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ANNUAL REPORT 2011-2012

Clinical care Research Education


ANNUAL REPORT 2011-2012

Prologue Prof. dr. M.J. Schalij

Prof. dr. R.J.M. Klautz

Looking at the past, both the Departments of Cardiology and Cardio-thoracic surgery have a long and fruitful history of advanced patient care, sophisticated science and teaching. The Department of Cardiology was established in 1947, thereby serving the patient for 65 years now, and making it one of the oldest academic Cardiology Departments in the Netherlands. The Department of Cardiothoracic surgery was established in 1952 and has rapidly become an internationally recognized stronghold of knowledge and expertise. Driven by the urge to provide optimal care and treatment for cardiovascular patients in a rapidly evolving environment, two had to become one. As of 2012, the Department of Cardiology and Cardio-thoracic surgery have joined their forces, thereby giving rise to the Heart Center Leiden (HLC). This multidisciplinary center within the Leiden University Medical Center (LUMC) offers optimal care and treatment by combining high-end technologies with excellent skills and knowledge, supported by dedicated nursing teams. Optimal patient care is further maintained by ongoing education and training of clinical staff.

To ensure that our patients will continue to receive the most advanced and effective modalities for diagnosis, treatment and prognosis in the near and further future, the HCL holds several lines of research, covering the entire spectrum of cardiovascular disease and medicine. These research lines involve both basic and clinical research and have a strong interactive and translational focus.

Best wishes, Prof. dr. M.J. Schalij and prof. dr. R.J.M. Klautz


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Content Prologue................................................................................. 3

Highlights of 2011 & 2012.................................... 30-31

The Heart Center Leiden................................................ 5

Education and Social involvement................... 32-34

Organisational structure............................................. 6-7 - Staff Cardiology - Staff Thorax surgery

Clinical care.................................................................... 8-11 - Clinical care tracks - EPD vision - Nursing - Clinical production - Clinical training

Science ........................................................................... 12-29 - Scientific programs - Scientific integrity - Production (books and PhD theses)

- PhD training, higher education - Social involvement

Anniversary of cardiothoracic surgery and cardiology .......................................................................... 35 Clinical results and production........................... 36-57 - Cardiology - Cardio Thoraic Surgery

Epilogue............................................................................... 59


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The Heart Center Leiden

The Heart Center Leiden is a multi-disciplinary organization within the Leiden University Medical Center (LUMC) offering optimal patient care and treatment by combining high-end technologies with excellent skills and knowledge, driven by sophisticated science.

It is the Heart Center Leiden’s aim to provide the patient with today’s most advanced and effective modalities for diagnosis, treatment and prognosis, and to contribute to the development and implementation of tomorrow’s modalities. This aim is pursued by a dedicated team of surgeons, cardiologists, nurses, scientists, technicians and secretaries.


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Organizational structure Staff Cardiology Head of department/ instructor Prof. dr. M.J. (Martin Jan) Schalij Deputy head of department Dr. H.F. (Harriëtte) Verwey Deputy instructor Prof. dr. J.W. (Wouter) Jukema Head outpatient clinic Dr. G.J. (Greetje) de Grooth Head nurse E.M. (Els) Nagtegaal Imaging Prof. dr. J.J. (Jeroen) Bax Dr. V (Victoria) Delgado Dr. E.R. (Eduard) Holman Dr. N. (Nina) Ajmone Marsan Dr. H.J. (Hans-Marc) Siebelink Dr. A.J.H.A. (Arthur) Scholte Heart Failure Dr. H.F. (Harriëtte) Verwey Dr. S.L.M.A. (Saskia) Beeres Congenital heart disease Dr. H.W. (Hubert) Vliegen Dr. M.R.M. (Monique) Jongbloed Dr. P. (Philippine) Kiès Interventional cardiology Prof. dr. M.J. (Martin Jan) Schalij Prof. dr. J.W. (Wouter) Jukema Dr. D.E. (Douwe) Atsma Drs. F. (Frank) van der Kley Dr. G.J. (Greetje) de Grooth Drs. I. (Iannis) Karalis Dr. B.L. (Bas) van der Hoeven Drs. T.N.E. (Tessel) Vossenberg

Electrophysiology Prof. dr. M.J. (Martin Jan) Schalij Prof. dr. K. (Katja) Zeppenfeld Dr. S.A.I.P. (Serge) Trines Dr. L. (Lieselot) van Erven Dr. M. (Marianne) Bootsma Scientific staff Dr. D.A. (Daniël) Pijnappels Dr. A.A.F. (Twan) de Vries Dr. Ir. E.T. (Enno) van der Velde Dr. A.C. (Arie) Maan Dr. P. (Paul) Steendijk Dr. Ir. C.A. (Cees) Swenne Prof. dr. D.L. (Dirk) Ypey Cardiologists in training Dr. R. (Reza) Alizadeh Dehnavi Drs M.P. (Marcin) Gawrysiak Drs A.G. (Alette) van Ginkel Drs H.A.A. (Hany) Girgis Dr. R.W. (Robert) Grauss Dr. A.D. (Arnaud) Hauer Dr. I.R. (Ivo) Henkens Dr. M.M. (Maureen) Henneman Drs. W.M.C. (Wilke) Koenraadt Dr. A. O. (Adriaan) Kraaijeveld Dr. S.A. (Sjoerd) Mollema Dr. L.F. (Laurens) Tops Dr. A.P. (Hadrian) Wijnmaalen Dr. C. (Claudia) Ypenburg Research nurses E. (Ellen) van der Willik A.E.J. (Josien) Pikaar Clinical nurses Can be found on our website

Staff secretary T.A.K. (Talitha) Karijodimedjo (head) K.J. (Kariene) van den Burg Secretary of planning C. (Christine) Larrewijn H.C.M. (Bea) Brugman-Nagtegaal C.G.P.M. (Carine) van Steijn - van der Wolf Quality and communication A.W. (Anne) van der Velde


ANNUAL REPORT 2011 - 2012

Organizational structure Staff Thorax surgery Head of department Prof. dr. R.J.M. (Robert) Klautz Head pediatric cardiac surgery Prof. dr. M.G. (Mark) Hazekamp Instructor Drs. M.I.M. (Michel) Versteegh Head nurse E.M. (Els) Nagtegaal Cardio-thoracic surgeons Prof. dr. R.J.M. (Robert) Klautz Drs. M.I.M. (Michel) Versteegh Drs. A. (Arend) de Weger Dr. J. (Jerry) Braun Dr. M. (Meindert) Palmen Drs. P. (Patrick) Klein Dr. H.G. (Hans) Smeenk Pediatric cardiac surgeons Prof. dr. M.G. (Mark) Hazekamp Dr. D.R. (Dave) Koolbergen Dr. V. (Vlado) Sojak Drs. A. (Aria) Yazdanbakhsh Cardio-thoracic surgeons in traning Dr. H.G. (Hans) Smeenk Drs. R. (Rody) Boon Drs. D.J. (Daan) Meester Dr. E. (Edris) Mahtab Physicians Drs. L.E. (Lotte) Couperus Drs. C.L.I. (Chantal) Gielen Drs. F.M.A. (Fabiënne) van Hout Drs. B.G. (Bryan) Martina

Physician Assistants M. (Maarten) Vrijburcht E.W. (Egbert) Hoekstra B.L.K. (Linda) Hoek A. (Anna) Metselaar T.C. (Teus) Visser Perfusionists Ing. E. (Eelco) van Es (head) A. (Araz) Abbas A. (Arjen) van der Baan L. (Leonardo) Coratella A. (André) Kopper L. (Lindy) Liebenberg H. (Hidde) Rombout P. (Peter) Schouten F.G.J. (Fred) Tyl Other staff members Drs. E.F. (Eline) Bruggemans Dr. P. (Paul) Steendijk Staff secretary Drs. G.H. (Gabriëlle) Veltema – de Kaart (head) M.J. (Mary) Moenen – van Berge-Henegouwen E.B.M. (Evelien) van Westerop (Children’s heart center) Secretary of planning C. (Christine) Larrewijn H.C.M. (Bea) Brugman – Nagtegaal C.G.P.M. (Carine) van Steijn – van der Wolf

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Clinical care Clinical Care Tracks All our clinical care tracks for patients suffering from cardiovascular diseases are covered by MISSION! care programs, thereby aiming to further improve the care and treatment of our patients. Different international committees have proposed guidelines for optimal care for cardiovascular patients. However, it appears that implementation of such guidelines is suboptimal. The use of MISSION! care programs guarantees full integration of these guidelines in daily practice and thereby leads to optimal patient care. Over time different MISSION! Care programs have been developed and implemented. Below you can find a brief overview of these programs.

MISSION! Myocardial infarction

MISSION! Atrial fibrillation

MISSION! Heart faillure

Cardiac rehabilitation has proven to be effective in the recovery after myocardial infarction. Nevertheless, in the Netherlands, less than half of the patients who qualify for the guidelines for cardiac rehabilitation after a heart attack are being registered for heart revalidation.

The MISSION! Atrial Fibrillation clinic is a tertiary care clinic and is linked to the MAZE ablation.

Heart failure is a clinical syndrome characterized by impaired cardiac pump function. As a result of reduced pump function, many organs do not have enough oxygen and nutrients. This leads to a combination of signs and symptoms including dyspnea, fatigue and edema, particularly in the lungs and in the legs.

The MISSION! project requires that all patients are registered for heart revalidation. In close consultation with the patient, a personal rehabilitation program is developed. After myocardial infarction, all treated patients will be seen at the specialized MISSION! outpatient clinic. In the first year after infarction, the patients are seen four times. Prior to every visit, the patient undergoes some studies to objectively evaluate the cardiac condition of the patient. It is shown that patients who understand the ‘why and how’ of the treatment, are more dedicated to the revalidation program, leading to greater health benefits.

This clinic is intended for patients that are referred for a MAZE ablation by a cardiologist of the LUMC or another hospital, and patients that are coming for a second opinion. Patients with newly diagnosed atrial fibrillation, where the overall cardiac work-up remains to be done, cannot be referred to this clinic. After the ablation procedure the patients are being followed for one year at this clinic. Depending on the findings, at one year the patients will be discharged from the control. Further follow-up takes place at a cardiologist in the region or by the GP.

In order to choose an appropriate therapy for the patient, it is necessary to screen all patients according to the same protocol. Besides the possibility for invasive treatment, much attention is paid to the optimization of medication policies, lifestyle guidelines and physical exercise. Hereby we work closely with a dietician, heart rehabilitation and social workers. Patients who qualify for the MISSION! Heart Failure clinic must have severe heart failure (NYHA class III or IV with moderate or poor left ventricular function) and are using medication for heart failure. Reference to the MISSION! Heart failure occurs mainly via outpatient cardiologists in Leiden and surroundings. Patients that are newly referred with heart failure are first seen at the general outpatient clinic. There, they are medically optimized. Afterwards they can be referred to the heart failure clinic. The heart failure patients are supervised by heart failure cardiologists and heart failure nurses. The heart failure nurse has a daily telephone consultancy hour, and, when necessary, she visits the patients at home.


