Prof. Samir Rafla, MD, PhD,  - Alexandria University - Emeritus professor of cardiology

Prof. Samir Rafla

MD, PhD,

Alexandria University

Emeritus professor of cardiology

Alexandria, Alexandria | Egypt

Main Specialties: Clinical Cardiac Electrophysiology

Additional Specialties: electrophysiology

ORCID logohttps://orcid.org/0000-0001-8688-6532

Prof. Samir Rafla, MD, PhD,  - Alexandria University - Emeritus professor of cardiology

Prof. Samir Rafla

MD, PhD,

Introduction

Primary Affiliation: Alexandria University - Alexandria, Alexandria , Egypt

Specialties:

Additional Specialties:

Research Interests:

Education

Jun 1972
Alexandria University Faculty of Medicine
Ph.D. Emeritus professor
Cardiology

Experience

Jun 1972
Alexandria University Faculty of Medicine
Emeritus professor
Cardiology

Publications

11Publications

-Reads

15Profile Views

6PubMed Central Citations

THE DANGER OF DUAL ANTIPLATELET THERAPY IN A PATIENT WITH ACUTE EFFUSIVE CONSTRICTIVE PERICARDITIS WHO WAS SUBJECTED TO STENTING.

Int. J. Adv. Res. 5(12), 1069-1072

Background: Patients admitted with chest pain and

electrocardiographic (ECG) changes have more than one possibility.

Wrong diagnosis and management can lead to complications up to

death.

Case presentation: A 55 year male presented with severe chest pain.

ECG revealed raised ST segment in inferior leads. The PR segment

depression of pericarditis was overlooked. The patient was admitted,

received loading doses of dual antiplatelet (DAP) (ASA 300 mg &

Clopidogrel 300 mg) plus heparin.

Clinical findings: Exam: B.P.: 110/70, T. 37 ˚C. Normal jugular

venous pulse (JVP). Heart: Normal. Echo revealed no regional wall

motion abnormalities and no pericardial effusion. CKMB = -ve,

Troponin Zero.

Diagnostic assessments: Coronary angio

View Article
February 2019

Copeptin as Early Marker of Acute Non-ST Elevation Myocardial Infarction in Patients Suspected with Acute Coronary Syndrome

Citation: Samir Rafla, et al. “Copeptin as Early Marker of Acute Non-ST Elevation Myocardial Infarction in Patients Suspected with Acute Coronary Syndrome”. EC Cardiology 6.1 (2018).

EC cardiology

Abstract

Keywords: Copeptin; Myocardial Infarction; Acute Coronary Syndrome

Conclusion: Copeptin seems to be an ideal confirmatory marker for rapid rule out of AMI. If the two tests (with troponin) are positive,

this is evident MI; if the two are negative it rules out MI.

Results: Males and females were 49 and 39. Age in G1 and G2 was 60 +/- 4 and 53 +/- 5. Copeptin analysis was done 6 hours after

Infarction or chest pain. All the patients with NSTEMI (30) had positive copeptin and positive troponin except one only who had +

Troponin only and another one who had + copeptin only. Of the 58 patients without MI none had the two tests positive, only one had

+ troponin and one had + copeptin. Using ROC curve: copeptin had sensitivity 100% and specificity 82.8% with using cut off point

13.2 pmol/l. So copeptin can be used for early detection of myocardial infarction.

Methods: This study included 88 patients with chest pain. They were divided into 2 groups. Group (1); included 30 patients with

diagnosis of NSTEMI. Diagnosis of AMI was established according to the universal definition of MI. Group (2); included 58 patients

with diagnosis of unstable angina (UA). Full medical history, physical examination, 12 lead ECG, random blood glucose level, renal

function, total cholesterol, triglyceride, cardiac troponin I and Copeptin were obtained on admission. Follow up cardiac troponin I

was done. Inclusion criteria: Defined as chest pain of ≤ 6 hour duration since onset, suggestive of myocardial ischemia, and lasting >

20 minutes at rest. Exclusion criteria: Patients with positive First cardiac troponin were rolled out, patients with ST segment elevation

were rolled out. Other exclusion criteria: Patients presenting after a cardiac arrest, Trauma or major surgery within the last 4

weeks; pregnancy; IV drug abuse; age less than 18 years; shock and sepsis. Patients who were included had second troponin I re-done

and copeptin analysis done. In group 1 (NSTEMI) 28 patients had ECG changes and only 2 had NSTEMI without ECG changes. In group

2 (UA) 23 patients had ECG changes and 35 patients had normal ECG.

Background: Rapid diagnosis and management of AMI have great impact on morbidity and mortality. Diagnosis which is based on

elevation of cardiac biomarkers has its limitations. One of the major limitations is the delayed release in circulation. So, looking for

a new marker with a short diagnostic time window is needed. Copeptin is the c-terminal part of the vasopressin prohormone. The

pathophysiology mode of release should theoretically add diagnostic information of cardiac cell necrosis. Aim is to determine the role

of copeptin as an early marker for acute non-ST elevation MI (NSTEMI).

