References & Acknowledgements

Discussion

Conclusion

Background & Motivation

LEFT VENTRICULAR RECOVERY FOLLOWING AORTIC VALVE REPLACEMENT OR REPAIR FOR AORTIC INSUFFICIENCY

Hamed Basseri BSc 1, Munir Boodhwani MD MMSc FRCSC 1,2 1 Faculty of Medicine, University of Ottawa. 2 Division of Cardiac Surgery, University of Ottawa Heart Institute

Aortic insufficiency (AI) or Aortic regurgitation is abnormal retrograde blood flow due to an incompetent aortic valve (AV) in the heart.

•  elucidate the efficacy and safety of AV repair compared to AV replacement

•  analyze characteristics of left ventricular recovery, particularly size and function following surgery (AV repair or replacement)

•  identify trends in postoperative recurrence of AI following AV repair or replacement

A B C

Materials & Methods

Objectives

Results

•  This preliminary study has identified characteristics of LV recovery in patients who have undergone AV repair or replacement at the University of Ottawa Heart Institute •  There are however some important limitations. In particular, this project has identified potential future avenues of research that may include expanding the patient sample, clinical correlation, identification of preoperative predictors of outcome, and analysis of left ventricular recovery over a longer follow-up time course

Figure 3 (above): Depicts basic 2D echocardiogram three chamber view. LV: Left Ventricle, LA: Left Atrium, Ao: Aorta. Figure 4 (left): Doppler echo shows turbulent flow of aortic insufficiency. Preoperative and postoperative assessments were based on echocardiographic parameters such as Left ventricular end-diastolic dimension (LVEDD), Left ventricular end-systolic dimension, fractional shortening (FS), and left ventricular mass (LV Mass). Both figures adapted from [4].

Works Cited: [1] Lilly LS. Pathophysiology of Heart Disease. Baltimore, MD: Lippincott Williams & Wilkins; 2011. [2] Bashore TM, Granger CB, Hranitzky P, Patel MR. Chapter 10. Heart Disease. In: McPhee SJ, Papadakis MA, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment 2012. New York: McGraw-Hill; 2012. [3] Bonow RO, Carabello B a, Kanu C, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2006;114(5):e84-231. [4] Fuster V, Walsh RA, Harrington RA, eds. Hurst's The Heart. 13th ed. New York: McGraw-Hill; 2011. Figure Citations: [5] Morton DA, Foreman KB, Albertine KH. Chapter 4. Heart. In: Morton DA, Foreman KB, Albertine KH, eds. The Big Picture: Gross Anatomy. New York: McGraw-Hill; 2011.[6] Surgical approach in aortic valve replacement: Fom Albertucci M, Karp RB: Prosthetic valve replacement. In Al Zaibag M, Duran CMG [eds]: Valvular heart disease. New York, 1994, Marcel Dekker, p 615.) and [4]. Acknowledgements: Financial support was provided through the University of Ottawa, Undergraduate Research Opportunity Program (UROP).

Causes of Aortic Insufficiency include: •  enlargement of the aortic root (aortic aneurysm, Marfan syndrome, aortic dissection etc.) •  abnormalities of the valve leaflets (bicuspid valve, degenerative, rheumatic) [1].

As a result of a chronic increase in regurgitant blood flow, the left ventricle (LV), which is responsible for pumping blood to the systemic circulation, undergoes compensatory remodeling. This adaptation includes:

•  left ventricular hypertrophy •  enlargement of the chamber •  increased wall thickness (eccentric hypertrophy) [2].

Patients may be asymptomatic for some time owing to this chronic compensatory phase, however they are monitored with serial echocardiograms as ensuing LV dysfunction and dilatation can indicate poor surgical outcome [2, 3].

•  Preoperatively, there was no statistically significant difference in LVEDD or LV Mass between patient groups ( p > 0.05). There was however a statistically significant difference in preoperative LVESD and FS for patients undergoing AV replacement vs. AV repair (paired t-test, p = 0.0129 and p = 0.0126 respectively). • Postoperative left ventricular echocardiographic parameters were compared to their respective preoperative value for each patient. Mean % difference is depicted for each parameter. Error bars represent standard error of the mean (SEM). There was a statistically significant difference in % change in Left Ventricular Mass (LV Mass) for patients who underwent AV Replacement compared to AV Repair (t-test, p < 0.05).

•  There was a statistically significant reduction in LV Mass in patients who underwent AV replacement compared to AV repair (t-test, p < 0.05) •  This data should be analyzed in light of loss of echocardiographic follow-up in patients and should be correlated with follow-up in months, in future studies •  There was a greater degree of improvement in all echocardiographic parameters following AV replacement when compared to AV repair • However it is not clear whether this degree of improvement reflects a poorer preoperative status in AV replacement patients

Figure 1 (above): Normal anatomy of the heart. Adapted from [5].

