach with a proper selection of anticoagulation, antiarrhythmic and invasive treatment and management of comorbidities in conjunction with the relevant specialties. The selection of patients for atrial fibrillation ablation is performed by the first in Greece Special Unit for Atrial Fibrillation.

The AF ablation procedures are performed both with the current method of cryoablation and with the help of the latest electroanatomical mapping systems, which also provide an objective assessment of each cauterization (CARTO 3, Smart-touch). In the Laboratory of Electrophysiology and Pacing of Athens Heart Center, the efficacy of these operations exceeds 80%.

Experience and special interest in the management of patients with ventricular arrhythmias within the Arrhythmia Unit is also adequate. Patients are selected based on the appropriate clinical- laboratory examinations and they will undergo safe and effective endocardial and epicardial ablations of ventricular tachycardias. Arrhythmia unit aims at the selection of patients with supraventricular arrhythmias and bundles for ablation procedures, often achieving final cure and free of any medication.An innovation of Athens Heart Center is the improved, innovative Diagnostic Laboratories and Units. In the Echocardiology Laboratory a three-dimensional echocardiography using modern techniques and transesophageal echocardiography are performed at any time, while Dobutamine Stress Echocardiography for the diagnosis of coronary heart disease and Stress echo using a bicycle ergometer for valvular heart disease investigation and assessment of myocardial viability are of unique experience.

In the Laboratory of Fatigue, Arrhythmias Control and Pressure Measurements of Athens Heart Center, we conduct fatigue test, cardiopulmonary exercise test on bicycle ergometer, a tilt-table test to investigate syncope, Holter rhythm with the possibility of sudden death risk assessment in patients with structural heart disease, and a 24- hour blood pressure monitor (pressure Holter) in connection with the Hypertension Unit. It is also possible to carry out tests and adjustment of pacing and defibrillation systems.

The Units of "Athens Heart Center" are designed for the systemic, holistic and contemporary management of the entire range of cardiovascular diseases, staffed by the most specialized cardiologists.

In the Hypertension Unit, a full diagnostic and laboratory testing (pressure Holter, heart triplex, albuminuria measurement, assessment of peripheral vessels) is performed. Emphasis is given to the investigation of secondary hypertension and in selecting patients for renal artery angioplasty, removal of endocrine tumors and sleep apnea treatment. At the same time, refractory hypertension cases are thoroughly investigated and patients are selected for renal artery denervation .

In the Cardiomyopathy and Congenital Disorders Unit patients and families with diagnosis of congenital cardiovascular disease are monitored, while pre-activity and pre-sport activity control is also carried out.

In the Coronary Disease Unit, an appropriate diagnostic disease approach is performed in cooperation with the specialized Echocardiology Laboratory and performing stress echo, while a relevant optimal invasive and non-invasive treatment is applied.

In the Syncope Unit, an appropriate diagnostic approach is done using rhythm Holter, heart triplex, tilt-table test and implantation of loop recorders, prognosis of patients is assessed and patients suitable for implantation of pacemaker and defibrillator systems are selected.

In the Pregnancy Heart Disease Unit, pregnant women who develop gestational hypertension are monitored in cooperation with gynecologists, as well as pregnant women with preexisting heart problems.

In Metabolic Disease and Pathological Condition Unit, patients with diabetes mellitus, metabolic syndrome, morbid obesity and special pathological metabolic diseases are monitored and their cardiac risk is assessed.

The Units and the Laboratories of the Standard Athens Heart Center, in addition to the best and innovative health services provided at clinical level, aims at providing both research results by the internationally recognized scientific personnel and educational work, either at undergraduate level on student education or providing high quality clinical training to cardiology residents. The ultimate goal is to help Athens Heart Center to develop in a special education center for cardiologists across Europe in specific innovative techniques ensuring its autonomy.

17.06.15
Interbalkan Medical Center: The first, second generation bioabsorbable stent for artery stenosis

The first second generation bioabsorbable stent in Greece- the most modern worldwide in interventional cardiology - was successfully implanted in the 42-year-old patient in the Interbalkan Medical Center of Thessaloniki by the invasive cardiologist, Dr. Lambros Karagounis, Director of the Laboratory of Cardiac Catheterization and Interventional Cardiology. 

The new bioresorbable stent is indicated for patients with elongated stenoses of coronary arteries mainly in the anterior central artery. It is a promising development especially for young people who will need several re-operations in the vessels due to coronary disease progression. Indicatively, the patient received the first second-generation stent in the Interbalkan Medical Center, experiencing coronary heart disease problem since he was 35 years old. 