View Article
February 2019

Validation of Cornell Product as a Method of Assessing Left Ventricular Hypertrophy

Rafla S, Elzawawy T, Elbahy OI, Mohamed AK, Elshourbagy A (2018) Validation of Cornell Product as a Method of Assessing Left Ventricular Hypertrophy. Int J Cardiovasc Res 7:6.

International Journal of Cardiovascular Research

Abstract

Background: LV diastolic dysfunction (DD) and diastolic HF is

a major and widely spreaded health proplem and it’s

associated with higher cardiovascular morbidity and all-cause

mortality, ECG –LVH is studied as an early predictor of LV

diastolic dysfunction.

Methods: diastolic dysfunction is evaluated in 100 patients

with Cornell product (CP) criteria >2440 mm.ms with complete

evaluation of diastolic function via mitral inflow velocities (mitral

E velocity, A velocity and E/A ratio ), tissue Doppler

imaging(septal and lateral annular velocity, E/E’ ratio),

deceleration time, isovolumic relaxation time, left atrial

Enlargement, left ventricular mass index.

Results: Among the 100 patients (59% female and 41%

males ), 14% presented with normal diastolic function, while

86% had diastolic dysfunction with different grades, with

increasing values of CP with more progression of the diastolic

dysfunction severity, in concern to the echocardiographic

parameters there were progressively higher values of LVEDD,

PWD, IVSD, LVMI, E/A ratio, E/E’ ratio and LAVI with

advancement of diastolic dysfunction ; while there were inverse

relation between the diastolic dysfunction severity and (Evelocity,

a-velocity, lateral E’ velocity and DT).

The IVRT shows higher values with mild degree of diastolic

dysfunction then with progression of diastolic dysfunction there

were progressive reduction in IVRT values, while there were no

significant difference in concern of LVESD and septal E’

velocity between normal population and different grades of

diastolic dysfunction.

Conclusions: CP LVH is a strong predictor of presence of

Diastolic dysfunction and with higher degrees of diastolic

dysfunction; the CP LVH was higher indicating good predictor

for the severity of diastolic dysfunction.

View Article
December 2018
1 Read

Upgrading patients with pacemakers to resynchronization pacing Predictors of success

https://doi.org/10.1016/j.ajme.2017.11.006

Alexandria Journal of Medicine

Original Article

Upgrading patients with pacemakers to resynchronization pacing:

Predictors of success

Samir Rafla ⇑, Aly Aboelhoda, Mostafa Nawar, J.Ch. Geller ⇑,1, Mohamed Lotfi

Alexandria University, Cardiology Dept. Egypt, Zentral Klinik, Bad Berka, Germany

a r t i c l e i n f o

Article history:

Received 14 August 2017

Revised 12 November 2017

Accepted 12 November 2017

Available online 11 January 2018

Keywords:

Heart failure

Resynchronization therapy

CPR

Ischemic vs non-ischemic cardiomyopathy

a b s t r a c t

Background: The investigations of predictors of success or failure of cardiac resynchronization therapy

were studied previously. Assessment of success in patients already on dual or single pacemakers and

upgraded to cardiac resynchronization therapy (CRT) were not extensively studied before. How to select

patients in whom this may be the most optimal strategy is unclear. We sought to determine factors associated

with success or failure in this group of patients who were already paced for heart block.

Methods: 81 pts were subjected to upgrade to CRT implantation after being on pacemaker. The study was

conducted in Germany. Data was presented as Median (Min.–Max.) for abnormally distributed data or

Mean ± SD. for normally distributed data. Parameters that revealed no statistical significance in response:

Age, sex, EF, diabetes, renal disease, GFR, MR, QRS duration (all above 150 ms), history of ablation, AF

recurrence, previous pacemaker, optimization. The following parameters revealed significant influence

on response to CRT: Less responders with: Higher C reactive protein (CRP), presence of tricuspid incompetence

(TR), presence of pulmonary hypertension (PHN), presence of previous MI, being ischemic vs

nonischemic cardiomyopathy (CM) (less responders with ischemic CM).

Conclusions: The findings through light on specific parameters that predict response to upgrade to CRT

after usual pacemaker.

2017 Alexandria University Faculty of Medicine. Production and hosting by Elsevier B.V. This is an open

access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Cardiac resynchronization therapy (CRT) has a broader range of

therapeutic benefits in appropriately selected patients. The

improvement includes cardiac function symptoms and quality of

life and reductions in HF-related hospitalizations and death.1–6

The investigations of predictors of success or failure of cardiac

resynchronization therapy were studied previously. But assessment

of success in patients already on dual or single pacemakers

and upgraded to CRT were not extensively studied before. How

to select patients in whom this may be the most optimal strategy

is unclear. We sought to determine factors associated with success

or failure in this group of patients who were already paced for

heart block.

Aim of the work was to study the value of upgrading patients

with pacemakers to CRT and assess the significant parameters

between responders and non-responders in this special population.

