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Learn more and get a better treatment plan for heart disease with *precisely chosen* top experts. Visit our Online Heart Expert Center at https://diagnosticdetectives.com/expe...

Professor Dr. Dale Adler MD, prominent cardiologist and medical heart disease treatment expert, and Dr. Anton Titov MD PhD MBA / Exclusive interview on medical therapy for coronary heart disease, high cholesterol and hypertension treatment, and sudden death prevention and treatment.

- What is the best way to keep the heart healthy? You know, it seems that from everything we learned, an optimal weight - it goes a very long way, because when people are overweight, of course, there's a higher blood volume and there's more blood flow coming into the heart every time, and there's going to be some tendency for it to stretch. And when people are overweight, they tend to have more high blood pressure, which means a heart is going to overwork, it can become thicker. And, of course, being overweight leads to something in the realm of diabetes. So we know that's going to be very bad for the blood vessels and worse for the cholesterol. So we say - an optimum weight. Fitness, I think, is the other key thing. One study after another has shown - in the people who go out of their way to push themselves lifelong, they retain a compliance to their heart, so in between beats, the heart is better able to relax. And, of course, they're also able to do a good job for keeping their blood vessels in better order. So I would say, it sounds boring, but optimal weight and some kind of real good fitness program - to me it will go a very long way...

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Professor Dr. Kent Yucel MD, prominent MRI and CT expert and interventional radiologist with particular focus on heart disease diagnosis by MRI and CT Angiography, and treatments by minimally invasive interventional radiology methods, and Dr. Anton Titov MD / Exclusive interview

- We had a very thorough discussion about advanced imaging technologies for patients with many health conditions. Let this be a concluding topic of our conversation today. What is your view on the impact that mobile devices have on practice and training in such visually oriented field as radiology? When we talk about mobile imaging devices, we're talking primarily about mobile ultrasound. Miniaturization of ultrasound devices has progressed very far. Now ultrasound machines have very good quality of ultrasound pictures that doctors can carry devices around with them from one place to the other, and use at the bedside, potentially. I think the risk of that is - while the imaging may be high quality there is still a tremendous need for doctors who are using this equipment to have adequate training in evaluating the pictures. Otherwise they may think that nothing is wrong with the patient when the patient has a serious condition that they failed to find. Or, equally concerning, they may see something on the picture they don't understand, which is actually not a problem - maybe it is a benign finding. And they misinterpret it as a significant finding. So the equipment issue is solved effectively with ultrasound. There are small devices that are very mobile. That's true. The real problem is making sure the doctors who are using these devices are adequately trained. They don't necessarily have to be radiologists. But radiologists as an example, or cardiologists, are very well trained at doing ultrasound exams, deciding what's important and what's not important. They know what the ultrasound may have failed to detect, and when patients need further imaging, based on the findings of ultrasound. I am not saying only the radiologist or cardiologist have to do ultrasound. But I am saying that doctors who are going to be doing ultrasound, really must have the extra training needed to interpret the pictures. As a follow-up question, MRIs and CTs are becoming widely available to patients and marketed to consumers. So does that bring an opportunity for more direct consultations of patients to radiologists? Maybe radiologists can now bypass a number of physicians that are traditionally inserted along the value chain for somebody who is scheduled to do CT or MRI? This is the consumer-driven healthcare culture. Can direct contact between radiologists and patients be actually beneficial for the practice of radiology? That's a very hot topic in the United States right now. Radiologists are talking about getting more involved in direct patient communication, as they have historically done, for example, with mammography. So with mammography, the decision of "do nothing" or to get further evaluation of patient's breast, is really up to the radiologist. The radiologist is responsible for communicating that decision to the patient. Extending direct communication between radiologists and patients to other areas is being discussed. I have a problem with that strategy. Many radiologic findings need to be placed in the overall clinical context of the patient to know how to manage them. The lab tests, the physical exam, the presenting symptoms - all need to be taken into the account to decide what to do about the radiology finding. Perfect example is MRI of the spine for back disease - it detects all kinds of abnormalities, many of them are not related to the patient's symptoms. So that's where the careful physical examination and talking to the patient is mandatory - to know whether these MRI findings in the back, in the discs, or in the nerves need to be treated or not. It's a great idea theoretically, but I think the way radiologist can add most to the "value chain" is by talking more directly to doctors who are ordering the exam and can help them put the findings in context. Sometimes the ordering doctors may have difficulty interpreting the reports. And that's where I think radiologists can add value to the patient's care - by communicating directly, verbally with the patient's doctors. The problem with communicating with the patients directly is it can create more confusion than clarity in their mind. So the traditional way of team interaction in patient care remains the golden standard and hopefully will be so in the foreseeable future.