As noted by Dr. L. Karagounis, "the comparative advantage of second-generation stents, is that the degree of difficulty of implantation is lower and the rate of absorption by the body, faster. This is a breakthrough in interventional cardiology. The earlier metal stents, since they remain permanently implanted in the vessel wall, limit significantly the future treatment options, such as coronary artery bypass grafting in the implantation area. In addition, a scar due to inflammatory reaction in the presence of the metal stent may be created on the vessel wall».

The novel bioabsorbable stent after implantation release local drug that inhibits restenosis. In two years, they restore vascular function and are fully degraded. The safety and efficacy has been demonstrated in large randomized trials.

05.05.15
Atrial Fibrillation

Written by Tsiachris Dimitrios MD, PhD Cardiologist - Electrophysiologist,  Director of Pacing and Electrophysiology Lab, Athens Medical Center , Athens Medical Group

Atrial fibrillation (AF) is a disease and not just a cardiac arrhythmia, which needs a holistic medical approach using a proper selection of anticoagulation, antiarrhythmic and invasive treatment and management of comorbidities in conjunction with the relevant specialties.

The Atrial Fibrillation Unit of Athens Heart Center is the first standard unit in Greece, which aims at the holistic management of the disease, covering the entire range of pharmaceutical and interventional methods.

Prevalence of Atrial Fibrillation

AF is detected in a surface ECG (electrocardiogram) by an irregular ventricular rhythm and loss of compatible P waves with the QRS. Continuous ECG recordings of patients with AF, have shown that more than half of AF episodes are not detected by conventional ECG recordings, even in symptomatic patients, increasing the actual prevalence of AF in 2% of the population.

Types of Atrial fibrillation

An AF episode is defined as an AF recorded in ECG lasting at least 30 seconds. The presence of subsequent episodes of AF requires the presence of sinus rhythm in ECG recordings between AF episodes. Paroxysmal AF is defined as the presence of recurrent AF (.2 episodes), which terminate spontaneously within 7 days. AF episodes lasting less than 48 hours and require electrical or pharmacological cardioversion for termination are also classified as paroxysmal AF episodes.

  • Persistent AF is defined as AF that lasts longer than 7 days. AF episodes, which are determined to terminate under electrical or pharmacological cardioversion after 48 hours and prior to 7 days, are also classified as episodes of persistent AF.
  • Long-standing AF is defined as AF lasting over a 12-month period.
  • Permanent or chronic AF is defined as AF, which is determined by both patient and physician not to persue cardioversion to sinus rhythm, regardless of its duration. If decision has been changed to perform cardioversion of AF, then it should be reclassified as persistent or long-standing AF, depending on its duration.

Classification of atrial fibrillation symptoms

The asymptomatic episodes increase in frequency with age. Asymptomatic patients are classified in EHRA (European Heart Rhythm Association) Phase I. Patients whose daily activity is not affected by the perceived presence of arrhythmia are classified in Phase II, while patients with serious symptoms and negative impact of AF on a person's daily activity are classified in EHRA (European Heart Rhythm Association) phase III. Phase IV symptoms, where the patient cannot perform any activity due to the onset of AF, occur less often.

Predisposing factors Can AF be prevented?

Some factors involved in the onset of AF may be controlled or modified, such as the treatment of high blood pressure (hypertension) and reducing alcohol consumption. Some risk factors are not controlled, such as the advanced age and family history.

 

Modifiable risk factors:

  • Hypertension
  • Heart Failure
  • Valvular Disorders
  • Cardiomyopathies and Primary electrical heart diseases
  • Stress
  • Alcohol abuse
  • Lack of exercise
  • Sleep Apnea
  • Thyroid disorders
  • Obesity
  • Diabetes Mellitus
  • Metabolic syndrome

Non-modifiable risk factors:

  • Family history
  • Advanced age
  • Congenital heart disorders
  • Gender - Men have a higher incidence of AF

Complications of Atrial Fibrillation

KM has an impact on people’s health by increasing mortality rate, stroke and thromboembolism, while reducing the ability for exercise and left ventricular function. The presence of MS doubles the mortality rate independently of other known risk factors. Patients without structural heart disease (lone AF), especially those who are younger than 60 years old show similar mortality rate to the general population. Stroke is the most serious complication of AF. 1 out of 5 strokes is due to AF. It must be noted that strokes occurring due to AF are accompanied by increased mortality rate and permanent disability and recur more often. A significant proportion of cryptogenic strokes (in which the cause has not been identified at the initial investigation) is also attributed to AF.