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Clinical care MISSION! Marfan

MISSION! LVAD

Q-MISSION!

The patients seen at the MISSION! Marfan clinic are patients with signs of, or suspected Marfan syndrome (dilation or rupture of the aorta, detached retina or first degree relative with Marfan syndrome) or related hereditary connective tissue disorders that are also associated with dilation or rupture of the aorta.

Despite a wide range of treatment options, the number of patients with severe symptoms of heart failure increases. The prognosis of this patient group is in general very limited. Despite optimal therapy, transplantation is currently the prescribed treatment for patients with severe heart failure. However, the number of donor hearts in the Netherlands is very limited and a large proportion of patients are not eligible for transplantation because of incidental disease.

In order to further improve patients care and safety the Heart Center Leiden started Q-MISSION! in 2007.

The diagnosis is determined by imaging (echocardiography or MRI, CT scan of the aorta). When a patient is diagnosed with MARFAN syndrome, drug treatment will be started to keep the blood pressure of the aorta as low as possible. Patients are seen at a regular basis at the outpatient clinic to determine the growth of the aorta. If the aorta becomes too large, a thoracic operation takes place where the dilated aorta is replaced. Patients are also provided with information and advice on pregnancy, childbirth and lifestyle guidelines concerning physical exercise.

The LUMC is the first hospital in the Netherlands that treats patients with severe heart failure, who are not eligible for heart transplants, with a mechanical heart support. This takes place in a unique “destination� program. A mechanical heart support, also called left ventricular assist device (LVAD), is a pump that is placed in the chest directly on the heart. This pump supports the weakened left ventricle. Power is supplied by an external battery with a drive line that enters through the skin.

This project allows physicians and nurses to report (almost-) accidents, complications and mistakes in a secured manner. Since the introduction of this project the number of reports has significantly increased, which is considered a positive development. Such reports are crucial for continuous quality improvement and serve as input for decision making.


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Clinical care EPD-Vision The Heart Center Leiden has developed its own electronic patient dossier (EPD), referred to as EPD-Vision. EPD-Vision replaces and supplements the conventional paper files. As of 2006 all patient dossiers are digital for both the physicians and nurses.

Nursing

Besides the written content, these dossiers also contain all test results (ECGs, echocardiograms, pacemaker data etc.), which are available only for certified personal on secured working stations, also at home.

The Cardiology department is divided into four sections:

Patients treated in our center have access to their own dossier via a webportal (http://patient.lumc.nl) using their DigiD-secured inlog. Through this portal they can also fill in different questionnaires or communicate with their physician, thereby further improving and tailoring their health care.

These four sections have their own nursing and/or technical staff. • In the Coronary Care Unit (8 beds) IC-nurses (15.5 fte) are appointed as well as trainees for IC-specialization. • In the Cardiology patient ward regular nurses (17.5 fte) are appointed, all having training in a Heart Disease training program, to become familiar with several practical and theoretical aspects of heart diseases and electrocardiograms (EKGs). • The Heart catheterization laboratory is equipped with 5 rooms and a nursing staff of 14 fte. Each nurse has followed a three-year training for the cardiac catheterization specialization.

1. 2. 3. 4.

Coronary Care Unit Patient ward Heart catheterization laboratory Heart function laboratory and Outpatient clinic

Within the Outpatient clinic/ Heart function laboratory a 4 beds Short stay room is equipped for day-care treatment like cardioversion, coronary angiography and medical treatment. The Heart function laboratory has an Echo lab with a technical staff of 9.5 fte, all being trained in echocardiography. In this function laboratory we also treat patients who have a pacemaker and/or an implantable cardiac defibrillator (ICD) with a technical staff of 3.5 fte. These technicians are trained on the job. The electrocardiography section has 4 technicians (EKGs and Holters) and in the bicycle ergometer room there is 1 technician. The Outpatient clinic has an administration staff of 4.5 fte. They are responsible for all the follow up appointments for about 21,000 patients per year. Optimization and efficiency of our administrating procedures is an ongoing effort for patient’s convenience. Within the Cardiology Department one nurse specialized in heart failure and one nurse specialized for patients with ICD are appointed.


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Clinical care Clinical training Cardiologist At the Department of Cardiology physicians are trained to become cardiologists. In general, these physicians have finished a two-year training of Internal Medicine. Afterwards, the physicians follow a four-year program to become a cardiologist. During these four years, they get trained in several aspects of the cardiology, such as the care for acute cardiac patients at the CCU, treating patients with (congenital) heart disease and the care for patients at the outpatient clinic. In addition, physicians in training develop specific skills, such as performing and evaluating echocardiographic studies of the heart, performing and evaluating coronary angiographies and interpreting imaging studies such as cardiac MRI and myocardial scintigraphy. The training takes place in collaboration with the departments of Cardiology of the Rijnland Hospital in Leiderdorp, the Groene Hart Hospital in Gouda and the Bronovo Hospital in Den Haag.

Cardiothoracic surgeon The duration of the training in cardiothoracic surgery is six years and consists of a number of modules, including some in general surgery (approximately one year) and continuous education for five years of cardiothoracic surgery. During the program, the residents acquire in depth knowledge of disease processes of the heart, lungs, mediastinum, chest wall and large thoracic blood vessels. Furthermore, they acquire diagnostic knowledge of pathology and indications for either surgical or non-surgical treatment. They also acquire knowledge of the conditioning of patients for surgery, knowledge of, and experience in intensive care treatment and postoperative care and finally knowledge of the basic principles and possibilities of heart and lung transplantations. From day one the residents are involved in the surgical program of the department. As experience increases, the performance of the residents becomes more independent.

During the continuous education, clinical internships are followed in order to deepen the understanding and knowledge. These internships concern: lung diseases (one month), cardiology (three months), a continuous involvement in congenital cardiac surgery or an internship at a study track that meets the Dutch standards for cardiac surgery for congenital defects (three months) and finally a three month internship at the postoperative intensive care. Other educational and training programs The surgical staff is involved in the education and training program for clinical perfusionist, which is the national education program of three years in this profession, and in the education and training program of medical students and residents of other disciplines. The Heart Center Leiden organizes various postgraduate courses for medical specialists and (IC) nurses. More information can be found at our website: www.hartcentrum.nl.


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Science The central theme of the Heart Center Leiden will be clinical care organized in care tracks with integrated research activities. Bench to Bedside (B2B) will be the central theme research-wise for the coming 5 to 7 years and therefore B2B activities will be stimulated. By accepting the B2B principles it will be possible to stimulate crossing border research activities both within the LUMC as with external partners. The Heart Center Leiden B2B program will offer unique opportunities in the development of new research activities and this program will also allow investigators easier access to other activities.

The B2B activities are concentrated around 5 themes: Arrhythmias, Atherosclerosis and Genetics, Congenital Heart Disease, Valvular Disease, Ventricular Dysfunction & Heart Failure.


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scientific programs

Arrhythmias The arrhythmia research is clustered around the two most common arrhythmias: ventricular arrhythmias and atrial fibrillation. Ventricular arrhythmia research At present the Heart Center Leiden is the largest center for treatment of ventricular arrhythmias (VA) in the Netherlands and one of the largest centers in Europe. The Heart Center Leiden is integrated in a network of the leading ventricular arrhythmia research centers worldwide. Electrophysiologists, Cardiothoracic Surgeons and the Laboratory of Experimental Cardiology focus in a joint effort on the substrate and mechanisms of ventricular arrhythmias and on new treatment modalities in the growing number of patients with heart failure and repaired congenital heart disease. Furthermore, a close collaboration is established with the departments of Radiology and Image processing. Research projects focus on the underlying substrate and mechanisms of ventricular arrhythmia, the development of new mapping and ablation technologies and risk stratification to improve treatment and prognosis in patients with ventricular arrhythmias. Three large interdisciplinary research projects focusing on the arrhythmogenic substrate in different stages and types of underlying heart disease are currently being conducted. In a large prospective study we focus on the substrate and mechanisms of ventricular arrhythmia in patients with nonischemic cardiomyopathy which affect >1/2500 children and adults. In this study, basic and clinical researchers closely collaborate to evaluate the substrate from the subcellular to the tissue and organ level. Understanding of the substrate is the first step to individualized treatment and risk stratification. In cooperation

with the department of Radiology and Image processing tissue imaging data are integrated during ablation procedures for complex ventricular arrhythmias and analyzed after the procedure in order to improve the understanding and visualization of the underlying arrhythmogenic substrate. Finally, the mechanism of ventricular arrhythmias in patients with Congenital Heart Disease is under evaluation to improve risk stratification and potential preventive intraoperative treatment strategies in patients who undergo repair or reoperation. State-of-the-art techniques are employed during ablation procedures for complex ventricular arrhythmias, integrating CT- and contrast-enhanced MRI-derived data in order to improve procedural safety and efficacy. Integration of pre-acquired 3D CE-MRI data with realtime electroanatomical mapping data is likely to provide supplementary substrate characterization and can facilitate catheter ablation. Novel substratebased treatment strategies are under development in order to even prevent the occurrence of ventricular arrhythmia. To gain more insights in the limitation and potential risks of ablation in particular if performed from the epicardium we are currently developing advanced techniques to visualize not only the VA substrate but also factors with impact on procedure safety and outcome like coronary arteries and epicardial fat. To further improve ablation results new ablation techniques such as bipolar two-irrigated-tip catheter ablation are applied in complex cases. Modern treatment strategies for ventricular arrhythmias concomitant with reconstructive left ventricular surgery

in patients after myocardial infarction are under evaluation and we currently develop new electroanatomical mapping technologies to facilitate intraoperative mapping and ablation of ventricular arrhythmia. Atrial fibrillation research Atrial fibrillation (AF) is the most widespread supraventricular arrhythmia, with a prevalence of 9.5 per 1000 people, which increases with age; ranging from 1 per 1000 below 55 years to 90 per 1000 above 80 years. Clinical research is directed at the various aspects of catheter and surgical ablation to improve safety and efficacy. In catheter ablation, a trial is being conducted comparing the effect of three different ablation techniques on procoagulation, cerebral micro-emboli and neuropsychological functioning. In surgical ablation, new ablation methods have been developed for both standalone ablation (mini-MAZE) as well as for concomitant ablation during valvular or coronary bypass surgery. Emphasis is both on outcome of this new methods as well as on atrial function after ablation. In addition, various experimental cellular models of AF are being developed to further improve our understanding of the underlying tissue substrate and mechanisms of AF. These novel insights are used to develop new treatment strategies aiming to effectively treat or prevent AF occurrence. The evolving expertise and integration of basic and clinical research results in clinical practice ensures ongoing improvement of our understanding of arrhythmias but is also likely to improve safety and success of treatment.