2. Methods

The study included 81 who were implanted with pacemakers

for heart block. Later they were found to be legible or in need for

CRT upgrading pts. The study was conducted in Germany. The

study was conducted from January 2010 to June 2012. All new

comers with ventricular pacing were studied (40%) plus previous

patients done before and their data were preserved.

How success was assessed: By improvement in NYHA class > o

ne level at least, improvement in EF > 5% at least, improvement

of LV end systolic volume by 15% at least. 6 min walk distance, if

the distance increased than before CRT by > 25% (not done in all

so not included in the statistics).

Follow up: Patients were followed one year after CRT

implantation.

3. Parameters assessed were

Sex, Age, C reactive protein (CRP), Ejection Fraction (LVEF),

Tricuspid incompetence, pulmonary hypertension, previous

infarction, QRS duration and etiology of HF (ischemic or

cardiomyopathy).

https://doi.org/10.1016/j.ajme.2017.11.006

2090-5068/ 2017 Alexandria University Faculty of Medicine. Production and hosting by Elsevier B.V.

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Peer review under responsibility of Alexandria University Faculty of Medicine.

⇑ Corresponding authors.

E-mail addresses: smrafla@yahoo.com (S. Rafla), aly.aboelhoda@gmail.com

(A. Aboelhoda), mosnawar@yahoo.com (M. Nawar), drmloutfy@yahoo.com (M. Lotfi).

1 https://www.zentralklinik-bad-berka.de

Alexandria Journal of Medicine 54 (2018) 311–313

Contents lists available at ScienceDirect

Alexandria Journal of Medicine

journal homepage: http://www.elsevier.com/locate/ajme

View Article
December 2018
1 Read

Journal of Clinical and Experimental Cardiology

Citation: Rafla S, Abdel-Aaty A, Sadaka MA, Elhoda AAA, Shams AM (2018) Predictors of Ischaemia and Outcomes in Egyptian Patients with Diabetes Mellitus Referred for Perfusion Imaging . J Clin Exp Cardiolog 9: 591. doi:10.4172/2155-9880.1000591

Predictors of Ischaemia and Outcomes in Egyptian Patients with Diabetes Mellitus Referred for Perfusion Imaging

Abstract

The predictors of scintigraphic ischemia were studied in 169 Egyptian diabetic patients. They underwent stressrest

gated-SPECT myocardial perfusion imaging (MPI) protocol; also 25 subjects (control group) underwent Rest-

Redistribution MPI protocol. The patients were followed up to 24 months.

Results: We found significant relation between Summed stress score (SSS) and sudden cardiac death, MI and

HF. Also there were statistically significant relation between atypical pain and HF. We found significant relation

between summed rest scores (SRS) and sudden cardiac death, MI, HF, and stroke with p<0.001, p<0.038, p<0.001

and p<0.016 respectively. On applying univariate, multivariate analysis and Kaplan Meier survival for prognostic

variables for MI, we found degree of typical pain (CCS class) is the most prognostic with HR=6.100, followed by TID

of LV, lung uptake and SSS with HR=1.401, HR=1.115, and HR=1.100 respectively. Also we found that transient

ischemic dilation (TID) of LV is the most prognostic variable for sudden cardiac death with HR=5.077, followed by

SSS, SRS, degree of pain (Canadian Cardiovascular Society classification of chest pain (CCS) class), with

HR=2.682, HR=2.636, HR=2.008, respectively.

Conclusion: Semi-quantitative parameters such as SSS, SRS, SDS and percentage of ischaemic myocardium

are independent predictors of MACE in both symptomatic and asymptomatic diabetic Egyptian patients, also In our

View Article
March 2018

Robotic Ablation of Atrial Fibrillation Saves Time and Irradiation Dose

Citation: Samir Rafla, Mostafa Nawar, Amr Kamal, Josef Kautzner (2017). Robotic Ablation of Atrial Fibrillation Saves Time and Irradiation Dose

Annals of Clinical Research and Trials

Open Access Full Text Article

Annals of Clinical Research and

Trials

Volume 1 • Issue 2 • 008 www.scientonline.org Ann clin Res Trials

Research Article

Robotic Ablation of Atrial Fibrillation Saves Time and Irradiation

Dose

Samir Rafla*, Mostafa Nawar, Amr Kamal

and Josef Kautzner

Department of Cardiology and Angiology, Alexandria

University, IKEM institute, Prague, Czech Republic,

Egypt

Introduction

The goals of AF ablation procedures are to prevent AF by either eliminating the

trigger that initiates AF or by altering the arrhythmogenic substrate [1-4]. The most

commonly employed ablation strategy today, which involves the electrical isolation of

the pulmonary veins by creation of circumferential lesions around the right and the

left PV ostia, probably impacts both the trigger and substrate of AF [5-7]. Catheter

based ablation of AF places significant demands on the skill and experience of the

electrophysiologist. The objectives of developing new technologies to facilitate these

procedures include precise and stable catheter navigation, reduced radiation exposure,

shorter procedures, and cost effectiveness. While new technologies generally increase

the cost of a procedure when they are introduced, the costs may be justified if they

improve outcomes.