Management of patients with atrial fibrillation

The management of patients with atrial fibrillation aims at reducing symptoms, if any, and preventing severe complications associated with AF. Complications are prevented by anticoagulation, heart rate control and adequate treatment of concomitant risk factors and cardiovascular diseases. Symptoms relief, on the other hand, often requires controlling the rate that can be achieved by either cardioversion, or antiarrhythmic therapy, or ablation procedures.

For patients at high thromboembolic risk of stroke and high hemorrhagic risk, it is possible to perform percutaneous closure of the flap of the left atrium and consequent discontinuation of anticoagulants, by an operation performed percutaneously through the femoral vein.

Ablation of atrial fibrillation

AF ablation, which has just started being used in the last 15 years, it is more effective in the long-term maintenance of sinus rhythm compared to antiarrhythmic drugs. In any case, the way arrhythmia occurs, the chronicity of arrhythmia, the presence and severity of cardiovascular diseases and the size of the left atrium must be taken into account. AF ablation is recommended in symptomatic patients with paroxysmal AF after failure of antiarrhythmic treatment: Indication I AF ablation is recommended in symptomatic patients with paroxysmal AF before the administration of antiarrhythmic treatment: Indication IIa AF ablation is recommended in symptomatic patients with Persistent AF after failure of antiarrhythmic treatment: indication IIa

Recommendations on the strategy for AF ablation

  • The main objective of all strategies is the electrical isolation of the pulmonary veins with ablation preferably in their antrum.
  • Confirmation of the electrical isolation to achieve bidirectional block, namely blocking electrical signals imput from the atrium into the veins and output with pacing failure of the pulmonary veins is required (Figure 1).
  • RF ablation is the standard technique to accomplish point-by- point transmural lesions in the ostium or in the antrum of pulmonary veins.
  • The use of electroanatomical mapping system creating a 3D anatomy of cardiac structures (CARTO system) helps reduce the radiation and improve safety.
  • Balloon cryoablation blocking pulmonary veins achieves isolation by one homogeneous transmural lesion (one shot) and reduces the operation time, while it requires less learning time.

The AF ablation procedures are performed both with the current method of cryoablation and with the help of the latest electroanatomical mapping systems, which also provide an objective assessment of each cauterization (CARTO 3, Smart-touch). The efficacy of these operations exceeds 80% in the Interventional Electrophysiology laboratory of Athens Heart Center, while the atrial flutter ablation is performed using electroanatomical mapping systems (CARTO 3, Smart-touch), increasing by far both efficacy (> 95 %) and safety.

16.02.15
Off-Pump Coronary Artery Bypass Surgery (OPCAB)

Vassilios N. Kotsis MDHead, Cardiac Surgery Department and Off-Pump Heart Center.

Coronary artery disease is the disease in which one or more of the main blood vessels feeding your heart is blocked and cannot supply enough blood to your heart.  Your doctor may recommend coronary artery bypass grafting. This is the most common heart surgery and restores blood flow into your coronary arteries.

Traditionally, coronary artery bypass surgery is performed with the assistance of cardiopulmonary bypass. The heart-lung machine replaces the heart and the lungs during the operation, so that the surgeon can operate on a surface which is blood-free and still. The heart-lung machine maintains life despite the lack of a heartbeat, removing carbon dioxide from the blood and replacing it with oxygen before pumping it around the body. The heart-lung machine has saved countless lives.

A desire to improve outcomes after surgery and advances in technology have led surgeons to perform coronary artery bypass surgery without cardiopulmonary bypass, called off-pump bypass (also called "beating heart") surgery.

Beating heart bypass surgery is – in simple terms – bypass surgery that is performed on your heart while it is beating. Your heart will not be stopped during surgery. You will not need a heart-lung machine. Your heart and lungs will continue to perform during your surgery.

Rather than stopping the heart, technological advances and new kinds of operating equipment now allow the surgeon to hold stabilized portions of the heart during surgery. With a particular area of the heart stabilized, the surgeon can go ahead and bypass the blocked artery in a highly controlled operative environment. Meanwhile, the rest of the heart keeps pumping and circulating blood to the body.