Surgical Correction: AV replacement with a prosthetic valve is an established surgical option, however it has inherent limitations and complications:

•  the requirement of lifelong anticoagulation •  durability of the valve •  risks of endocarditis [4]

A reconstructive surgical approach, namely AV repair has recently gained increasing interest as an alternative to AV replacement. Figure 2 (right): Surgical aortic valve

replacement. Adapted from [6].

Study Design:

Echocardiography:

Patient Demographic Data:

Preoperative echocardiographic parameter results:

g"

Volume X, Issue X 2010Volume 7, Issue 2 2012

Family medicine is an important setting for managing cardiovascular risk factors and preventing the onset of heart disease, as well as managing risk factors following a cardiac event. If a patient is a smoker, explained Dr. Andrew Pipe, Chief of Prevention and Rehabilitation at the University of Ottawa Heart Institute, helping that patient quit smoking should be a priority.

“Helping a patient quit smoking is in fact the most important thing we can do to prevent heart disease and reduce risk of a future cardiac event in those with heart disease,” said Sophia Papadakis, PhD, MHA, Program Director of the Primary Care Smoking Cessation Program at the Heart Institute. Quitting smoking is more powerful in reducing risk than lowering blood pressure or managing cholesterol, but it is not always addressed in the same way in family medicine settings as are other risk factors, she added.

To support positive changes in the way smoking cessation is managed in the community, the Heart Institute has adapted its Ottawa Model for Smoking Cessation, a comprehensive smoking cessation program

originally developed for patients who have been hospitalized, for use by primary care physicians.

Since 2002, the Ottawa Model for Smoking Cessation has speci!cally tar-geted smokers admitted as inpatients (for any medical condition, not only heart disease). "e program’s success in getting participants to quit has led to its adoption in more than 120 hospitals across Canada. "e model ensures all patients who smoke are identi!ed and o#ered evidence-based

counseling and smoking cessation medi-cations. "ose who attempt to quit also receive automated follow-up support for two to six months or a referral to a community-based support program.

"e results have proven impressive: In an evaluation of the Ottawa Model in hospitals within the Champlain Local Health Integration Network, quit rates rose from less than 19 per cent to almost

Adapting the Ottawa Model for Smoking Cessation for the Solo Practitioner

(continued on page 2)

Recent visits to China and India by University of Ottawa Heart Institute staff represent their ongoing commitment to aid in modernizing cardiovascular medicine abroad. Dr. Thierry Mesana, Chief of Cardiac Surgery, (top left) and colleagues visited Qingdao, China, in the process of establishing a cooperative agreement with the Qingdao Municipal Hospital. Surgeon Dr. Marc Ruel (bottom right) traveled to the Indian cities of Indore, Nagpur and Hyderabad to train local surgeons in his minimally invasive technique for cardiac bypass grafting. (See “Collaboration in Fast-Growing Nations” on page 6.)

The University of Ottawa Heart Institute is Canada’s

largest and foremost cardiovas-cular health centre dedicated

to understanding, treating and preventing heart disease. We serve the local, national and international community, and

are pioneering a new era in heart health.

www.ottawaheart .ca

“While several other smoking cessation education programs are available today for physicians, they are not as specifically tailored to the realities of a family doctor in Canada.”

– Sophia Papadakis, Program Director Primary Care, Smoking Cessation Program, UOHI

IN THIS ISSUE

P. 1 Adapting the Ottawa

Model for Smoking Cessation for the Solo Practitioner

"e Heart Institute is taking its widely adopted smoking cessation program into the primary care setting for individual physicians.

P. 2Introducing the New Chief of Cardiology

Dr. Rob Beanlands brings broad experience in care, education and research, as well as a family legacy, to his new role as Chief of Cardiology.

P. 3Introducing the New

Chief of Cardiac Anesthesiology

Emphasizing quality care and a renewed focus on research, Dr. Jean-Yves Dupuis takes over as Chief of Cardiac Anesthesiology.

P. 4Using the Right Tools

to Manage Heart Failure

A new assessment of guideline-based treatments brings into focus the importance of actively managing this challenging chronic condition.

P. 6Collaboration in

Fast-Growing Nations

Members of the Heart Institute sta# share their expertise with colleagues in countries including India and China to help them improve medical techniques and processes.

P. 8A Quarter-Century of Recognizing Research

Excellence

For 25 years, Research Day has been an opportunity for trainees to share their work with their peers and to celebrate outstanding scienti!c achievements.