The Hansen Sensei robotic system (Hansen Medical Inc., Mountain View, California

®) integrates robotic technology with computed movement. The key aspect is an

electromechanical manipulator that is designed to provide physicians with precise

catheter control and 3-D navigation within the heart from the workstation, while the

operator is away from the operating table [8]. The aim of this work was to evaluate

the feasibility of catheter ablation in patients with paroxysmal atrial fibrillation using

different technologies and its effect on terms of procedural efficacy and success rate

Patients and Methods

We studied 150 patients (pts) (86 males and 64 females) having a mean age of 51.3 yrs

(54 > 50, 96 below 50 yrs), who suffered from symptomatic drug refractory paroxysmal

*Corresponding author: Samir Rafla, Department

of Cardiology and Angiology, Alexandria University,

IKEM institute, Prague, Czech Republic, Egypt, E-mail:

smrafla@yahoo.com

Abstract

This analysis assesses the effect of Robotic technique on the results of ablation of

paroxysmal AF.

Methods: We studied 150 patients (pts) (86 males and 64 females) having a mean

age of 51.3 yrs (54 > 50, 96 below 50 yrs), who suffered from symptomatic drug refractory

paroxysmal AF. Work was done in IKEM hospital in Prague. Cardiac MSCT image

integration to the 3D electroanatomic LA map was used in 106 pts (70.6%, however all

of them underwent intracardiac echo guided imaging during the ablation procedure. 40

pts underwent manual RF ablation using CARTO, 40 pts underwent ablation using NavX

system, 70 pts underwent robotic ablation using Sensui system. Pulmonary vein isolation

was done to all pts using either pulmonary vein (PV) antral isolation in 116 (77.3%) or

circumferential pulmonary vein ablation in 34 pts (22.7%). All pts were followed at 3, 6, 9,

and 12 months.

Results: Procedural time was significantly longer in manual (202.0 ± 19.4 minutes)

compared to Robot group (146.4 ± 10.8 minutes). Total fluoroscopy time was significantly

shorter in Robot group (6.9 ± 1.9 minutes) compared to non-robotic group (19.9 ± 3.1

minutes). The mean fluoroscopy dose area-product was significantly lower in Robot group

(552.7 ± 194.1 μ Gy.cm2) compared to manual group (2257.2± 568.1 μGy.cm2).

Conclusions: The robotic group showed evident and clear benefit of the use of robotic

navigation system in the form of much shorter total procedure time, shorter total fluoroscopy

time and fluoroscopy exposure dose with less number of ablation points.

Keywords: Atrial fibrillation, Ablation techniques, Pulmonary vein isolation, Robotic

ablation procedures, Radiation, Administration and dosage

This article was published in the following Scient Open Access Journal:

Annals of Clinical Research and Trials

Received November 28, 2017; Accepted December 06, 2017; Published December 13, 2017

Citation: Samir Rafla, Mostafa Nawar, Amr Kamal, Josef Kautzner (2017). Robotic Ablation of Atrial Fibrillation Saves Time and Irradiation Dose

Page 2 of 5

Volume 1 • Issue 2 • 008 www.scientonline.org Ann clin Res Trials

AF. Work was done IKEM institute, Prague, Czech Republic from

2008 to 2010 as part of the doctoral degree of Dr. Amr Kamal.

Patients were subjected to the following

I- Full History Taking & Clinical Examination

II- Baseline 12- Lead Electrocardiogram (ECG)

III- Routine Laboratory Investigations

VI- Cardiac Imaging Modalities

• Chest X ray Examination

• Transthoracic Echocardiography (TTE)

• Transesophageal Echocardiography(TEE)

• Cardiac Multislice Computed Tomography (MSCT)

• Intracardiac Echocardiography(ICE)

V- Preprocedural Management

• Informed consent

• Preprocedural anticoagulation

• Preprocedural antiarrhythmic drugs

VI- Procedural management

• Vascular access

• Procedural sedation

• Procedural anticoagulation

• Double transseptal puncture

• Catheters positioning

VII- Three dimensional electroanatomic mapping

• The EnSite NavX® system (Endocardial Solutions, St. Jude

Medical, Inc.)

• The CARTO mapping system (Biosense, Diamond Bar, CA,

USA®)

VIII- Radiofrequency Catheter Ablation

• Robotic Catheter Navigation System (Sensei System,

Hansen Medical, Inc. ®)

• Manual Catheter Ablation

XI- Post procedural management & follow up patients were

followed up regularly at the outpatient arrhythmia Clinic at 3, 6, 9

and 12 months, as well as at any time for any possible attacks of

arrhythmic recurrences.

Patients were followed up as regards

• Clinical symptoms

• Standard 12- lead Electrocardiogram (ECG)

• In hospital Telemetry

• 7- Day Holter Monitoring

• Outpatient Mobile Telemetry with Loop Recording

The patients were divided into three groups

• Group C (Carto): Forty patients with paroxysmal atrial

fibrillation who underwent ablation using CARTO

technology and manual ablation.