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Professor Dr. Dale Adler MD, prominent cardiologist and medical heart disease treatment expert, and Dr. Anton Titov MD PhD MBA / Exclusive interview on medical therapy for coronary heart disease, high cholesterol and hypertension treatment, and sudden death prevention and treatment.

But the first part of your question, in terms of health systems, I think the focus that has arisen during the past few years and the idea of accountable care organizations, the idea that somehow you're going to try to be responsible for a person's health - that means preventing them from coming in the hospital, and if they come into the hospital, - because you know so much about them already from their devices that they wore, you can treat them quickly, you can send them out of the hospital more quickly, because you know you're going to be able to monitor them very well. And you can keep them out of the hospital because you'll be able to continue to monitor them. All of those are things that will be rewarded and should be rewarded as we build systems that are rewarded for keeping people healthy. And so the drive to have larger and larger systems really occurs because we say, "All right, we want to do everything we can to keep all these people healthy." On the other hand, at some point people are going to get sick. And they're going to need a lot of attention, and we need to have facilities that can handle that. We need to have physicians who really are good at handling that, we need to have the physicians who can teach that, and the physicians who can study it. But if you're keeping so many people out of the hospital, you're no longer treating things in the hospital, you have to have a very very broad reach, so that you are assured that at your hospital you'll have all of those kinds of ill patients. So I think the trend is going to be in that direction. But I think it's a good trend, This is very important to emphasize, what you said a few sentences ago, that in order to have a fast turnaround in a hospital, the maximum efficiency of use of very expensive and very sophisticated systems inside the hospital, the key is to know a lot about the patient before that patient has to come into the hospital, and therefore spreading the wings widely and using the integrated health care systems that are either monitoring the patient at home or at the local clinic and then learning all about them to prevent them from overutilizing the health care. And when they have to use the health care, then you can bring them in, treat them efficiently and discharge them, and therefore become very efficient provider organization. That's the goal, that's absolutely the goal! Professor Adler, thank you very much for this very interesting conversation about heart disease and preventive medicine! And I hope that it will be very interesting to our viewers. And also thank you for your continued leadership in healthcare and in clinical and research medicine.

- Thank you!

- You're very welcome, thank you!

Exclusive interview / Professor Dr. Lawrence Cohn MD, eminent heart surgeon and medical educator, pioneer in minimally invasive heart valve surgery and Dr. Anton Titov MD

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- This brings us to a very important question: How does one choose a medical specialist? How does one choose a surgeon? There is an increasing amount of clinical outcomes data for individual surgeons available in the US. Other countries perhaps do not have similar data transparency about clinical outcomes. But oftentimes the method of presentation of results of the surgery and availability of these data does not help patients, but confuses them even more. How does one choose a cardiac surgeon? Well, I think a lot of this is by referring doctors and cardiologists. It's not only about the intrinsic risk of the operation, but also, how experienced that surgeon is in doing the procedure which you have to have. Particularly with mitral valve repair, for example, surgeon needs to have done many operations to become good at it. If a patient is referred by a cardiologist to a new surgeon who has done only 5 of these operations in his life - that is a problem! But if you are sent to a surgeon who has done 500 of these operations, then you have a better chance to have correct operation done. A lot of doctors know each other's records [surgery results]. On the other hand, there are databases that are being generated around our country. They will have clinical outcomes data for surgeons and hospitals eventually.