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Atherosclerosis & Genetics Atherosclerosis is, by inducing ischemic cardiac syndromes, the main driver of cardiac disease and of cardiac mortality and morbidity. The department of Cardiology at the Heart Center Leiden has a large dedicated department involved in treating patients with atherosclerosis as well as doing research how to treat and prevent it. Treatment of atherosclerosis is performed firstly by counselling, advice, and medication. However in many cases this is not sufficient on its own and mechanical revascularisation is needed by percutaneous coronary angioplasty of coronary bypass operations. To this end large and well equipped catheterization laboratories and operation theatres are available with cutting edge and state of the art technologies. Extensive research (e.g. innovative medication, novel (drug eluting) stents, renal denervation and percutaneous heart valves) is performed to get more insights in the basic processes of atherosclerosis and its treatment. This is performed in the basic laboratory, transgenic animal models and in patient care. A true translational model is used here, from bench to bedside and back.

Furthermore an intensive patient tracking and monitoring system, with regional involvement, has been developed (MISSION! care tracks, such as the acute myocardial infarction care track) to optimally implement latest guideline and evidence based therapy. (Pharmaco)genetics Pharmacogentic studies search for heritable genetic variations (polymorphisms) that influence disease like atherosclerosis and responses to drug therapy. Pharmacogenetics has many possible applications in cardiovascular pharmacotherapy, including screening for polymorphisms, to choose for the right patient the right drug, with the greatest potential for efficacy and least risk of toxicity. Pharmacogenetics also informs dose adaptations for specific drugs in patients with aberrant metabolism. The department of Cardiology of the LUMC has a long and extensive track record in doing pharmacogenetic research and bringing the results into practise.

Cardiogenetics In recent years it has become apparent that an increasing number of cardiac diseases are caused by specific genetic defects. Afflicted patients may have for example structural heart disease like hypertrophic or dilated cardiomyopathies, but also channelopathies like Long QT syndrome or Brugada syndrome. For these patients, the Department of Cardiology of the LUMC provides dedicated cardiogenetic out-patient clinics aimed at counseling, (cascade) screening and guideline-driven patient care. This latter includes medical management, but also invasive therapeutic options like (surgical or alcohol) septum ablation in HCM and implantation of Implantable Cardioverter Defibrillators (ICDs) in arrhythmic disease. Also, clinical and basic research into disease mechanisms is performed by studying genotype-phenotype relations and modeling of disease using patientspecific induced Pluripotent Stem cell (iPS) generation.


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Congenital heart disease This group focuses on the morphology and development of congenital heart disease in relation to clinical treatment strategies. Key subjects are therapy and prognostic determinants of pulmonary hypertension, right ventricular function, arrhythmias and imaging of complex anatomical variants of congenital heart disease.

increased life-span and complexity has led to a whole new spectrum of longterm complications, as well as unclear outcomes of relatively new treatment strategies.

Altogether the field of grown up CHD is rapidly expanding and data on developmental background and prognostic determinants of adverse outcomes are mandatory.

CHD is the most common birth defect with an estimated incidence of 6 per 1000 live born children.

For instance, experience with grown-up patients born with hypoplastic left heart syndrome, does not yet exist. In addition there is no consensus yet regarding the optimal treatment strategies for several forms of complex CHD (e.g. the indication for anticoagulant therapy, the indication of ACE inhibition in right ventricular failure and the use of beta-blockers).

The cornerstones of the Leiden Congenital Heart Disease research group are: 1. The development and pathomorphology of CHD; 2. Pulmonary hypertension and right ventricular (dys)function and 3. Arrhythmias. The intensive support of advanced imaging techniques including HR-CT, 3D echocardiography and MRI is indispensable in each of these topics.

Both insight in the developmental background and pathomorphology of congenital heart disease as well as in the functional mechanisms contributing to the disease will optimize clinical treatment strategies.

The research of this group is narrowly related to the other research pillars of the Leiden Heart Center and performed in close collaboration with them.

Due to significant improvement in surgical and percutaneous treatment techniques over the past decades, the number of grown-up patients with congenital heart disease has increased resulting in an incline of patients reaching the reproductive age. This number is expected to continue to expand in the following years. Additionally, the cardiac defects treated are progressively more complex. This


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Valvular disease Valvular heart disease is an important public-health problem with significant morbidity and mortality.

In Western countries, the prevalence of significant (moderate and severe) valvular heart disease increases significantly with age and peaks up in patients aged 75 years and older (11.7%). Despite the decrease in rheumatic valvular heart disease in the last decades, the increased lifespan of the population of in industrialized countries have led to an increase in the prevalence of degenerative valvular heart disease, maintaining the global prevalence of valvular heart disease still high. In addition, the characteristics of patients with significant valvular heart disease has significantly changed, patients being older and with more associated comorbidities that cumulatively increase the operative risk or may even contraindicate surgical treatment.

Increasing experience in surgical repair techniques has provided excellent results and outcomes of patients with mitral and aortic valve disease.3-6 Furthermore, during the last decade, advances in percutaneous treatments have provided feasible and safe alternative therapies for patients without surgical options.7, 8 Multimodality imaging, and particularly, 3-dimensional imaging techniques, have improved the visualization and assessment of valvular structures permitting accurate and tailored treatment for each patient (Figure 1). In addition, these imaging techniques have provided novel insights permitting the development of new devices such as sutureless aortic valves or transcatheter devices.

The Department of Cardiology and Thoracic Surgery of the Leiden University Medical Center have regularly collaborated in numerous research projects on valvular heart disease that have resulted in a large number of scientific papers.3-7, 9-18 The Heart Center Leiden is pioneering a line of research that spans from experimental models and basic research that will provide new insight into the pathophysiology of valvular heart diseases to the evaluation of the clinical impact of novel imaging modalities in the decision making of patients with valvular heart disease.


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Ventricular dysfunction & Heart failure Chronic heart failure is a major healthcare problem associated with high morbidity and mortality.

In the European population, the prevalence of heart failure is 2-3%; in 70-80 year old people the prevalence rises to 10-20%. Common causes of heart failure are coronary artery disease (70%), valvular disease (10%) and cardiomyopathies (10%). The prognosis of heart failure patients is poor: around 40% of patients admitted to the hospital with heart failure are dead or readmitted within 1 year and 50% of patients die within 4 years. Currently, there is a broad variety of treatment options for heart failure patients consisting of lifestyle changes, pharmacological therapy, cardiac resynchronization therapy, revascularization, surgical left ventricular reconstruction, valve surgery, left ventricular assist devices, heart

transplantation and cell therapy. In order to select the optimal treatment strategy for each individual patient the Leiden Mission! Heart failure program was developed in 2005. This multidisciplinary structured screening protocol aims to determine the etiology of heart failure and select the optimal treatment modality for each individual patient in line with the most recent guidelines. Furthermore, it comprises a follow-up protocol to monitor the effectiveness of the therapeutic interventions. Based on the broad experience in heart failure treatment the Heartcenter Leiden performs extensive research based on which patient selection and therapeutic modalities itself are constantly being improved. Especially, with the use of multimodality imaging patient selection

for cardiac resynchronization therapy, surgical left ventricular reconstruction and mitral valve surgery is being optimized. Furthermore, clinical research is being performed to evaluate the effectiveness of cardiac cell therapy in patients with heart failure and left ventricular dysfunction. At the same time, pre-clinical research aims to optimize the effect of the transplanted cells and understand the mechanisms of complications in heart failure surgery. These research lines aim to continuous improve and innovate the clinical treatment of heart failure in the Heart Center Leiden.


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Science:

scientific integrity

Scientific integrity The Heart Center Leiden feels a great responsibility towards our grant suppliers and the scientific and general community for our scientific work. Therefore it is one of our highest priorities to keep our data bases, analyses, interpretations and publications transparent and controllable. To this purpose the R-Mission! project was developed.

To further secure and improve the processes of data management a scientific staff member of the Heart Center Leiden has been appointed to randomly check data bases of our research fellows and perform data-to-source analyses. This staff member is not directly involved in the research project subjected to investigation, and together with the research-fellows analyses the processes of data gathering, analyses and interpretation in a step-by-step and interactive manner.


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Cross-linked Advanced Integrated Research Data Base

Cross-linked Advanced Integrated Research Data Base In addition to the R-Mission! project the Heart Center Leiden has developed a secured and dedicated data-base system, called cross-linked advanced integrated research data base (CLAIR DB). Below you can find a detailed overview of the different interconnected scientific subjects.


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Science:

Books

Production & Highlights 2011 & 2012 In 2011 and 2012, the Heart Center Leiden published in a wide range of peer-reviewed journals, but especially in journals focusing on cardiovascular disease and medicine. An up-to-date list of publications per research theme can be found on our website (www.hartcentrum.nl).