Off-pump coronary artery bypass surgery may be performed in all patients with coronary artery disease. With present technology, all arteries on the heart can be bypassed off-pump. It may be ideal for certain patients who are at increased risk for complications from cardiopulmonary bypass, such as those who have heavy aortic calcification, carotid artery stenosis, prior stroke, or compromised pulmonary or renal function.

Off-pump coronary artery bypass surgery is now possible, but is it better?

Both OPCAB and conventional on-pump surgery restore blood flow to the heart. However, off-pump bypass surgery has proven to reduce side effects in certain types of patients.

The aim of off-pump bypass surgery is to decrease the morbidity of coronary artery bypass surgery, such as stroke, renal failure and need for blood transfusion. Also of great interest is the possibility that the off-pump approach may lessen the risk of what are called cognitive changes that have been seen in many patients who underwent CABG with cardiopulmonary bypass. These short-term changes include memory loss, difficulty thinking clearly and problems concentrating for lengthy periods. They usually improve over the months following surgery. Although the reason for these cognitive changes is not yet definitely known, many physicians believe the changes are related to the fact that emboli (tiny particles, most commonly atherosclerotic plaque) are dislodged into the bloodstream when the heart-lung bypass machine is used. As they travel throughout the circulation, the emboli may affect the brain, resulting in cognitive dysfunction.

Recent studies found that the results of both on- and off-pump surgeries were excellent. The risk of stroke, heart attack during surgery, and death were similar and low in patients undergoing both on- and off-pump CABG. There were fewer cognitive side effects in the off-pump patients, less renal (kidney) failure requiring dialysis, less red blood cell usage, shorter hospital and ICU stay and fewer pulmonary infections and infections of chest incisions in the off-pump patients. One concern is that off-pump patients had more incomplete revascularization, meaning that fewer patients had blood flow fully restored than on-pump patients.

We believe that the last, depends on the surgeons experience and in Athens Medical Center we are able to completely revascularize almost all patients off-pump.

Are there patients who might benefit from off-pump surgery?

Since morbidity is reduced with off-pump revascularization, most patients should benefit from CABG performed without cardiopulmonary bypass. Patients at high risk for complications from cardiopulmonary bypass, such as people with reduced contractility of left ventricle, vascular (blood-vessel) disease, previous strokes or mini-strokes (transient ischemic attacks), patients with COPD , those in their 70’s or older and Redo cases, should benefit the most from off-pump revascularization.  Also patients on antiplated treatment or refusing blood transfusion for religious reasons have a solution for coronary artery revascularization    

Worldwide more than 30% of all coronary artery bypass surgery cases are performed on a beating heart. Approximately every 10 minutes, someone has a beating heart or "off-pump" bypass surgery.

In our institution we perform all the coronary cases “Off Pump” using as grafts both internal thoracic arteries for the left coronary system and vein grafts for the right one. Our patients remain in ICU for few hours and four or five days at a general ward.

15.01.15
Special Heart Failure Clinic in the Interbalkan Medical Center of Thessaloniki

The Interbalkan Medical Center of Thessaloniki inaugurated a Specialised Heart Failure Clinic in outpatients, in order to provide comprehensive services to patients at an advanced stage of the disease. The operation of relevant clinics internationally is the most modern and comprehensive practice and is aimed at patients who do not respond to medications, require frequent hospitalizations and have poor quality of life.

The special clinic assesses the severity of the disease, identify and address the causes of exacerbations that are likely to be reversed or decide to disease progression and the need for advanced therapeutic interventions. These include the implantation of biventricular pacemaker-defibrillator, the regular programming of devices depending on the course of the disease, the mechanical heart support and heart transplantation.

The special clinic also provides services for the relief of symptoms of end stage patients.

The Heart Failure Clinic operates since January 22, 2016 and every Friday, from 11:00 to 15:00 under the supervision of the qualified cardiologist, Christos Pantsios. For appointments, interested parties may contact the Secretariat of Outpatients by telephone on 2310 400 464 & 463 

Heart failure is a complex clinical syndrome characterized by the limited ability of the heart to extrude or to fill with blood. Patients with heart failure often have shortness of breath, fatigue, reduced exercise capacity and fluid retention. They are conditions that require long-term monitoring and frequent medical check.  

04.09.14
Beating-heart bypass or using the typical method?

Written by Vasilios N. Kotsis MD, Cardiothoracic Surgeon, Director of Cardiac Surgery Clinic and Beating- Heart Surgery Center in Athens Medical Center

The beating-heart surgery of coronary vessels is an innovative and internationally recognized method, by which the coronary bypass is performed with the heart to beat and function normally.