• Group N (NavX): Forty patients with paroxysmal

atrial fibrillation who underwent ablation using NavX

technology and manual ablation.

Group R (Robotic): Seventy patients with paroxysmal atrial

fibrillation who underwent ablation using NavX technology with

use of robotic catheter navigation system (Sensei System).

Integration of CT Image into CARTO Mapping System: CT

image fusion with 3D Carto map was done to most of the patients;

the CT image was imported into the EAM system using special

software (CartomergeTM, Biosense Webster, Inc., Diamond Bar, CA,

USA) (Figure 1).

Integration of CT Image into EnSite NavX Mapping System

The contrast enhanced CT image in standard DICOM format

Figure 1: Segmentation process of 3D-CT image using Carto Merge Software.

Citation: Samir Rafla, Mostafa Nawar, Amr Kamal, Josef Kautzner (2017). Robotic Ablation of Atrial Fibrillation Saves Time and Irradiation Dose

Page 3 of 5

Volume 1 • Issue 2 • 008 www.scientonline.org Ann clin Res Trials

was imported into the mapping system using the EnSite System

software tools for digital image fusion in the same way.

Ablation Procedure: Ablation was done in all patients using

the open irrigation ablation catheter in the power controlled

mode either manually or after mounting on Artisan catheter for

remote robotic catheter navigation system.

The end point of the ablation was the disconnection between

the PV and LA, and noninducibility of AF/AFL.

Periprocedural Anticoagulation during AF Catheter Ablation:

After the procedure, heparin infusion is discontinued. Warfarin

therapy is restarted in all patients either the same evening of the

ablation procedure or next morning. In the initial period, LMWH

(e.g., Enoxaparin at a dosage of 0.5-1.0 mg/kg twice a day) is

often given as bridging therapy by starting 3-4 hours after the

ablation or alternatively heparin is administered intravenously

until the day after the procedure, starting about 3 hours after

sheath removal at a rate of 1000 IU/h. Thereafter, LMWH is

administrated until the INR is ≥2. Once the therapeutic INR is

achieved, LMWH is stopped, whereas warfarin is continued for

at least 3 months. The anticoagulation strategy after the initial 3

months varies according to patient and procedure related factors

and for most patients with a CHADS2 score of ≥2 to continue longterm

warfarin treatment with a targeted INR of 2-3 is usually

needed.

Cardiac MSCT image integration to the 3D electroanatomic LA

map was used in 106 pts (70.6%, however all of them underwent

intracardiac echo guided imaging during the ablation procedure. 40

pts underwent manual RF ablation using CARTO, 40 pts underwent

ablation using NavX system, 70 pts underwent robotic ablation

using Sensui system. Pulmonary vein isolation was done to all pts

using either pulmonary vein (PV) antral isolation in 116 (77.3%)

or circumferential pulmonary vein ablation in 34 pts (22.7%).

Circumferential PV ablation was usually associated with posterior

wall ablation. All pts were followed at 3, 6, 9, and 12 months.

Statistical analysis of the data

Data were fed to the computer and analyzed using IBM SPSS

software package version 20.0. Qualitative data were described

using number and percentage. Quantitative data were described

using mean and standard deviation. Comparison between

different groups regarding categorical variables was tested using

Chi-square test. When more than 20% of the cells have expected

count less than 5, correction for chi-square was conducted

using Fisher’s exact test. Correlations between two quantitative

variables were assessed using Pearson coefficient. Significance

of the obtained results was judged at the 5% level. Data was

presented as Median (Min. -Max.) for abnormally distributed data

or Mean ± SD. for normally distributed data.

Results

Total fluoroscopy time: Manual group vs. Robotic group 19.9

minutes vs. 6.9 minutes, P <0.000 (Table 1). 34 patients (22.6%)

developed early recurrence of AF after an initial blanking period

of 3 months. We had 16 patients (10.6%) with treatment failure at

short term follow up, this number increased to 18 patients (12%)

at midterm follow up and further small increase to 20 patients

(13.3%) at long term follow up, recurrences were any episode of

AF and /or AFL/AT > 30 seconds after the blanking period. The

incidence of recurrence of AF in males was 13% (11/86), 14% in

females (9/64), P NS.

Complications rate (Table 2): None in 92,5%, air embolism

zero, cardiac tamponade zero, trivial pericardial effusion 1,

groin hematoma 5%, pulmonary vein stenosis > 50% zero. No

difference in complications between robotic and manual groups.

Long term success rate

The primary efficacy endpoint was complete success with no

recurrences from 9 months and up to 12 months after ablation

procedure without use of AAD in 77.5% of manual group and

85.7% in Robot group. Long term comprehensive success

was also calculated from 9 months and up to 12 months after

ablation procedure as the sum of primary and secondary efficacy

endpoints, reflecting the reduction of AF burden, it was 82.5 %

for manual group and 91.4 % for Robot group (Table 3).