Books We are also actively involved in the production of book chapters and editing of books for educational and professional purposes. A number of these books are found below. Fetal Therapy • • •

Edited by: M.D. Kilby, A. Johnson, D. Oepkes Chapter 9. Structural heart disease A.C. Gittenberger-de Groot, M.R.M. Jongbloed

Hands-On Ablation: The Expert’s Approach •

Cardiovascular Imaging • •

Edited by: V.B. Ho, G.P. Reddy Chapter 84. Advanced ThreeDimensional Postprocessing in Computed Tomographic and Magnetic Resonance Angiography J.W. Jukema

Edited by: A. Al-ahmad, D. Callans, H.H. Hsia, A. Natale, O. Oseroff, P.J. Wang Chapter 47. How to Ablate Ventricular Tachycardia in Patients with Congenital Heart Disease K. Zeppenfeld

Management of Myocardial Reperfusion Injury • •

Edited by: J.C. Kaski, D.J. Hausenloy, B.J. Gersh, D.M. Yellon Chapter 8. Nuclear Imaging to Assess Infarction, Reperfusion, No-Reflow, and Viability V. Delgado, J.J. Bax

Coronary Stent Restenosis Pediatric Cardiovascular Medicine, second edition • • •

Edited by: J.H. Moller, J.I.E. Hoffman Chapter 1. Normal and abnormal cardiac development A.C. Gittenberger-de Groot, M.R.M. Jongbloed

Edited by: I.C. Tintoiu, J.J. Popma, J-H Bae, A. Rivard, A.R. Galassi, C. Gabrie Chapter: 16. (Late) stent malapposition in the BMS and DES era. J.J.W. Verschuren, T.A.H.N. Ahmed, J.W. Jukema Chapter 23. Small animal models to study restenosis and effects of (local) drug therapy. J.W. Jukema, M.M. Ewing


ANNUAL REPORT 2011 - 2012

Science:

021

Books

Klinische probleemstellingen

Coronair Vaatlijden in de Dagelijkse Praktijk

• •

Edited by: C.J.E. Kaandorp All chapters about cardiovascular disease S.A.I.P. Trines

Clinical echocardiography • • •

Edited by: A.L. Klein, C.R. Asher Chapter 14. Dyssynchrony Evaluation/AV optimization V. Delgado, J.J. Bax

Ventricular Assist Devices • •

Edited by: J. H. Shuhaiber Chapter 3. Altered Expression of miRNA during Mechanical Support of the Failing Human Heart A. van der Laarse

Congenital coronary artery anomalies •

• • •

Edited by: Río J. Aguilar Torres, J. Carles Paré Bardera Chapter 2.1.3. Doppler Tisular V. Delgado

H.W. Vliegen, J.W.J. Jukema, A.V.G. Bruschke

Percutaneous Interventional Cardiovascular Medicine •

Libro Blanco de la Sección de Imagen Cardíaca, Sociedad española de Cardiología

H.W. Vliegen, I.R. Henkens

Edited by: E. Eeckhout, P.W. Serruys, W. Wijns, A. Vahanian, M. van Sambeek, R. De Palma. Chapter 2.4. Non-invasive imaging for structural heart disease V. Delgado, N. Ajmone Marsan, M.J. Schalij, J.J. Bax

Human Cell Manual, second edition • •

Edited by: J. Loring, S. Peterson Chapter 27. Cardiomyocyte Differentiation of Human Pluripotent Stem Cells C. Dambrot


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ANNUAL REPORT 2011 - 2012

Science:

PhD theses 2011

PhD theses

Many PhD research fellows and PhD students choose the Heart Center Leiden for their scientific training. Their training is completed with the publication of their thesis, which after a successful public defense will yield them the title PhD (doctor of philosophy). A number of recent PhD theses are listed below, for more information please go to our website (www.hartcentrum.nl).

Incremental value of advanced cardiac imaging modalities for diagnosis and patient management: Focus on real-time threedimensional echocardiography and magnetic resonance imaging Nina Ajmone Marsan Promotores: Prof. dr. J.J. Bax, Prof. dr. M.J. Schalij The objectives of this thesis were to investigate the incremental value of advanced cardiac imaging modalities, and in particular of real-time three-dimensional echocardiography (RT3DE), myocardial deformation imaging, contrast-enhanced echocardiography and magnetic resonance imaging (CMR), for diagnosis and patient management in different cardiac disease. In Part I, the use of RT3DE for quantification of left ventricular (LV) volumes and function and for the assessment of LV dyssynchrony was explored in heart failure patients undergoing cardiac resynchronization therapy (CRT, Part IA). Different 3D measures of LV dyssynchrony, based on the full volume approach or on the tri-plane approach were applied to improve candidate selection for CRT and to predict favorable response after implantation. In Part IB, RT3DE was applied in patients with atrial fibrillation or heart failure for the quantification of left atrium volume and for the assessment of different left atrial functions (conduit, active and reservoir function).

New insights in mechanism, diagnosis and treatment of myocardial infarction Sandrin C. Bergheanu Promotores: Prof. dr. J.W. Jukema, Prof. dr. F.R. Rosendael This thesis aimed to present new molecular and genetic findings in the pathology and diagnosis of acute myocardial infarction. Furthermore, a special focus was granted on the current invasive treatment of myocardial infarction. Here, new aspects were investigated in relation to a) the role of IVUS in preventing late stent thrombosis, and b) differences in coronary plaque composition, as assessed with IVUS – Virtual Histology, after drug-eluting versus bare-metal stent implantation. Finally, the influence of the stent type as well as the patient’s genetic profile were investigated in relation to the occurrence of post-stenting complications.


ANNUAL REPORT 2011 - 2012

Science:

PhD theses 2011

Cardiovascular computed tomography for diagnosis and risk stratification of coronary artery disease Jaap M. van Werkhoven Promotores: Prof. dr. J.J. Bax, Prof. dr. J.W. Jukema, Prof. dr. A. de Roos In part 1 of the thesis the value of CTA for diagnosis of CAD, and its relationship to existing diagnostic imaging modalities is described. In the second part the value of CTA for risk stratification is evaluated; in addition, the prognostic value of CTA is compared to other non-invasive imaging techniques used for risk stratification. In part 3 the potential future perspectives of CTA imaging are discussed. In addition to non-invasive coronary angiography and LV volume and function assessment, CTA also has the potential to assess myocardial perfusion imaging.

Innovative therapies for optimizing outcomes of coronary artery disease Tarek A.N. Ahmed Promotores: Prof. dr. J.W. Jukema, Prof. dr. M.J. Schalij This thesis aimed to evaluate the importance of combined pharmacological and mechanical adjunctive therapies for optimization of outcomes of primary percutaneous coronary intervention (PPCI) in the setting of ST-elevation myocardial infarction (STEMI), and to assess the predictors of large thrombus burden among STEMI patients and to what extent that would influence the outcomes and the pre-hospital triage of these patients. Furthermore, a special focus was granted on the clinical performance of biodegradable-polymer drug eluting stents (DES) comparing the incidence of definite stent thrombosis (DST) and target lesion revascularization (TLR); a) between biodegradable-polymer biolimus, sirolimus and paclitaxel DES, and b) between biodegradable-polymer DES and permanent polymer DES. We also discussed the recently emerging drugs for coronary artery disease, with special focus on antiplatelets, antithrombotics and antidyslipidemics. Finally, we provided an overview of post-stenting problems of in-stent restenosis and late stent malapposition.

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ANNUAL REPORT 2011 - 2012

Science:

PhD theses 2011

Advanced echocardiography and cardiac magnetic resonance in congenital heart disease Insights in right ventricular mechanics and clinical implications

Annelies van der Hulst Promotores: Prof. dr. N.A. Blom, Prof. dr. J.J. Bax, Prof. dr. A. de Roos The first part of this thesis aimed to characterize ventricular mechanics and performance with advanced echocardiographic imaging techniques in patients with congenital heart disease (CHD), with particular focus on the right ventricle (RV). The second part of the thesis aimed to investigate the role of advanced cardiac magnetic resonance (CMR) techniques to characterize RV mechanics in CHD patients. CMR plays an increasing role during clinical follow-up of CHD patients, especially those with complex CHD. The prediction of clinical outcome is an important goal of clinical studies on cardiac imaging techniques. The last part of this thesis focused on the prediction of clinical outcome of CHD patients with the use of conventional and advanced echocardiographic techniques.

(Epi)genetic Factor in Vascular Disease Douwe Pons Promotor: Prof. dr. J.W. Jukema This thesis examines the impact of genetic and epigenetic factors on several aspects of vascular disease. Part 1 has addressed the influence of genetic variation in genes involved in the different processes that lead to the occurrence of adverse events after percutaneous coronary intervention (PCI), mainly restenosis after bare metal stent (BMS) placement, but also late acquired stent malapposition (LASM) after implantation of a drug-eluting stent (DES). The role of a relatively new area of research, which we refer to as ‘epigenetic epidemiology’ in restenosis and other aspects of coronary heart disease has been discussed in part 2.


ANNUAL REPORT 2011 - 2012

Science:

PhD theses 2011

Acute myocardial infarction treatment: From prehospital care to secondary prevention Jael Z. Atary Promotores: Prof. dr. M.J. Schalij, Prof. dr. J.J. Bax This thesis shows that consistent implementation of a structured regional treatment and prevention program for acute myocardial infarction patients is feasible when health professionals of various disciplines collaborate. In chapter 3 results of the randomized MISSION!-intervention study demonstrates that safety of SES is comparable to BMS three years after the index event, in terms of death, stent thrombosis and nonfatal recurrent MI. In chapter 4 an effort was made to relate plaque characteristics at stent edges to clinical outcome at 9 months post PCI in 40 AMI patients by utilizing virtual histology intravascular ultrasound imaging (VH-IVUS). In the study presented in chapter 5, a strategy of adjunctive thrombus aspiration before primary PCI in AMI patients in combination with early abciximab administration, was associated with a significant improvement in post-procedural ST segment resolution and with a lower mortality at one year follow-up. In chapter 6 it was shown that the majority of occlusions occur in the proximal parts of the LAD and RCA with worse post-procedural LV function in particular for LAD and LCX culprit lesions. The study shows that plaques in the proximal parts of the LAD and RCA are more prone to rupture. Chapter 7 aimed to provide more insight into the clinical profile, treatment delays, medication compliance and 12 month outcome of treatment in the elderly AMI patient population (>75 years). The study presented in chapter 8 investigated clinical relevance of resting heat rate in post AMI patients who were treated with primary percutaneous intervention and relatively preserved LV-function. Chapter 9 aimed to assess the number of patients in daily clinical practice that meets criteria for implantation of an ICM following AMI when treated according to an aggressive treatment protocol. Findings of the study described in chapter 10 suggest the properties of the baseline stimulation threshold may be used clinically as an indicator of chronic changes caused by ischemic heart disease which increase the risk of arrhythmic event requiring ICD therapy and risk of mortality. Chapter 11 aimed to provide more long-term data on the characteritics of recurrent atrial tachyarrhythmias after ablation of post-operative tachyarrhythmias in 53 patients with congenital heart defects. The final chapter aimed to provide more insight into long-term outcome of cavotricuspid isthmus ablation in terms of atrial flutter recurrence and particularly in terms of atrial fibrillation occurrence.

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Science:

PhD theses 2012

Surgical Treatment of Functional regurgitation Jerry Braun Promotores: Prof. dr. R.J.M. Klautz, Prof. dr. J.J. Bax In this thesis, studies on the clinical and echo- cardiographic outcomes of a structured approach to functional mitral regurgitation are combined. Functional mitral regurgitation results from left ventricular wall motion abnormalities. As such, treatment should be directed at the mitral valve (by means of an undersized annuloplasty), but also at the level of the left ventricle. The structured approach to patients with heart failure by the Leiden Heart Team, a collaboration between cardiologists and cardiothoracic surgeons, has led to good outcomes and has received international recognition.