In the typical heart surgery method, Bypass is performed using the extracorporeal circulation device, which simulates the heart and lungs during the surgery, interrupting their functioning and the blood flow to them. In this way, the surgeon can proceed in a clean field surgery, without any blood, in a still, unbeating heart. The restart of the heart takes place upon completion of the surgery. The morbidity of such operation reaches 6-8% mainly due to the use of extracorporeal circulation device.

In the beating-heart coronary vessel surgery, the use of advanced surgical instruments, called stabilizers, allows to maintain the still parts of the heart surface. In this way it is safe to perform anastomosis and bypass of the blocked vessel, while the rest of the heart contracts normally. The blood circulation is kept normal (without passing through tubes), and thus the operation is simplified and similar to all other non-cardiac surgery in the human body.

Conducting a beating-heart operation is the result of years of training and dedication. All cardiothoracic surgeons are initially trained in the typical heart surgery. It is the natural way of thinking of each surgeon, ie to stop the heart and to perform the task safely. Over the last fifteen years, many cardiothoracic surgeons, in order to reduce complications due to the use of the extracorporeal circulation device, take the risk of operating on a live moving target. The beating-heart coronary vessel surgery is said to increase the stress on the doctor, while reducing the risk of patient complications, in contrast to typical heart surgery that reduces the stress of the doctor, but increases the risk of patient complications.

A Cardiothoracic Surgery community, in which most cardiothoracic surgeons, even today, operate using the conventional method, is almost unlikely to accept an alternative method. While among cardiothoracic surgeons, as a signatory, the superiority of the method of the beating heart surgery has been proven in daily practice, we have to respect the results of scientific research. Instead of using sources possibly be regarded as biased in favor of the method, we based this article on an independent randomized trial comparing the two methods.

The study was published in 2012 in the journal "The New England Journal of Medicine". This is the largest randomized study, not only in heart surgery field, but throughout the surgical literature by Dr. A. Lamy and colleagues, called CORONARY. This study involved 4,752 patients from 79 centers of 19 countries. The aim was to compare the two methods. The cardiothoracic surgeons of these centers, as opposed to previous studies, were experienced in both techniques and not residents.

In summary the CORONARY study did not find differences in the two methods during the first 30 days, in terms of death, stroke, myocardial infarction or renal failure requiring dialysis among patients undergoing beating-heart coronary bypass and the typical heart surgery classical method using extracorporeal circulation.

However, differences were shown in the need for blood transfusion, reopening due to postoperative bleeding, less acute kidney damage and fewer respiratory infections in favor of cases undergoing beating-heart coronary artery surgery, but also a need for some kind of reoperation (angioplasty or surgery) in the same patients.

No difference was observed, as expected, in neurological disorders, which though explains why patients with atheromatous aorta were all underwent a beating heart surgery (102 patients). Thus, for the first time, it was found that patients at low risk (EUROSCORE <3) have worse outcomes with the use of extracorporeal circulation and patients at moderate or high risk (EUROSCORE> 3) have better results on beating heart surgery.

The authors conclude that beating-heart surgery may be possible for high and moderate-risk patients and typical surgery in low-risk patients.

It is now commonly accepted and understood that the results after the first thirty days are equal. The difference lies in the immediate postoperative period, defining though the general recovery progress, especially in high-risk groups (> 80 years), with low cardiac output, patients with diabetes mellitus, chronic respiratory disease, renal patients, and especially those with atheromatous aorta. Furthermore, the type of implant used is also important in the long-term outcomes. In our clinic, the choice of grafts mainly aims at the using arterial grafts in the left coronary network and venous grafts in the right. We have enriched the method using composite grafts made from arterial ones and most importantly we avoid handling the aorta which can be the cause of ischemic stroke, if atheromatous.

In conclusion, based also on the long experience and the published papers, the key benefits of coronary artery surgery can be summarized as follows:

  • Reduced need for blood transfusion.
  • Shorter surgery time and stay in the Intensive Care Unit.
  • Fewer postoperative complications in the respiratory system and kidneys.
  • Almost eliminating the risk of stroke and other neurological disorders.   

19.05.14
Minimally invasive Coronary Angiography -Angioplasty, Radial approach, no risk for bleeding, along with quick mobility and discharge in a few hours

Dr. George Papaioannou, MD MPHDirector of the Hemodynamic Lab of the Athens Medical Center.

