Cardiovascular Journal of Africa: Vol 27 No 6 (November/December 2016)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 6, November/December 2016 AFRICA 397
Connolly reported on the ongoing trial of the antidote,
andexanet alfa, in patients treated with a factor Xa inhibitor
presenting with critical bleeding. Haemostasis was achieved in
79% of patients. However, thrombotic events have been observed
after reversal. The 30-day mortality rate was 15%.24
Arrhythmias
The channelopathies include long-QT syndrome (QT interval
> 480 ms or > 460 ms in association with syncope and in the
absence of factors prolonging the QT interval), short-QT
syndrome (QT interval < 340 ms or < 360 ms in the presence
of additional features), Brugada syndrome, catecholaminergic
polymorphic ventricular tachycardia, early repolarisation
syndrome, progressive conduction system disease and idiopathic
ventricular fibrillation. Although genetic testing is helpful in a
variety of these conditions, it cannot rule out the presence of a
particular condition. However once a genetic marker has been
identified in a patient, there is a class I indication for testing
family members. ‘Overlap’ syndromes may occur.
Depending on the specific diagnosis, the management
armamentarium includes lifestyle changes, reduction in the
risk of exposure to triggers (e.g. exercise, sudden fright) beta-
blockade (possibly nadolol to be preferred), late sodium channel
blockers (e.g. flecainide, propafenone), quinidine, ablation of an
ectopic focus and consideration of an ICD or pacemaker. Fever
and alcohol exposure should be avoided in Brugada syndrome.
Priori presented her basic science research on gene therapy in
mice using adeno-associated virus (AAV) infection to either add
an active gene or silence a mutant. Problems may be posed by the
high incidence of antibodies to this virus.25
Valvular heart disease
In a session on mitral valve repair, Obadia illustrated several
surgical approaches to the mitral valve. Alifieri discussed the
problems associated with mitral valve repair. He emphasised
the importance of recognising that ‘everything is closer than
you think’: the commissure between the left and non-coronary
aortic valve leaflets, the circumflex coronary artery, the artery
to the atrioventricular node, the atrioventricular node itself and
the coronary sinus all lie in close proximity to the mitral annulus
and risk being injured during repair. It is challenging to remove
calcification from the mitral annulus. As a result, mitral leaks in
the region of the posterior annulus are seen more frequently in
the elderly. Mitraclip®, discussed by Latib, may be complicated
by inadequate grasping of the leaflet or leaflet perforation.
Occasionally systolic anterior motion of the mitral anterior
leaflet may result in intermittent mitral regurgitation during
exercise only; this may require provocation with isoprenaline to
demonstrate its presence.
It is important to recognise that in patients with aortic
regurgitation, only 50% have primary aortic valve disease; the
primary pathology is in the aorta in the other half. Sinotubular
dilatation, aortic dissection and occasionally aortic dissection flap
prolapse may be at fault. Three-dimensional echocardiography is
to be preferred over two-dimensional to quantify the degree of
aortic regurgitation. A left ventricular end-systolic diameter > 50
mm or left ventricular end-diastolic diameter > 70 mm predicts
the need for surgery. However, earlier referral for surgery is
recommended in symptomatic patients and those with LVSD.
TEE is strongly recommended prior to referral for surgery as
well as intra-operatively.
The feasibility of aortic valve repair depends upon the
pliability of the leaflets and their freedom from calcification.
Repair of a bicuspid aortic valve is less successful, especially
when decalcification and cusp repair with a pericardial patch
is required. There are many smaller studies reporting successful
aortic root repair with freedom from re-operation and absence of
residual regurgitation.
Venous thromboembolism
Computed tomographic pulmonary angiography (CTPA) is
frequently used in suspected acute pulmonary embolism (PE).
The majority of these costly investigations yield a negative
result. The YEARS project devised a simplified algorithm for
diagnosing acute PE. The first step is to obtain a D-dimer test
and score 1 point for each of the following: clinical assessment
for signs of deep venous thrombosis (DVT), haemoptysis and
whether PE is the most likely diagnosis. If the YEARS score is 1
or more or if the D-dimer value is > 1 000 ng/ml, order CTPA. If
not, PE can be ruled out and CTPA is unnecessary. This method
has been shown to be safe and will reduce the frequency of
CTPA by 14% overall and to a greater degree in younger patients.
In DVT-PE the outcome is not influenced by whether
treatment is initiated with rivaroxaban or with enoxaparin with
later bridging to rivaroxaban.
Following treatment for venous thromboembolism (VTE),
it is problematic to decide whether anticoagulant therapy
may be safely withdrawn owing to the potential for recurrent
events. Rodger presented a validation of the ‘men continue and
HERDOO2 rule’ which identifies those at low risk of recurrence
in whom anticoagulation can be withdrawn. The rule states
that all males and certain females scoring 2 or more using the
HERDOO rule must continue anticoagulation long term after
unprovoked or minor provoked VTE. The HERDOO factors
are HER: hyperpigmentation, oedema or redness in either leg,
D: level of D:dimer assessed through blood testing, O: obesity
defined as BMI ≥ 30 km/m2, and O: older than 65 years of age.
Anthony J Dalby, FCP (SA), FACC, FESC
Previously published by deNovo Medica, Cape Town, October 2016
cardiology-congress-update-2016/
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