Viral vector-mediated gene transfer infundamental and applied cardiovascular research Jim Swildens Promotores: Prof. dr. M.J. Schalij, Prof. dr. A van der Laarse To treat various cardiac diseases, modification of gene expression for the purpose of increased or decreased expression of a particular gene, is regarded as a potential therapy. As a vehicle to introduce the gene of choice into the heart cell, virus vectors have given the most promising results. This thesis describes studies that are undertaken to investigate how virus vectors may be used to efficiently target cardiac cells and what the effects of certain genetic interventions are on the (patho)physiology of heart cells. We used lentivirus vectors to study the effects of integrin stimulation in neonatal rat cardiomyocytes on the uptake of macromolecules by these cells and through which pathway integrin stimulation leads to cardiac hypertrophy. Furthermore, the role of gap junctional coupling in the development of arrhythmias and in the cardiac differentiation of mesenchymal stem cells was investigated by modulating the expression of connexin 43 using lentivirus vectors. As adeno-associated virus vectors in particular have shown great potential as vector system to target the heart, we aimed to develop AAV vectors that may be used to specifically target either the cardiomyocytes or fibroblasts in the heart.


ANNUAL REPORT 2011 - 2012

Science:

PhD theses 2012

Novel insights into Cardiac Imaging in Cardiovascular Disease J.M.J. (Mark) Boogers Promotores: Prof. dr. J.W. Jukema, Prof. dr. J.J. Bax The purpose of the thesis was to explore the role of novel insights from cardiac imaging for diagnosis (Part I), therapeutic options (Part II) and risk stratification (Part III) of patients with cardiovascular disease. Rapid developments in cardiac imaging techniques have already contributed significantly in the evaluation of patients with a broad spectrum of cardiovascular disease, including coronary artery disease and chronic heart failure. New insights in cardiac imaging and post-processing technologies can further refine the currently applied diagnostic, therapeutic and prognostic algorithms for patients with cardiovascular disease. Moreover, further developments in cardiac imaging can help to generate a more patient-tailored health care system, which in turn should result in an improved cost-effective health care system as patients are more appropriately selected for diagnostic procedures and therapeutic interventions, such as (percutaneous) coronary intervention procedures and dedicated cardiac device therapies.

Substrate of Ventricular Tachycardia Adrianus P. Wijnmaalen Promotores: Prof. dr. M.J. Schalij, Dr. K. Zeppenfeld The research was focused on the substrate and catheter ablation of ventricular arrhythmias. Catheter ablation is of increasing importance in the treatment of patients with ventricular arrhythmias. This thesis evaluates risk factors, substrate characteristics and outcome in different patient populations undergoing catheter ablation. Furthermore it is shown that the use of new mapping criteria and integration of electroanatomical mapping with imaging like MRI and CT can enhance the efficacy of ablation.

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ANNUAL REPORT 2011 - 2012

Science:

PhD theses 2012

Cardiac Resynchronization Therapy. Determinants of patient outcome and emerging indications Rutger J. van Bommel Promotores: Prof. dr. J.J. Bax, Prof. dr. M.J. Schalij In this thesis, a comprehensive analysis was performed on the long-term effects of cardiac resynchronization therapy (CRT) in selected patients with heart failure. CRT has evolved as a successful treatment strategy in selected patients with drug refractory heart failure. Evidence of large clinical trials established the beneficial effects of CRT in addition to optimal medical treatment on both morbidity and mortality. Nonetheless, about 30% of patients do not demonstrate response to CRT. This thesis demonstrated that several patient characteristics have a strong influence on both response at 6 months follow-up and prognosis during long-term followup. In addition to these patient characteristics, the position of the LV pacing lead in relation to the site of latest activation and potential scar tissue may have a great influence on outcome. Integration of patient characteristics, LV lead position with information on LV dyssynchrony and scar tissue may help to improve patient selection and response to CRT. Furthermore, it is not unlikely that the favorable effects of CRT will be extended to other patient groups in the coming years. These groups include asymptomatic (NYHA class I) patients, patients with a narrow QRS complex (<120 ms) or patients with heart failure but preserved LVEF (â&#x2030;Ľ45%). Data from this thesis showed that CRT also seems to improve other conditions frequently observed in patients with heart failure. The improved LV systolic function induced by CRT increases cerebral blood flow and also results in stabilization of renal function. Finally, patients with severe functional MR and high operative risk also derive benefit from CRT. Perhaps CRT may one day be used as an effective treatment strategy in these patient groups.


ANNUAL REPORT 2011 - 2012

Science:

PhD theses 2012

Imaging of Coronary Atherosclerosis and Vulnerable Plaque. From mechanism to management JoĂŤlla E. van Velzen Promotores: Prof. dr. E.E. van der Wall, Prof. dr. J.J. Bax The aim of this thesis was to evaluate the role of imaging in the assessment and characterization of atherosclerosis and vulnerable plaque in the coronary arteries. Non-invasive computed tomography coronary angiography (CTA) is a relatively new technique for the evaluation of coronary atherosclerosis. Therefore, the performance of CTA in characterizing coronary atherosclerosis was assessed and was compared to invasive imaging techniques, in addition to determining the impact on clinical management. In part 1, the current advances of coronary CTA in characterizing atherosclerosis and vulnerable plaque were explored and in part 2, the relation between characterization of atherosclerosis on CTA and the effect on clinical management was evaluated.

Imaging of Coronary Atherosclerosis and Vulnerable Plaque. From Cardiovascular Diagnosis to Clinical Management Fleur R. de Graaf Promotores: Prof. dr. J.J. Bax, Prof. dr. E.E. van der Wall The primary objective of this dissertation is to determine the diagnostic performance of 320-row computed tomography angiography (CTA) for cardiac applications, particularly in the assessment of significant coronary stenosis in patients with known or suspected coronary artery disease. It was shown that 320-row CTA allows accurate, non-invasive assessment of significant coronary artery disease and global left ventricular function in patients with suspected atherosclerosis, as well as in patients with a history of revascularization. Importantly, all diagnostic accuracy studies demonstrated that 320-row CTA has a particularly high negative predictive value, which makes this modality particularly suitable for the exclusion of CAD. The second objective was to investigate the prognostic value of CTA and its role in clinical management of patients with suspected coronary artery disease. In addition the potential of CTA to serve as a gatekeeper prior to invasive coronary angiography was explored.

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ANNUAL REPORT 2011 - 2012

Highlights 2011-2012 Members of the Heart Center Leiden are active at various national and international conferences (both as organizers and attendees), and are requesting new funding for scientific research on a regular basis 2011 M.J. Schalij, MD, PhD, was president of the Netherlands Society of Cardiology (NVVC). From January - November 2011, he was chairman of the Netherlands Cardiovascular Data Registration (NCDR), and currently he is board member of the NCDR. He was editorial board member of the Journal of Cardiovascular Electrophysiology and Europace and member of the Quality Group of the Dutch Order of Medical Specialists. Prof. M.J. Schalij, MD, PhD was also board member of the platform Vital Vessels. J.W. Jukema, MD, PhD, was chairman of the working group Leiden Vascular Medicine (LVM) and the Dutch Atherosclerosis Society (DAS). He was founding director of the Durrer Institute for Cardiogentic Research and nucleus member of the European Society of Cardiology on WG Atherosclerosis and Vascular Biology. Prof. J.W. Jukema, MD, PhD, was investigator and co-applicant of the the European PhrameWork 7 (WP7-Health) TRUST study, Multi-Modal effects of thyroid hormome replacement for untreated older adults with subclinical hypothyroidism; a randomised placebo controlled trial. For this study he received the EU KP7 grant. He was co-principal investigator of the GENIUS (Generating the best evidence-based pharmaceutical targets for atherosclerosis) project CVON (CardioVascular Onderzoek Nederland/NHS) Project, total 4,9 million euros. Prof. J.W. Jukema received an Industry Grant for DIACARM (DIAbetes CArdiovascular Risk Management) Project of 40.000 euros. J.J. Bax, MD, PhD was associate editor of the Journal of the American College of Cardiology and chairman of the European Society of Cardiology (ESC) Guidelines Committee. D.E. Atsma, MD, PhD, was projectleader of the research project “Cardiomyocyte Progenitor Cells for Clinical Application in Cardiac Repair”. This project received a 1.9 million euro grant from ZonMw for Translational Adult Stem cell research. E.T. van der Velde, PhD, was chairman of the nucleus of the ESC Working Group on e-Cardiology and (ex-officio) board member of the ESC European Heart Rhythm Association. He is also editorial board member of the Europace Journal. M.R.M. Jongbloed, MD, PhD, received the NWO/ZonMw Grant “Clinical Fellow” for the project “Tracing and Characterization of the Cardiac Conduction System; Contribution of the Second Heart Field”. A.A. Ramkisoensing, MSc, MD, received the American Heart Association International Travel Grant. Furthermore, she received the Keystone Symposia (National Heart, Lung and Blood Institute) Scholarship and the First Contact Initiative Grant from the Council of Basic Science (European Society of Cardiology) to visit the laboratory of Dr. S.M. Wu at the Cardiovascular Research Center of the Massachusetts General Hospital, Harvard University. G.E. Hoogslag, MSc, was elected to follow the MD/PhD-MSc/PhD-track for excellent students of the Leiden University Medical Center. J.W.W. Verschuren, MD, won the Moderated poster award at the ESC Congress in Paris, France for the poster “A Genome-wide association study identifies a region at chromosome 12 as a susceptibility locus for restenosis after percutaneous coronary intervention”.


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Highlights 2011-2012

S.F.A. Askar, MSc, won the Young Investigator Award at the Europace 2011 congress in Madrid, Spain. C.F.B. van Huls van Taxis, MD, won the Snellen Posterprize at the NVVC spring congress for the abstract “Cryoablation for ventricular arrhythmias during LV reconstruction: Preliminary results of a randomized trial comparing encircling endocardial-epicardial cryoablation with endocardial cryoablation”. N. Ajmone Marsan, MD, PhD, received 3rd place in the Einthoven Dissertation Prize for her thesis.