Groups No of Patients Mean P

Total no. of ablation points

Manual Gr 80 72 0.000

Robotic Gr 70 49.9

Total ablation time

Manual Gr 80 2094 0.000

Robotic Gr 70 1323

Total fluoroscopy time

Manual Gr 80 19.9 0.000

Robotic Gr 70 6.9

Total fluoroscopy dose

Manual Gr 80 2257 0.000

Robotic Gr 70 552

Table 1: Comparison between manual and robotic groups as regards ablation

points.

Complications

Manual group

(n = 80)

Robotic group

(n = 70) X2 P

No % No %

No complications 74 92.5 66 94.4 0.432 0.692

Trivial pericardial effusion 2 2.5 0 0 1.332 0.235

Cardiac tamponade 0 0 0 0 0.000 1.000

Air embolism 0 0 1 1.4 0.647 0.622

Small groin hematoma 4 5 3 4.2 0.236 0.134

Thromboembolism 0 0 0 0 0.000 1.000

Table 2: Comparison between manual and robotic groups as regards

complications.

Efficacy

Group C

(n = 40)

Group N

(n = 40)

Group R

(n = 70) X2 P

No % No % No %

Short term

Good (without AAD) 32 80 30 75 54 77.1 1.646 0.801

Average (with AAD) 4 10 4 10 10 14.3

Comprehensive success 36 90 34 85 64 91.4

Failure 4 10 6 10 6 8.6

Mid term

Good (without AAD) 30 75 32 80 58 82.9 2.161 0.706

Average (with AAD) 4 10 2 5 6 8.6

Comprehensive success 34 85 34 85 64 91.4

Failure 6 15 6 15 6 8.6

Long term

Good (without AAD) 30 75 32 80 60 85.7 3.014 0.555

Average ( with AAD) 2 5 2 5 4 5.7

Comprehensive success 32 80 34 85 64 91.4

Failure 8 20 6 15 6 8.6

Table 3: Comparison between the three groups as regards procedural efficacy

and success rate.

Citation: Samir Rafla, Mostafa Nawar, Amr Kamal, Josef Kautzner (2017). Robotic Ablation of Atrial Fibrillation Saves Time and Irradiation Dose

Page 4 of 5

Volume 1 • Issue 2 • 008 www.scientonline.org Ann clin Res Trials

Discussion

Catheter ablation of AF is now a realistic therapeutic option

for patients with paroxysmal AF. (9) In this study, one hundred and

fifty patients were enrolled for catheter ablation of symptomatic

paroxysmal AF who had failed at least one antiarrhythmic drug.

Multivariate analysis of predictors of success in Group

C (Carto)

In our study, a multivariate analysis of predictors of success

for patients with paroxysmal AF who underwent ablation using

Carto 3D EAM technology and manual ablation was done and

different variables were evaluated as regards their significance as

predictors of success.

The significant predictors of success in Carto group were PV

antral isolation as the used method of eliminating PV triggers,

PV antrum as a target PV ablation site, early recurrence during

blanking period, rhythm outcome, baseline ECG, duration of

AF and additional ablation line (roof line) in order, while other

predictors were not significant.

Zhong et al. [10] was very strict in conclusion and showed

that Carto Merge system is inaccurate and they suggested that

this inaccuracy may be reduced by using CT and electroanatomic

images obtained at the same point in the atrial mechanical

cycle. Accuracy was significantly improved when the end-atrial

contraction CT image was used for registration.

Multivariate analysis of predictors of success in NavX

(N) group

In our study, a multivariate analysis of predictors of success

for patients with paroxysmal AF who underwent ablation using

NavX 3D electroanatomic mapping (EAM) technology and

manual ablation was done and different variables were evaluated

as regards their significance as predictors of success.

The significant predictors of success in NavX manual group

were early recurrence during blanking period, rhythm outcome,

LV EF (systolic heart failure (HF), baseline ECG, test for AF

inducibility, additional ablation line (roof line), diabetes mellitus,

and hypertension in order, while other predictors were not

significant.

Multivariate analysis of predictors of success in Group

R (Robot)

In our study, a multivariate analysis of predictors of success

for patients with paroxysmal AF who underwent ablation using

NavX 3D EAM technology and Robotic ablation was done and

different variables were evaluated as regards their significance as

predictors of success.

The significant predictors of success in Robot group

were early recurrence of AF during blanking period, rhythm

outcome, LV EF, systolic HF, test of AF inducibility, baseline ECG,

hypertension and duration of AF in order, while other predictors

were not significant.

Robotic Catheter Navigation System

In the present study it was evident that the major advantage of

robotic navigation as compared to manual navigation is catheter

stability (Figures 2 and 3). It is obvious from our observations

that robotic navigation system is proved to be safe and feasible

with same has been proved on experimental studies [11,12] and

on early human experience reported in literature [8,13-17].

Owing to the precise catheter navigation in conjunction with

better catheter stability of the robotic navigation system, patients

in the robotic arm of this study needed less RF applications as

well as much less RF time, when compared to the other two

groups of manual ablation, and these findings was independent

on the type of the three dimensional LA map.