The coronary artery disease is a heart arteries disease and is the main reason of morbidity and mortality to men and women of the western hemisphere. This means that blood vessels (coronary arteries), which provide blood and oxygen to the heart, develop some type of stenosis or blockage, leading either to angina or myocardial infarction (necrosis), even to sudden death. The final diagnostic exam for the verification or not of the diagnosis is coronary angiography, while in many cases, treating the disease includes further invasive techniques (angioplasty – stent placement), if deemed necessary.

Coronary angiography method

Invasive cardiology uses the human circulatory system (arteries) as a «route» for the passing of small catheters (little tubes, shaped like macaroni) of 2 mm diameter or even smaller, which are lead painless to the area of the heart. Those little tubes allow the administration of radiopaque liquid inside the coronary arteries, by which the artery network of the heart is depicted. The insertion of the catheter to the artery is usually done via leg puncture (femoral artery). The puncture could also be done to the arm βραχίονα (humeral artery) or to the wrist (radial arteryαρτηρία). The last one is the ideal approach for the minimally invasive coronary angiography.

Leg puncture

Leg puncture is the most frequently used technique for the creation of a route to the circulatory system and the insertion of catheters up to the heart in order to display coronary arteries. This technique, invented back in 1960, is the most widely used, but has some limitations. The femoral artery could have some disease (e.g. a patient with peripheral artery disease), something that does not allow a catheter’s insertion. In other cases, the patient is overweight and the femoral artery is located deeply inside subcutaneous tissue, making the approach quite difficult and also its compression after the end of the surgery even more difficult in order to stop hemorrhaging. Rarely, a potential hemorrhage by the artery after the end of the exam is not visible to the naked eye and could happen to the back of the artery, creating from a simple discoloration to a crucial hematoma. Finally, with the femoral artery puncture there is a small possibility of damaging the femoral nerve, due to the fact that it is located to close proximity. All previous complications, despite the fact of their low number, are the limitations of the femoral approach for coronary angiography.

Most limitations related to the approach by the femoral artery do not exist to the radial approach.

Radial approach

Despite the fact that the radial artery is much smaller in diameter in comparison with the femoral artery, each diameter is sufficient to allow most catheters to pass through it and to reach the coronary arteries. Further improvements of the materials have lead to the creation of special sheaths (the small tubes initially placed initially inside the artery), which are autramatic, as well as special catheters of a smaller diameter for the conduction of the diagnostic coronary angiography as well as of the surgery to the coronary vessels (angioplasty and/or stent placement).

Advantages of the radial approach

Most limitations related to the approach by the femoral artery do not exist to the radial approach. Even for overweight patients, radial approach is close to the skin, making the initial puncture much simpler. For the same reason, when diagnostic coronary angiography has finished, a short compression of the radial artery is sufficient to stop bleeding, even in patients receiving anti-clotting medication, such as after the execution of angioplasty. Finally, the radial artery is not proximal to any large nerve. Thus the possibility of damaging a nerve during surgery is not existent.

Radial approach does not present the risk of bleeding. Thus, the patients do not need the painful pressing of the femoral artery after the end of the exam or to lie down for many hours in order to avoid potential hemorrhage from the femoral artery. After the end to the diagnostic exam they can get up and walk right away. Also, due to the simpler process of healing of the artery wound on the wrist, most patients are able to leave to leave the hospital in a few hours without the need to spend the night.

Are all patients eligible for radial approach?

There are some requirements for a patient to be perfect candidate for the minimally invasive coronary angiography. The first one is to certify that there is a «double» supply of blood in the hand. The radial artery creates a loop in the hand and is united with the ulnar artery. Both arteries supply blood to the hand and fingers (Image 3). This double blood supply of the hand makes the radial approach completely safe. Even if the radial artery for some reason is “blocked” (a very rare complication), the clinical result is not important due to the fact that the hand is still supplied by the ulnar artery. The first step of the invasive cardiologist is to test the normal operation of both radial and ulnar artery. A simple test, which is done by pressing the arteries of the hand, is able to show the double provision of blood to the hand. If the test fails then the femoral approach is the preferred choice. Also, the femoral artery is preferred, when we know in advance the need to use catheters of larger diameter, the presence of bypass grafts and/or the coiling of blood vessels in the neck, which could inhibit the passage of the catheter from the hand to the coronary arteries. In total a high percentage of patients (70%-80%) are eligible for radial approach.