2012 M.G. Compier, MSc, MD, won the prize for best presentation of session at the NVVC spring congress. E.M. Joyce, MB BCh, BAO MRCPI, received the European Society of Cardiology (ESC) Training Grant Award 2012. At the Euroecho congress in Athens, Greece, she received the Clinical Young Investigator Award with the project titled “Left ventricular subepicardial twist represents a novel marker of contractile reserve in patients after acute myocardial infarction: a speckle-tracking dobutamine stress echocardiography study”. S.R.D. Piers, MD, won the prize for best oral presentation of the session ‘Electrophysiology and arrhythmias’ at the NVVC spring congress. At the ESC congress in Munich, Germany, he won the prize for best moderated poster at the session “Imaging for electrophysiologist: the spectrum gets broader”. B.O. Bingen, MD, received the Dekker grant of the Dutch Heart Foundation to study the pro-arrhythmic mechanisms of cardiac hypertrophy, including means to treat cardiac arrhythmias through genetic modification. At the Netherlands Heart Rhythm Association congress, he won the award for best presentation in the category “atrial electrophysiology”. R. Vicente Steijn, PhD, received the Dekker grant of the Dutch Heart Foundation. She will use this grant to do study atrioventricular reentrant tachycardia in children. V. Kamperidis, MSc, MD, received the ESC Training Grant 2012. This grant consists of a 1-year training on the use of multimodality imaging techniques (3D echo and MDCT) for evaluating patients who are candidates to TAVI, transcatheter edge-to-edge mitral valve repair and transcatheter valve-in-valve procedures and to guide the interventions. M.L.A. Haeck, MD, won the award for best oral presentation during the Right Ventricle Session at the NVVC spring congress. The title of the presentation was “Right Ventricular Dyssynchrony Impairs Left Ventricular Performance in Patients with Pulmonary Hypertension”. P.J.M.R. Debonnaire, MD, received the European Association of Cardiovascular Imaging (EACVI) Research Grant 2013. C.E. Veltman, MD, got mentioned in the congress daily newspaper of the AHA congress in Los Angeles, USA, about her presentation titled “Variation in coronary anatomy in adult patients late after arterial switch operation”.


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ANNUAL REPORT 2011 - 2012

Education & Social involvement PhD training & Higher education Those graduate students that would like to pursue a career in academic science or medicine often start a PhD training. A typical PhD training at the Heart Center Leiden involves 3-5 years of basic and or clinical research, during which he or she is supervised by one of our clinical or scientific staff members. The supervisor provides the PhD candidate with a detailed plan for the following years and follows the candidate’s progress and adjusts this plan if needed. During this period he or she is trained to become an independent researcher who is therefore able to generate hypotheses, design the required experiments, and also to analyze, interpret, present and publish the obtained data in peer-reviewed scientific journals. Typically, at least 4 publications as first author are needed to allow the PhD candidate to defend his or her thesis during a public meeting. For more information please visit our website. The Heart Center Leiden is also actively involved in courses for the studies in Medicine and Biomedical sciences. Courses are coordinated by course directors, and, although teachers in a course may have their home base in various departments of the LUMC, a given course is considered primarily the responsibility of a specific department when this is the home base of the course director. Hence, in this report, we primarily discuss the courses with a course director in the Heart Center Leiden.

Medicine, Years 1-3 (Bachelor Phase) The Heart Center Leiden participates in multiple courses in the study of Medicine. The medicine curriculum of Leiden has completely been revised and since the beginning of the academic year of 2012-2013 the medicine students are schooled accordingly to this ‘new’ curriculum. The current medicine students of the second and third year are able to finish their bachelor phase accordingly to the ‘old’ curriculum. Within the context of the old curriculum the Heart Center contributes mainly to the next courses: Heart and circulation (coordinator: dr. Steendijk; instructors: dr. Maan and dr. van Erven). This first year course (3 weeks) covers the cardiovascular anatomy and physiology, including the cardiac electrophysiology. The main goal is to gain insight into the function and regulation of the heart and vessels based on basic physiologic principles and underlying molecular mechanisms. The students use this knowledge to gain insight into the origin and the therapies for the main cardiovascular diseases.

Pathophysiology (coordinator: dr. van Vlijmen, dept. of Thrombosis and Haemostasis; instructors: dr. Steendijk and dr. Vliegen). This second year course (3 weeks) covers for example the pathophysiology of ischemic and valvular cardiac diseases but also cardiac failure including the diagnostic process based on auscultation, electrocardiograms and a diversion of imaging techniques. Thorax (coordinators: dr. Willems, dept. of Lung Diseases and dr. Vliegen; instructors: dr. Holman, dr. Steendijk and dr. Van Erven). This clinically oriented course (6 weeks) covers the epidemiology, etiology, diagnostics and management of the main cardiac and lung diseases.


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Education & Social involvement Course of choice Cardiac failure (coordinators: dr. Verwey and dr. Steendijk). In this interactive course (3 weeks) different instructors discuss the subject cardiac failure from their specific expertise in front of small groups of third year medical students. In the last week of the course the students select a subject for a literature study which has to be rounded off with a report and presentation about the chosen subject. In the new curriculum dr. Steendijk and prof. Aarts, dept. of Anesthesia coordinate the first year course ‘From base to homeostasis’.

This course (8 weeks) covers the physiology and interaction of the ‘vital’ organ systems: the cardiovascular system, the respiratory system and the kidneys. The main goal of this course is to gain understanding in how these organ systems function and how the reciprocal interactions contribute to the homeostasis of the human during changing circumstances. The new curriculum concerning the years 2 and 3 is still being developed.

Biomedical science, bachelor phase (year 1-3) During the first year the Heart Center Leiden contributes to the course Humane Biology (coordinator: dr. Hierck, dept. of Anatomy). Dr. Steendijk gives lectures and leads (computer) practical lectures concerning the subject of cardiovascular function and interaction. Two courses are being organized bij the Heart Center in concordance with the dept. of Anesthesiology (dr. Teppema): ‘Physiology, basic concepts’ (coordinator dr. Steendijk) and ‘Physiology, advanced concepts’ (coordinators: dr. Pijnappels and dr. de Vries). ‘Physiology, basic concepts’ covers the normal physiology of the cardiovascular system, lungs and kidneys.

Biomedical science, master phase (year 4-5) The Heart Center organizes the course ‘Electrical interactions of the heart’ during the ‘Frontiers of Science’ which lasts 3 weeks (coordinators: dr. Pijnappels and dr. de Vries). The themes of this course are the molecular mechanisms and treatment of cardiac arrhythmias (instructors: dr. Zeppenfeld, prof. dr. Ypey and dr. Atsma).

The course ‘Physiology, advanced concepts’ covers the regulation of these organ systems and their role in homeostasis. The Heart Center Leiden additionally contributes to the second year course ‘Human Pathology’ (coordinator: dr. Gorter, dept. of Pathology). Within the theme cardiopathology, different lectures and practical lecturs concerning among other things the themes atherosclerosis and lipid metabolism are given (instructors: dr. Steendijk, dr. Verwey, prof. Havekes and prof. Jukema).


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ANNUAL REPORT 2011 - 2012

Education & Social Involvement

Social involvement

Non-profit placement

Social media

The Heart Center Leiden is involved in several public activities such as work-shops, presentations and events aiming to inform the general public about our clinical and scientific work.

Since 2011, the Heart Center Leiden facilitates non-profit placements for 3rd and 4th grade students (age 14 to 15).

We have a Twitter account (@Hartcentrum) to provide our patients, colleagues and other interested with information about the Heart Center Leiden.

In this way we hope to contribute to a better understanding of cardiovascular diseases in general and especially to emphasize the importance of a healthy lifestyle and other means to prevent or counteract such diseases. On the other hand it should also become clear why scientific research is crucial for new development in cardiovascular medicine and how we use public donations for our scientific research.

Due to regulations, these students are obliged to do a 2-day placement in a non-profit organization. Learning through democratic education is an opportunity for students to learn the value of community service through first-hand experience. We feel proud to be able to facilitate these placements. Currently the Heart Center has facilitated 25 students to undergo this nonprofit placement (school year 2011-2012). We look forward to providing an increased number of relevant projects in the coming year.


ANNUAL REPORT 2011 - 2012

Anniversary In 2012, the Departments of Cardiothoracic Surgery and Cardiology celebrated their 60th and 65th anniversary. This festive occasion was celebrated on the 13th of December at a special location: the Museum Volkenkunde in Leiden. Around 300 guests were invited, among whom a lot of old colleagues like former heads of the Department of Cardiology professor Bruschke and professor van der Wall. The visitors enjoyed the food, presented in Heart Center theme and the Surinam band â&#x20AC;&#x153;La Fiestaâ&#x20AC;? made sure that everybody got on the dance floor. It was a great night where colleagues got the chance to catch up with their former colleagues and where co-workers once could talk without bringing up the heart. As from 2012, the Departments of cardiothoracic surgery and cardiology together form the Heart Center Leiden. We are already looking forward to the first anniversary!