In our pooled data analysis, the total number of ablation

points was significantly higher in manual group (Carto and NavX)

(72.2 ± 29.4) compared to Robot group (49.9 ± 12.6). Moreover,

the total ablation time was significantly higher in manual group

(Carto and NavX) (2094.8 ± 911.7 seconds) compared to Robot

group (1323.1 ± 355.6 seconds).

Conclusions

The ideal ablation strategy for Atrial Fibrillation (AF) uses the

least amount of ablation needed to achieve the highest possible

Figure 2: Hansen Robotic System.

Figure 3: Comparison of efficacy between the three groups.

Citation: Samir Rafla, Mostafa Nawar, Amr Kamal, Josef Kautzner (2017). Robotic Ablation of Atrial Fibrillation Saves Time and Irradiation Dose

Page 5 of 5

Volume 1 • Issue 2 • 008 www.scientonline.org Ann clin Res Trials

success rate. Comparison of the manual groups (group C and

group N) showed that use of Carto technology was associated with

greater number of ablation points and longer total ablation time

for a comparable set of lesions, however this was not translated

into either a significant difference in procedural time or procedural

outcome and complications rate was comparable between the 2

groups with no significant difference. Robotic navigation system

could perform ablation procedures in a substantially equivalent

manner to conventional manually controlled catheters; however,

the remote robotic navigation system would be able to overcome

the limitations of manual control by combining the ease of

navigation with a readily available wide navigational field. In

addition, it will reduce the physician’s radiation exposure during

long procedures of electrophysiologic study and catheter ablation.

Remote robotic catheter navigation system can add

precise catheter control, stability and maneuverability to

electrophysiology mapping and ablation procedures. These

features, coupled with the added safety of IntelliSense and the

potential of lesion and map optimization using catheter tissue

interface pressure, make robotic catheter control an attractive

option for the modern EP lab.

Robotic ablation was associated with significantly lower

fluoroscopy exposure well as significantly shorter overall

procedure time.

Robotic ablation is as effective and safe as manual ablation

with very low procedural and post procedural complication rates.

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Copyright: © 2017 Samir Rafla, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits

unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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December 2017
61 Reads

Effect of Kidney Dysfunction on Results of Revascularization of Multivessel Coronary Disease

Merit Research Journal of Medicine and Medical Sciences (ISSN: 2354-323X) Vol. 5(11) pp. 538-542, November, 2017

Merit Research Journal of Medicine and Medical Sciences

Kidney dysfunction is a risk factor for interventional procedures in coronary

artery disease. We analyzed this point. We studied 120 patients who had

objective and angiographic evidence of myocardial ischemia and significant

coronary artery disease (lesion > 70%) in two or more vessels. Forty

patients underwent Percutaneous Coronary Intervention (PCI) of the

significant lesions beside optimal medical therapy (PCI group II), 40 received

optimal medical therapy alone (medical-therapy group III) and 40 were

subjected to CABG (Group I). The choice between PCI and CABG was based

on the Syntax score. The 40 pts on medical therapy alone either refused

surgery (18), or were not suitable for surgery (12) or the lesions were not

severe as assessed by FFR (7) or failed stenting (3). The primary outcome

was death from any cause and nonfatal myocardial infarction during a

follow-up period of 1 year. There was no significant difference between the

three groups as regards incidence of diabetes, hypertension, dyslipidemia

or age. Renal dysfunction (creatinine >2) was present in 18 pts (10+4+4). The

highest was 2.28 mg/dl. Results comparing pts with creatinine >2 (18 pts)

with those with creatinine < 2 (102 pts): Death 0 vs 4 (NS), non fatal MI 3 vs 8

(NS), heart failure 0 vs 10 (NS), recurrence of chest pain 3 vs 7 (NS).

Conclusion: In 120 patients with multivessel disease treated by CABG or PCI

or medical therapy, the presence of creatinine >2 and < 2.3 did not affect the

results or prognosis or incidence of complications.

View Article
November 2017

Smoking is a more dangerous risk factor than metabolic syndrome in Egyptian patients with acute myocardial infarction

Merit Research Journal of Medicine and Medical Sciences (ISSN: 2354-323X) Vol. 5(9) pp. 427-431, September, 2017

Merit Research Journal of Medicine and Medical Sciences

The aim of the manuscript is to assess the incidence of each risk factor in

our community as a predictor of acute myocardial infarction. Fifty patients

(Pts) admitted to the main university hospital with acute MI were studied.

Inclusion criteria were: pts diagnosed as acute ST segment elevation

myocardial infarction (STEMI) based on typical retrosternal chest pain

associated with typical electrocardiographic changes of STEMI, with at least

one cardiac enzyme assay result above twice the limit of normal. Incident

cases of acute STEMI presenting within 24h of symptoms onset were

eligible. Metabolic Syndrome (MS) components were defined as detailed in

the ATP III report: 1) waist circumference >102 cm in men and >88 cm in

women, 2) fasting triglycerides ≥150 mg/dl. 3) HDL cholesterol <40 mg/dl in

men and <50 mg/dl in women, 4) BP ≥130/85 mmHg, and 5) fasting - glucose

≥ 110 mg/dl. Participants with at least three of these components were

determined to have the MS. MS was present in 27 pts (54%) The incidence of

different risk factors in the 50 pts: Family history of any point (before age

60) as coronary disease, sudden death, diabetes, Ht was present in 36 pts

(72%), smoking 38 pts (76%). 60 % had diabetes. Comparing to incidence in

Egypt: Diabetes in infarcted patients was 5 (6) times more. Smoking was

twice more, metabolic s. was twice more; HT was twice more (48%). We

highlight the danger of diabetes and smoking as the most significant

predictors of MI in Egyptians.