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Professor Dr. Paul Sugarbaker MD, abdominal peritoneal metastatic cancer treatment expert, co-author of The Sugarbaker Procedure - Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy CRS HIPEC, and Dr. Anton Titov MD PhD MBA / Exclusive interview

- Dr. Sugarbaker, you pioneered and, together with your colleagues, developed the procedure now known as the Sugarbaker Procedure for cytoreductive surgeryand Hyperthermic Intraperitoneal Chemotherapy Where do you see peritoneal cancer treatment going into the future? How do you see the Sugarbaker procedure developing in the next years? With your colleagues, you are working hard to bring cytoreductive surgery and HIPEC to more cancer patients. What is the future for peritoneal metastatic cancer treatment? I think the future for peritoneal cancer treatment is limitless. 20 years ago we had the first international congress on peritoneal surface oncology. It was in London at a small hospital, North Hampshire Hospital. There were about 30 or 40 people there. I had no idea at that time that this would be growing the way that it is now. So next year in Washington, DC, we will get together with about a 1,000 surgeons and oncologists from around the world. We will try and think through now, 20 years later, where are we going with the treatment of peritoneal metastases. We have not found out the optimal medications to use on individual patients. We need to optimize

- that's a good word - the chemotherapy that goes with cytoreductive surgery. It is a huge challenge in terms of surgical technology education. I would say that are our greatest challenge at this point in time is to educate surgeons to perform a cytoreductive surgery that's down to the microscopic level of cancer metastatic disease, to do that with a less than 1% mortality and with less than 10% serious complication rate. That is the #1 focus of our activity at this point in time. We will be working on educating cancer surgeons with videos and workshops to allow best practices in peritoneal metastases treatment to be safely disseminated around the globe. Of course, high quality of cytoreductive surgery is a challenge in the United States, Europe, Japan and Korea. But what about the developing countries? Well, there is a huge challenge with quality of cancer surgery in developing countries. What about cancer surgery quality with our islamic neighbors? We are trying to get something going now in Kuwait and Saudi Arabia. We have got a peritoneal cancer conference coming up in Cairo, Egypt. But it's a huge challenge there. Because the level of surgical expertise is not the same as we have in the US. I was trained at Harvard and then at National Institute of Health. I had absolutely the best training in surgery you could ever imagine. We don't have that quality of surgical training around the world. South America is a huge challenge in quality cancer surgery training. We have made some real progress in Mexico, with a big effort to educate cancer surgeons. But is cytoreductive surgery and HIPEC a treatment only for the US and Europe? It is not! It is a treatment that should be initiated around the globe. That is a huge challenge.

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Exclusive interview / Dr. Anton Titov MD and Professor Dr. Francesca Cordeiro, leading retinal disease, glaucoma, neurodegeneration, macular degeneration, retinal detachment and early Alzheimer's diagnosis eye test expert.

- Hello from London! We are with Dr. Francesca Cordeiro, who is Professor of Retinal Neurodegeneration and Glaucoma Studies at the Institute of Ophthalmology, University College London. Prof. Cordeiro is Honorary Glaucoma Consultant Ophthalmologist at the Western Eye Hospital, Imperial College Healthcare NHS Trust in London, where she is Director of the Clinical Trials Research Unit Prof. Cordeiro graduated from St. Bartholomew Hospital Medical School at University of London and completed training in general and surgical ophthalmology at Moorfield's Eye & St. Thomas' Hospitals in London. She also did her PhD at the University College London. Prof. Cordeiro's research is focused on origins and treatment of retinal neurodegenerative diseases, including glaucoma, Alzheimer's, macular degeneration, retinal detachment and diabetes. She has established new methods of early diagnosis of these diseases, with aim to avoid disability and identify early markers in neurodegenerative diseases. Prof. Cordeiro received many awards for her work, including Research to Prevent Blindness International Research Scholar Award USA 2014, an Allergan Glaucoma Achievement Award in 2010, the Lewis Rudin Glaucoma Prize in 2005, from the New York Academy of Medicine, 2000 International Glaucoma Review Award... Professor Cordeiro, hello and welcome! - Hello!

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Professor Dr. Paul Sugarbaker MD, abdominal peritoneal metastatic cancer treatment expert, co-author of The Sugarbaker Procedure - Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy CRS HIPEC, and Dr. Anton Titov MD PhD MBA / Exclusive interview

- So here's what I would say about ovarian cancer surgery today. The concept of debulking, which is the standard of care for most surgeons performing their surgery in ovarian cancer - they just remove most of it - and they expect the systemic chemotherapy

- which is quite effective - more effective in ovarian cancer than in the gastrointestinal cancer - surgeons expect the systemic chemotherapy to clean it up. Bad concept. Bad concept. Ovarian cancer patients should have the same meticulous cytoreduction with peritonectomy and visceral resections, down to no visible evidence of cancer. The same as we would do, say, for peritoneal mesothelioma. That's not happening at this point. That is the first and biggest step in the improved treatment of ovarian cancer - is to bring these surgical oncology principles with peritonectomy into the treatment of all patients with either primary or recurrent ovarian cancer.