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ANNUAL REPORT 2011 - 2012

Clinical results and production Daycare

Number of admissions 3.000 2.500

2.312

2.452

2.683

2.717

2.667

2843 2555

3000

2731 2402

2500

2.000

2000

1.500

1500

1.000

1000

500

500

1.438

1648

1.043

0

0 2006

2007

2008

2009

2010

2011

2012

2006

14.000

11.826

12.000

8.977

9.189

8.816

8.797

12095

8.000

2009

2010

2011

9.919

9.863

2010

2011

2012

8.056

8.296

2006

2007

8.813

9.154

2008

2009

10314

6.000

6.000

4.000

4.000

2.000

2.000 0

0 2006

2007

2008

2009

2010

2011

2012

3,88

1.686

1.800

3,75

3,5

1.600

3,5 3,1

3

1.400

3

1.466 1.265

1.200

2,2

2,5

2,2

2012

PCIâ&#x20AC;&#x2122;s

Duration of patient stay (days) 4

2008

12.000 10.000

9.728

8.000

4,5

2007

First consults

Number of patient days

10.000

640

740

1.309

1.305

1.392

1.138

1.000

2

800

1,5

600

1

400

0,5

200 0

0 2006

2007

2008

2009

2010

2011

2012

2006

2007

2008

2009

2010

2011

2012


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ANNUAL REPORT 2011 - 2012

Clinical results and production Stents

Ablations

3.000 2.500

2.521 2.108

2.000

2.627

2.588

800

2.799 2381

703

700

636

500

665

2010

2011

562

600

2.015

671

612

455

400

1.500

300

1.000

200 500

100 0

0 2006

2,5

2007

2008

2009

2011

1,67

1,8

1,77

1,9

2006

2012

2008

14.000

11.533

12.000

1,87

10.000

1,4

1,5

2007

2009

2012

Echo-Doppler studies

Mean number of stents per procedure 2,08

2

2010

9.076

12.073 12.300 12.389 10.570

10.252

8.000 6.000

1

4.000 0,5

2.000 0

0 2006

2007

2008

2009

2010

2011

2006

2012

700

500

2008

2009

2010

2011

2012

Bicycle exercise test

ICDâ&#x20AC;&#x2122;s 3.000

617

600

2007

535

530

447

491

2.355

2.500

452

429

400

2.000

1.942

1.860

1.875

2007

2008

2009

2.533

2.644

1.581

1.500

300 1.000

200

500

100

0

0 2006

2007

2008

2009

2010

2011

2012

2006

2010

2011

2012


038

ANNUAL REPORT 2011 - 2012

Clinical results and production Outpatient Clinic

Oesophagus echo studies 600

544

570

500

30.000

437

400

25.000 20.000

260

300

10.000

100

5.000

0 2007

2008

2009

21.890

24.909

23.400

15.000

200

2006

18.966

20.854

23.015 23.372

2010

2011

2012

0 2006

2007

2008

2009

2010

2011

2012

ER

Stress echo studies 900

810

800 700

3.500 3.000

609

600

2.500

500

2.000

400

2.367

2.591

2.741

2.751

2009

2010

2.990

3.218

2.285

1.500

300

1.000

200

98

100

500

12

0 2006

2007

2008

2009

2010

2011

2012

0 2006

2007

2008

2011

Pacemaker/ICD followup visits

ECGâ&#x20AC;&#x2122;s 25.000

8681

8800

20.000

15.813

2012

16.027

16.819

17.100

19.132

19.370

20.000

8600 8400 8200

15.000

7801

7800 10.000

8056

7987

8000

7477

7600 7400

5.000

7200 7000

0 2006

2007

2008

2009

2010

2011

2012

6800 2006

2007

2008

2009

2010

2011

2012


039

ANNUAL REPORT 2011 - 2012

Clinical results and production MSCT studies

MRI Cardio studies

900

430

811

800 700

599

600

672

617

652

400 390

400

380

300

370

200

360

100

350

0 2007

2008

415

410

500

2006

421

420

2009

2010

2011

2012

386 367

340 2006

2007

2008

2009

2010

2011

2.500

4.000

2.035

2.000

2012

Holter studies

Myocard perfusion scans 2.031

382

3.505

3.500

1.948

3.000

2.686

2.788

2008

2009

3.024

2.500

1.500

1.064 1.000

2.000

713

1.500 1.000

500

500 0 2006

2007

2008

2009

VT-ablations VT-ablations 160

143

140

2010

2011

2012

151 126

122

133

120 100 80 60 40 20 0 2006

2007

2008

2009

2010

2011

2012

0 2006

2007

2010

2011


040

ANNUAL REPORT 2011 - 2012

Clinical results and production LVAD

Mitraclip 17

18 16

12

11

10

14

8

12 10

6

8

4

4

6 4

2

2

0

0 2006

2007

2008

2009

2010

2011

2006

2012

56

60 50

60

2009

2010

2011

2012

10

57

9

8

8 7

43

6

40

5

5

26

30

2008

Pulmonal valve implantation

Aortic valve implantation 70

2007

4

3

3

20

3

3

2011

2012

2

10

1 0

0 2006

2007

2008

2009

2010

2011

2012

2006

2007

2008

2009

2010


ANNUAL REPORT 2011 - 2012

041

Clinical results and production 1.  GENERAL FIGURES Number of procedures in adults and children All (surgical) procedures1

2010

2011

Adults (≥16 years)

1,040

1,076

309

315

1,349

1,391

Children (<16 years) Total ______________

 Including pacemaker procedures, intra-aortic balloon pump procedures, resternotomy for bleeding, wound therapy, sternal wire removal, cardiac tumor resection, et cetera.

1

Number of procedures per type of surgery Type of surgery

2010

2011

7153

7503

205

206

9

8

Tota

929

964

Congenital heart surgery CAHAL1

438

411

Pulmonary and thoracic surgery2

2303

2073

Open heart surgery Adult cardiac surgery (≥16 years) Paediatric cardiac surgery LUMC (<16 years) Other procedures with CPB

______________ CPB = cardiopulmonary bypass. 1  Procedures performed at the Center for Congenital Heart disease Amsterdam Leiden, CAHAL. Procedures are performed at the Leiden University Medical Center for paediatric cardiac surgery and at the Academic Medical Center for congenital heart disease in adults. 2  Including medistinoscopy / mediastinotomy. 3   Combined cardiac and pulmonary surgery in 2010: n = 3; in 2011: n = 2.


042

ANNUAL REPORT 2011 - 2012

Clinical results and production 2.  ADULT CARDIAC SURGERY (≥16 YEARS) Numbers according to procedure Procedure

2010

2011

Coronary artery bypass graft surgery (+/-)

387

420

Aortic valve surgery1 (+/-)

242

268

Mitral valve surgery (+/-)

142

139

79

86

9

3

Surgical treatment of cardiac arrhythmias (+/-)

72

68

Thoracic aortic surgery (+/-)

67

74

Tricuspid valve surgery (+/-) Pulmonary valve surgery (+/-)

______________ 1

 Including transcatheter aortic valve implantations.

Operative mortality 2010

2011

Operative risk

Number of patients

Predicted mortality

Observed Mortality

Number of patients

Predicted mortality

Observed mortality

Low risk

221 (30.9%)

1.6%

0.5%

220 (29.3%)

1.6%

0

Intermediate risk

177 (24.8%)

3.8%

1.1%

210 (28.0%)

4.1%

0

High risk

317 (44.3%)

16.2%

7.6%

320 (42.7%)

16.9%

6.6%

715

8.6%

3.8%

750

8.8%

2.8%

Total


ANNUAL REPORT 2011 - 2012

043

Clinical results and production 2.1  Coronary artery bypass graft surgery (+/-) General 2010

2011

387

420

66.9 ± 10.8 (32 - 90)

67.4 ± 9.9 (30 - 87)

Redo CABG

21 (05.4%)

15 (03.6%)

Urgent

30 (07.7%)

30 (07.1%)

Additive EuroSCORE

4.7 ± 3.2 (0 - 16)

4.5 ± 3.2 (0 - 15)

Logistic EuroSCORE

5.8 ± 7.2 (1 - 67)

5.6 ± 7.8 (1 - 57)

2010

2011

266 (68.7%)

307 (73.1%)

29 (/266; 10.9%)

36 (/307; 11.7%)

163 (/266; 61.3%)

184 (/307; 60.1%)

121 (31.3%)

113 (26.9%)

Number Age

______________ CABG = coronary artery bypass grafting.

Procedure

Isolated CABG - OPCAB - Complete arterial revascularization Combined CABG ______________

CABG = coronary artery bypass grafting; OPCAB = off-pump coronary artery bypass grafting.


044

ANNUAL REPORT 2011 - 2012

Clinical results and production Isolated CABG: Risk and mortality 2010 Risk group

2011

Number

Mortality

Number

Mortality

137 (51.5%)

1 (/137; 0.7%)

167 (54.4%)

0

Intermediate (3≤ EuroSCORE1 ≤5)

80 (30.1%)

2 (/80; 2.5%)

93 (30.3%)

0

High (EuroSCORE1 ≥6)

49 (18.4%)

2 (/49; 4.1%)

47 (15.3%)

0

266

5 (1.9%)

307

0

Low (EuroSCORE1 ≤2)

Total _______________ CABG = coronary artery bypass grafting. 1  Logistic EuroSCORE.


ANNUAL REPORT 2011 - 2012

045

Clinical results and production 2.2  Aortic valve surgery (+/-) General 2010

2011

242

268

69.4 ± 14.2 (16 - 94)

68.7 ± 15.1 (17 - 94)

Redo aortic valve

30 (12.4%)

27 (10.1%)

Urgent (<24 hours)

13 (05.4%)

13 (04.8%)

7.9 ± 3.2 (2 - 16)

7.6 ± 2.9 (2 - 15)

13.8 ± 12.5 (2 - 67)

12.2 ± 11.4 (2 - 61)

2010

2011

Isolated aortic valve1

114 (47.1%)

133 (49.6%)

Aortic valve + CABG

44 (18.2%)

39 (14.6%)

Aortic valve + mitral valve (+/- other)

25 (10.3%)

30 (11.2%)

Aortic valve + other combination

59 (24.4%)

66 (24.6%)

242

268

60 (/242; 24.8%)

82 (/268; 30.6%)

Number1 Age, years

Additive EuroSCORE Logistic EuroSCORE ______________ 1  Including transcatheter aortic valve implantations.

Procedure

Total Root replacement (+/- valve) ______________ CABG = coronary artery bypass grafting. 1  Including transcatheter aortic valve implantations.


046

ANNUAL REPORT 2011 - 2012

Clinical results and production Prosthesis 2010

2011

15 (06.2%)

22 (08.2%)

151 (62.4%)

172 (64.2%)

AV replacement, mechanical valve

21 (08.7%)

14 (05.2%)

TAVI, transfemoral

17 (07.0%)

18 (06.7%)

TAVI, transapical

38 (15.7%)

42 (15.7%)

AV repair AV replacement, tissue valve

______________ AV = aortic valve; TAVI = transcatheter aortic valve implantation.

Isolated surgical aortic valve1 : Risk and mortality 2010 Risk group

Number

Mortality

Number

Mortality

Low (EuroSCORE2 ≤2)

14 (23.7%)

0

18 (24.7%)

0

Intermediate (3≤ EuroSCORE2 ≤5)

19 (32.2%)

0

28 (38.4%)

0

High (EuroSCORE2 ≥6)

26 (44.1%)

0

27 (37.0%)

1 (/27; 3.7%)

59

0

73

1 (1.4%)

Total _______________ Not including transcatheter aortic valve implantations.   Logistic EuroSCORE.

1  2

2011


047

ANNUAL REPORT 2011 - 2012

Clinical results and production Transcatheter aortic valve implantation: Risk and mortality 2010 Risk group

2011

Number

Mortality

Number

Mortality

Low (EuroSCORE1 ≤2)

1 (01.8%)

0

0

-

Intermediate (3≤ EuroSCORE1 ≤5)

2 (03.6%)

0

2 (03.3%)

0

52 (94.5%)

3 (/52; 5.8%)

58 (96.7%)

0

55

3 (5.5%)

60

0

High (EuroSCORE1 ≥6) Total _______________ 1 

Logistic EuroSCORE.

Aortic valve + CABG: Risk and mortality 2010 Risk group

Number

Mortality

Number

Mortality

Low (EuroSCORE1 ≤2)

7 (15.9%)

0

6 (15.4%)

0

Intermediate (3≤ EuroSCORE1 ≤5)

9 (20.5%)

0

16 (41.0%)

0

28 (63.6%)

3 (/28; 10.7%)

17 (43.6%)

1 (/17; 5.9%)

44

3 (6.8%)

39

1 (2.6%)

High (EuroSCORE1 ≥6) Total _______________ CABG = coronary artery bypass grafting. 1 

2011

Logistic EuroSCORE.