View Article
September 2017

Analysis of Bleeding Complications in Acute Coronary Syndrome: Comparison of Effect of Tirofiban in Diabetic and Non-Diabetic Patients

J Clin Exp Cardiolog, an open access journal ISSN:2155-9880 Volume 9 • Issue 7 • 1000598

Journal of Clinical and Experimental Cardiology

Abstract

Background: Coronary artery disease (CAD) is the most prevalent manifestation of cardiovascular diseases and

is associated with high mortality and morbidity. The clinical presentations of CAD include silent ischemia, stable

angina pectoris, unstable angina, myocardial infarction (MI), heart failure, and sudden death.

Objective: This study was designed to define the frequency of hemorrhagic complications and to identify clinical

variables associated with increased risk of bleeding complications in diabetic versus non-diabetic patients presented

with acute coronary syndrome whom received aspirin, clopidogrel and heparin only or in combination with GPIIb/IIIa

receptors blockade (Tirofiban) and to detect any bleeding complications in all patients during the period of admission

in the hospital.

Patients and Methods: 150 patients with ACS were divided into two groups, 82 diabetic patients and 68 nondiabetic

patients. 40 patients out of total sample received tirofiban. Assessment of in hospital TIMI bleeding, GRACE

and CRUSADE risk scores was estimated for all of them.

Results: We observed that, there is no statistically significant difference in TIMI bleeding in both heparin and

tirofiban group in diabetic versus non-diabetic patients. Cardiac catheterization access site was the most frequent

location of bleeding most likely secondary to the high rate of coronary angiography performed in the study. Tirofiban

added to heparin did not increase the risk of bleeding at the vascular access site.

Conclusion: There was no statistically significant increase in all TIMI bleeding, thrombocytopenia or blood

transfusions with the combination of tirofiban with heparin in both diabetic and non-diabetic patients.

View Article
July 2017

Clinical Significance of Inferior Vena Cava Index in Monitoring Patients in Acute Exacerbation of Chronic Heart Failure

Med. J. Cairo Univ., Vol. 84, No. 3, December: 377-385, 2016

Background: Patients in acute exacerbation of chronic heart failure represent an important health problem and economic burden that requires proper intervention and treat-ment.

Aim of Work: To investigate the validity of Inferior Vena Cava (IVC) dynamics as a noninvasive diagnostic monitoring tool in patients with acute exacerbation of heart failure.

Methods: Thirty patients with decompensated heart failure (NYHA class III-IV) 16 males and 14 females mean age 50±13 years were included, admitted to ICU, and had full echocar-diographic study including IVC dynamics: IVC diameter at end of expiration, at end inspiration, and collapse index (IVC-CI%) on admission, on days 5 and 10 of medical treatment. Also, ten volunteers were included as control group.

Results: After therapy, the IVC-CI% significantly increased

View Article
April 2016

Detection of Intrapulmonary Shunts in Schistosomal Cor Pulmonale*

Chest

Detection of Intrapulmonary

Shunts in Schistosomal Cor

Pulmonale*

Samir M. Rajla, M.D., FC.C.P.; a111l Salah Sourow; M.D.

Two patients with schistosoma! cor pulmonale and central

cyanosis were studied by contrast-enhanced echocardiography,

using indocyanine green injection. Intrapulmonary

shunts were detected by this method. To our knowledge,

this is the first report that proves the presence of intrapulmonary

shunts in schistosoma) cor pulmonale detected by

contrast-enhanced echocardiography.

(Chest 1993; 104:1280-81)

CE =contrast enhanced

T he picture of schistosoma! cor pulmonale is a composite

one. In 1957, Zaki' described the various vascular shunts

in this disease. namely, (a) bronchopulmonary, (h) pulmonary

arteriovenous. (c) portopulmonary, and (d) intrasplenic. In

1964, Zaki et al' reported this type of pulmonary artery-

*From the Department of Medicine. Cardiolo!-,'}", and Chest Units,

Faculty of Medicine, Alexandria University, Alexandria, E!-,'}·pt.

Presented at the 57th Annual Seientifk Assemhlv, American

College of Chest Physicians, San Francisco, Novemht;r 4-H, 1991.

Fl<:t 'IIE I . Patient A (top): lndocyanine green injt•eled intravenously

and appearing in the right atrium and right \"t'ntricle. B (bottom):

Dye appeared in the left atrium and left ventricle after five cycles

denoting presence of intrapulmonary shunts. Cycles are counted

from video tape record.

Detection of

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December 1993

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