The first step of the invasive cardiologist is to test the normal operation of both radial and ulnar artery.

What are the reasons for the limited use of the radial approach in Greece?

The most common reason that patients are not informed for the radial approach is that that there is a very small number of invasive cardiologists that prefer this technique. Many places in Europe and/or Japan and also the United States of America and Canada have centers that are using either exclusively or mostly the radial approach as the main approach for the conduction of diagnostic coronary angiographies and angioplasties. Other reasons for the low use of radial approach for the conduction of coronary angiography is the lack of financial motive from the part of insurance companies and also hospitals but mainly due to the existing structure of the insurance system, the lack of information by patients and also the reluctance of invasive cardiologists to promote this technique. However this situation changes dynamically. More and more centers and invasive cardiologists begin to see the advantages of radial approach characterized by low implications, increased satisfaction on behalf of the patients, but also lower cost (reduced hospitalization time and low percentage of complications). At the Medical Center of Athens, the radial approach is for the last two the main personal diagnostic approach of patients submitted to coronary exams.

The femoral approach for the conduction of coronary angiography exists and will exist as a main technique for many years. The radial approach, offering a minimally invasive coronary angiography with almost zero percentage of complications and excellent satisfaction on behalf of the patients, requires specialized medical and nurse staff and greater skills. But its advantages are such that will make it the main approach for diagnostic and treatment purposes to the coronary vessels for the next years. 

By Georgios Ι. PapaioannouMD, MPH, FACC, FSCAI Invasive Cardiologist, of the Hemodynamic Lab of the Athens Medical Center.

19.05.14
Cardiac failure – The disease with the gradually increased hospitalization

Congestive Cardiac Failure (CCF) is a disease during which the heart is not able to supply tissues with a sufficient blood quantity, in order to satisfy the needs of the organs. The CCF clinical syndrome is the final manifestation of many cardiac conditions.

CCF was known since the antiquity. The father of medicine Hippocrates believed that: «A flesh oedema is caused mainly when someone, following a long-term disease remains without catharsis for some time. The flesh deteriorates and melts and becomes viscous. The abdomen is filled with water, tibias and legs are getting swollen. If the treatment starts from scratch before the concentration of water becomes extensive, one should administer cathartic medicine (diuretics) which will expel water or phlegm».

Nowadays almost 6 million Americans in the USA and 1% of the United Kingdom population suffer from CCF. The occurrence of the diseases is 10 persons /1000 in ages over 65. CCF is either acute, when symptoms are recent or chronic when there is a gradual evolution. Symptoms are dyspnea (effort or calm), weakness, fatigue, lower limbs oedema, tachycardia or arrhythmia, reduced ability for exercise, stubborn cough or whistling with white or red sputum, ascitic concentration, body weight increase (due to liquids retention), anorexia or nausea, difficulty to concentrate or reduced reflexes.

The risk factors for CCF are multiple.

The existence of one factor is sufficient to induce CCF but the combination of multiple factor is sure to increase the risk for the occurrence of the disease.

The main risk factors are: high blood pressure due to which the cardiac workload is increased, coronary disease during which narrowed arteries could not supply the heart with sufficient quantity of oxygen and lead to weakening of myocardial tissue as well as acute ischemic stroke which causes an extended myocardial damage ο and could lead to the reduction of the performance of the pumping ability of the heart. Arrhythmias many times cause an increase of the cardiac workload and weakening of the cardiac muscle. Also, diabetes could lead to CCF because it increases the risk for coronary disease as well as of high blood pressure. Also guilty for CCF occurrence are some anti-diabetic pills. Apnea during sleep is also an additional burdening factor, because it leads to the reduction of oxygen levels of the blood as well as to arrhythmias –which are both weakening factors of the cardiac muscle. Viruses, extensive alcohol consumption and renal diseases could lead to CCF. A small percentage of CCF patients are born with structural cardiac problems. Finally, neglected valve diseases could also cause CCF.

The Complications are multiple. CCF could lead to renal insufficiency (mainly for neglected cases) due to reduced blood supply to the kidneys. Also the operation of heart valves and the liver could worsen by the increased liquids retention. The flow through the heart pump is reduced, a fact contributing to the potential clot development and occurrence of cardiac and/or cerebral strokes. Nowadays the timely treatment could significantly improve the symptoms and life quality of patients. Despite that CCF keeps being a life threatening disease because it might lead to sudden death.