048

ANNUAL REPORT 2011 - 2012

Clinical results and production 2.3  Mitral valve surgery (+/-) General 2010

2011

142

139

63.5 ± 13.0 (25 - 90)

67.3 ± 11.4 (30 - 87)

11 (07.7%)

12 (8.6%)

1 (00.7%)

0

Additive EuroSCORE

6.2 ± 2.8 (2 - 16)

7.3 ± 2.9 (2 - 16)

Logistic EuroSCORE

8.4 ± 9.1 (2 - 67)

11.4 ± 11.5 (2 - 64)

2010

2011

Isolated mitral valve

29 (20.4%)

19 (13.7%)

Mitral valve + CABG (+/- other)

44 (31.0%)

41 (29.5%)

Mitral valve + tricuspid valve

19 (13.4%)

18 (12.9%)

Mitral valve + rhythm surgery (+/- tricuspid valve)

19 (13.4%)

20 (14.4%)

Mitral valve + other combination

31 (21.8%)

41 (29.5%)

Number Age, years Redo mitral valve Urgent (<24 hours)

Procedure

______________ CABG = coronary artery bypass grafting.


049

ANNUAL REPORT 2011 - 2012

Clinical results and production Prosthesis

MV repair MV replacement, tissue valve

2010

2011

120 (84.5%)

119 (85.6%)

13 (09.2%)

12 (08.6%)

8 (05.6%)

7 (05.0%)

0

0

1 (00.7%)

1 (00.7%)

MV replacement, mechanical valve TMVI, transfemoral TMVI, transapical ______________ MV = mitral valve; TMVI = transcatheter mitral valve implantation.

Mitral valve (all procedures): Risk and mortality 2010 Risk group

Number

Mortality

Number

Mortality

Low (EuroSCORE1 ≤2)

35 (24.6%)

0

17 (12.2%)

0

Intermediate (3≤ EuroSCORE1 ≤5)

37 (26.1%)

0

34 (24.5%)

0

High (EuroSCORE1 ≥6)

70 (49.3%)

5 (/70; 7.1%)

88 (63.3%)

7 (/88; 8.0%)

142

5 (3.5%)

139

7 (5.0%)

Total _______________ 1

2011

  Logistic EuroSCORE.


050

ANNUAL REPORT 2011 - 2012

Clinical results and production 2.4  Tricuspid valve surgery (+/-) General 2010

2011

79

86

64.3 ± 13.6 (25 - 84)

68.0 ± 12.5 (31 - 86)

1 (01.3%)

2 (02.3%)

0

0

Additive EuroSCORE

6.3 ± 2.6 (2 - 13)

7.8 ± 2.8 (2 - 16)

Logistic EuroSCORE

8.1 ± 6.9 (2 - 34)

12.5 ± 11.0 (2 - 64)

2010

2011

5 (06.3%)

3 (03.5%)

74 (93.7%)

83 (96.5%)

2010

2011

79 (100%)

82 (95.3%)

TV replacement, tissue valve

0

3 (03.5%)

TV replacement, mechanical valve

0

1 (01.2%)

Number Age, years Redo tricuspid valve Urgent (<24 hours)

Procedure

Isolated tricuspid valve Combined tricuspid valve

Prosthesis

TV repair

______________ TV = tricuspid valve.


ANNUAL REPORT 2011 - 2012

051

Clinical results and production 2.5  Pulmonary valve surgery (+/-) General 2010

2011

9

3

39.7 ± 12.7 (16 - 60)

35.9 ± 16.6 (16 - 46)

Redo pulmonary valve1

8

1

Urgent (<24 hours)

1

0

Additive EuroSCORE

6.2 ± 2.3 (5 - 12)

6.3 ± 1.5 (5 - 8)

Logistic EuroSCORE

8.3 ± 11.2 (4 - 38)

7.0 ± 4.4 (4 - 12)

2010

2011

Isolated pulmonary valve

5

1

Combined pulmonary valve

4

2

2010

2011

PV repair

0

0

PV replacement, tissue valve

3

1

PV replacement, mechanical valve

0

0

PV replacement, homograft/autograft

6

2

Number Age, years

______________ 1

  Including Fallot.

Procedure

Prosthesis

______________ PV = pulmonary valve.


052

ANNUAL REPORT 2011 - 2012

Clinical results and production 2.6  Surgical treatment of cardiac arrhythmias (+/-) General 2010

2011

72

68

63.7 ± 11.5 (32 - 79)

67.5 ± 11.9 (24 - 84)

2010

2011

Atrial fibrillation (+/- ventricular tachycardia)

60 (83.3%)

60 (88.2%)

Ventricular tachycardia

12 (16.7%)

8 (11.8%)

2010

2011

9 (12.5%)

8 (11.8%)

Number Age, years

Pathology

Procedure

Isolated surgical treatment of cardiac arrhythmias


ANNUAL REPORT 2011 - 2012

053

Clinical results and production 2.7  Thoracic aortic surgery (+/-) General 2010

2011

67

74

59.0 ± 15.7 (16 - 82)

58.9 ± 15.4 (17 - 83)

Redo thoracic aortic

9 (13.4%)

8 (10.9%)

Urgent (<24 hours)

13 (19.4%)

13 (17.6%)

8.5 ± 2.4 (4 - 15)

8.8 ± 3.1 (5 - 15)

15.6 ± 10.7 (2 - 55)

18.8 ± 15.3 (5 - 61)

2010

2011

Aneurysm

48 (71.6%)

57 (77.0%)

Dissection

13 (19.4%)

11 (14.9%)

6 (09.0%)

6 (08.1%)

2010

2011

46 (68.7%)

43 (58.1%)

Arch

3 (04.5%)

3 (04.1%)

Descendens

4 (06.0%)

3 (04.1%)

10 (14.9%)

25 (33.8%)

Arch + descendens

2 (03.0%)

0

Ascendens + arch + descendens

2 (03.0%)

0

Number Age, years

Additive EuroSCORE Logistic EuroSCORE

Pathology

Other

Aortic region

Ascendens

Ascendens + arch


054

ANNUAL REPORT 2011 - 2012

Clinical results and production Thoracic aortic surgery in aneurysms: Risk and mortality 2010 Risk group Medium (EuroSCORE1 ≤2) Intermediate (3≤ EuroSCORE1 ≤5) High (EuroSCORE1 ≥6) Total

2011

Number

Mortality

Number

Mortality

0

-

0

-

6 (12.5%)

0

15 (26.3%)

0

42 (87.5%)

1 (/42; 2.4%)

42 (73.7%)

2 (/42; 4.8%)

48

1 (02.1%)

57

2 (3.5%)

_______________   Logistic EuroSCORE.

1

Thoracic aortic surgery in dissecton: Risk and mortality 2010 Risk group

Number

Mortality

Number

Mortality

Medium (EuroSCORE1 ≤2)

0

-

0

-

Intermediate (3≤ EuroSCORE1 ≤5)

0

-

0

-

13 (100%)

3 (23.1%)

11 (100%)

2 (18.2%)

13

3 (23.1%)

11

2 (18.2%)

High (EuroSCORE1 ≥6) Total _______________   Logistic EuroSCORE.

1

2011


055

ANNUAL REPORT 2011 - 2012

Clinical results and production 3.  CONGENITAL HEART SURGERY Age groups and mortality

2010 Age group

2011

Number

Mortality

Number

Mortality

<1 Month (neonates)

48 (11.0%)

2 (/48; 4.2%)

71 (17.3%)

2 (/71; 2.8%)

>1 Month and <1 year

116 (26.5%)

4 (/116; 3.4%)

111 (27.0%)

3 (/111; 2.7%)

>1 Year and <18 years

155 (35.4%)

3 (/155; 1.9%)

117 (28.5%)

1 (/117; 0.9%)

>18 Years

119 (27.2%)

2 (/119; 1.7%)

112 (27.3%)

2 (/112; 1.8%)

438

11 (2.5%)

411

8 (1.9%)

Total

4.  PULMONARY AND THORACIC SURGERY General

Number1 Age, years ______________   Including mediastinoscopy / mediastinotomy.

1

2010

2011

230

207

56.5 ± 16.7 (9 - 82)

57.7 ± 17.2 (0 - 88)


056

ANNUAL REPORT 2011 - 2012

Clinical results and production Procedure 2010

2011

2 (02.4%)

4 (05.3%)

73 (89.0%)

70 (93.3%)

7 (08.5%)

1 (01.3%)

82

75

13 (/82; 15.9%)

13 (/75; 17.3%)

4 (/82; 04.9%)

11 (/75; 14.7%)

342

17

61 (53.0%)

62 (53.9%)

Isolated lung perfusion + metastasectomy

8 (07.0%)

8 (07.0%)

Lung volume reduction surgery

4 (03.5%)

11 (09.6%)

Thymectomy

6 (05.2%)

3 (02.6%)

Diaphragm plication

3 (02.6%)

15 (13.4%)

332 (28.7%)

16 (13.9%)

1152

115

Lung cancer Segmentectomy (Bi-)lobectomy Pneumonectomy Total Sleeve resection Extended resection Mediastinoscopy / mediastinotomy Other Wedge resection / bullectomy

Other1 Total _______________ 1â&#x20AC;&#x201A;

Including empyema treatment, mediastinal tumor resection, diagnostic thoracotomy, et cetera.

â&#x20AC;&#x201A; Mediastinoscopy converted to pulmonary surgery: n = 1.

2


057

ANNUAL REPORT 2011 - 2012

Clinical results and production Pulmonary and thoracic surgery: Mortality 2010 Risk group

Number

Mortality

Number

Mortality

82

1 (/82; 1.2%)

75

4 (/75; 5.3%)

342

0

17

0

Other

1152

1 (/115; 0.9%)

115

1 (/115; 0.9%)

Total

230

2 (0.9%)

207

5 (2.4%)

Lung cancer1 Mediastinoscopy / mediastinotomy

_______________ â&#x20AC;&#x201A; Not including mediastinoscopy / mediastinotomy. â&#x20AC;&#x201A; Mediastinoscopy converted to pulmonary surgery: n = 1.

1 2

2011


058

ANNUAL REPORT 2011 - 2012


ANNUAL REPORT 2011 - 2012

059

Epilogue Looking at the future, we know it will come with further development of new medical technologies as well as new insights regarding disease development and treatment. Therefore, the integration of these future technologies and insights in daily clinical practice needs to be facilitated. Due to the interactive and multidisciplinary nature of the Heart Center Leiden, such novelties can be quickly, robustly and safely investigated and also implemented in patient care strategies according to recent guidelines. In other words, the Heart Center Leiden comprising two Departments whom are not only very proud of their history but also employ their long-term experiences and knowledge, in combination with modern technologies, for the sake of todayâ&#x20AC;&#x2122;s but also tomorrowâ&#x20AC;&#x2122;s patients.

Prof. dr. M.J. Schalij

Thank you very much, after having reached this final page, we hope you have a better view on our staff, facilities, strategies, output and future goals. For up-todate information you can always visit our website: www.hartcentrum.nl. Best wishes, Prof. dr. M.J. Schalij and prof. dr. R.J.M. Klautz

Prof. dr. R.J.M. Klautz



Annual report Heart Center Leiden 2011 & 2012