Diagnosing CCF is based to taking the patients’ history, clinically examine him/her, αbut also a series of exams including blood tests including NT - pro-BNP which is a reliable prognostic index, chest x-ray, electrocardiogram and fatigue test or the dobutamine stress echo. Clearly the most important role to the evaluation of cardiac function for this disease is the echocardiogram. During this exam one could calculate the fraction of expulsion which is an objective index of evaluation for the severity of the disease. In some cases, information for the causes of the disease and also its severity might be given by Heart MRI. The results of clinical and other exams help each cardiologist to classify the severity of the case and to define treatment.

The classification according to the New York Heart Association (NYHA) is international in order to classify patients based in symptoms. Class Ι (NYHA) patients do not have any symptoms. For Class ΙΙ (NYHA) no symptoms to ordinary activities but patients feel fatigue after extensive exercise. For Class ΙΙΙ (NYHA) symptoms now appear to ordinary activities and finally for Class IV (NYHA) which is the most severe, the patient has acute dyspnea even when calm. A second classification is that of the American Cardiology College using a grading for the disease from το Α to D depending on aggravating factors of the patients, symptoms and the dynamic evolution of the disease. For example the patients of Stage Α present some aggravating factors for CCF without occurrence of the disease. Patients of Stage D are in the final stage of the disease and could be treated only in a hospital. The abovementioned classification helps to the documentation of risk factors and the start of timely and aggressive treatment, in order to prevent or to slow down the progress of the disease.

Nowadays for its treatment are used many categories of medicine such as β- inhibitors, inhibitors of the receptors of angiotensin ΙΙ, digitalis therapy, diuretics, spironolactone or epleronone. Also many times is deemed necessary based on the indications, by-pass or valves replacement. In case of recording dangerous (threatening) arrhythmias there is the option to plant a defibrillator which in various ways replaces the normal heart rate.

Evolution in the level of research contributed to the identification of the notion of bisynchronism presented by some CCF patients and caused by damage to the electric system of the heart. In specific patients the implant of a biventricular pacemaker and the equilibration of the synchronization of parts of the heart lead to impressive results. For the last years patients with final stage CCF are implanted with Left Ventricular Assist Devices (LVADs) to the abdominal or precordial area. The initial design of those devices has been made as a «bridge» for transplant, because in some cases the transplant is not plausible or finding a heart takes a lot of time. However recent studies showed that in many cases LVADs could improve cardiac function and substitute the transplant. However these findings are still in development. Patients that do not react to any of mentioned therapies are lead to transplant. Unfortunately many times the waiting could be many months or years.

It must be noted that important modification of the daily life could prevent the aggravation of the disease. Initially giving up smoking protects coronary blood vessels, reduces blood pressure and cardiac workload. Also the regulation of body weight (BW) as well as the daily limitation of saturated fatty acids and cholesterol reception  - as aggravating CCF factors ­ reduces the potential for CCF occurrence. It must be also made clear that it highly recommended to reduce alcohol consumption for CCF cases, since on one part its use interacts with the medicine taken, on the other it weakens the cardiac muscle and also increases the risk for arrhythmias. Without doubt in severe CCF cases it is recommended to limit the consumption of salt and liquids, since it leads to water retention. The recommended salt reception for CCF patients should not be over 2 mg. If there is also high blood pressure or the patient is older than 50 the quantity is 1.5 mg. Aerobic exercise helps essentially for the reduction of the myocardial muscle needs. A special work-out program for CCF patients must be organized. The avoidance of intense emotional burden and stressing factors essentially leads to the reduction of cardiac workload and as a result to the stabilization and improvement of the disease. Finally in cases of apneas during sleep a relevant sleep study must be made and directions should be given.

In the USA each year are recorded 500 thousand new cases. It is calculated that in the next years, CCF would be the most common diagnosis and will be «responsible» for most admissions to hospitals. This happens because with new techniques and medicine, many patients survive and are lead long-term to heart failure.

With the currently applied drastic treatment we achieve not only slowing down the disease but also the improvement of the function of the left ventricle dye to reversal of each reformation. As a result the quality of life of patients is improved (since they are relieved of their symptoms) the main target of CCF treatment. The prevention of the CCF is everything so all risk factors should be checked and eliminated by modifying diet, way of life and taking, where necessary the required medication. 

By Dr. Aggeliki Eleftheriou, Special Cardiologist, Direct of the Cardiology Department, Athens Medical Center.