- And at the moment it's not happening? - No! At this point in time, only a small number of ovarian cancer patients have this very meticulous surgery. Now, some of them are older women. They are not so fit. And it's not appropriate to put them through an 8-hour surgical procedure. So, of course, you have to be selective. It doesn't pay to do a big operation on someone and then have them die, or do such an extensive surgery that they can never recover a reasonable quality of life. So you have to be selective, of course! But the first step to improving the outcome with ovarian cancer is to use peritoniectomy with visceral resections with removal of all visible evidence of disease as the goal.

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Professor Dr. Paul Sugarbaker MD, abdominal peritoneal metastatic cancer treatment expert, co-author of The Sugarbaker Procedure - Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy CRS HIPEC, and Dr. Anton Titov MD PhD MBA / Exclusive interview

- Everyone who develops and promotes a pioneering treatment or a pioneering discovery, meets a lot of resistance. It is resistance from peers, from very smart men and women. And we know that. Nobel Prize for discovering H. pylori was given to Australian doctors who were neglected and ridiculed by peers for a long time. There is a saying by Gandhi: "First they ignore you, then they laugh at you, then they fight you, and then you win." And I saw that criticism in science when I was doing my PhD. My mentor has experienced a lot of criticism until it was clearly shown he was right. And in a world of surgery you encounter criticism and you have to operate. And every time criticism bears down on you. How do you overcome criticism? How do power through the critics? How do you keep going? Well, what you say was very true about this work. Early on, when I was younger, there were a lot of criticism. Not at Harvard, not at the National Institute of Health - but elsewhere. One professor would evaluate my work as "Extensive surgery in patients who will inevitably die of cancer". Because the general surgeon at that time had never seen a patient survive peritoneal metastases. And, I guess, it was asking a lot of these surgical leaders to believe that we could achieve this kind of success [with HIPEC]. I think you just have to have enough faith in yourself and in the concepts that you are developing, that, no matter what the criticisms, you keep moving towards your goal. Of course, the answer to those criticisms is data. Luckily, I was in a situation, where I was allowed to accumulate reams of data - First, about appendiceal cancer patients. [= pseudomyxoma peritonei] Actually, they did unbelievably well - the pseudomyxoma peritonei patients. We then had results of treatment of the peritoneal mesothelioma patients. Previously, they virtually all died. Now we are looking at 60% to 70% long-term survival. The metastatic colon cancer work is a little bit more challenging. And we're finding out that we just need to initiate the treatments for colon cancer with peritoneal metastases at a very small extent of metastases. We'd like to be curing a single peritoneal metastasis lesion from colorectal cancer. And then we can have 50% to 70% of those patients survive long-term. So, data is what you need to generate. You need to critically evaluate what you are doing, publish your results, and publish not only your good results, but your bad results too. This is a big issue in medicine. There is a bias of selection that only the good results or successful clinical trials are published. That prevents a lot of evaluation of data. We are struggling still in some cancers. Surgery by itself is a failure for a large number of gastrointestinal malignancies. Cancer surgery for gastric cancer for the most part is a failure, 60+% of the patients still die because of local recurrence and peritoneal metastases. So gastric cancer surgery is definitely flawed. Surgery for pancreas cancer is flawed: A majority of patients recur right where the surgeon was working - right at the pancreatectomy site. Pancreatic cancer surgery is extremely flawed, and it should be improved. It used to be the same with rectal cancer. We had a large number of patients whose rectal cancer recurred locally. There are now surgical technologies that have shown us that we don't need to have more than a 5% or so local recurrence for rectal cancer. Cancer surgery has, as its first and foremost goal, a local control of cancer. If the surgeon gains local control of cancer, then medical oncologist can do great things with cancer around the rest of the body. But if a surgeon cannot get local control of tumor, there is no opportunity to help the patient in the long term.

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Exclusive interview / Dr. Anton Titov MD and Professor Dr. Francesca Cordeiro, leading retinal disease, glaucoma, neurodegeneration, macular degeneration, retinal detachment and early Alzheimer's diagnosis eye test expert.

- Well, as you say, the eyes are the window into the brain, and it's clear that diagnosing Alzheimer's disease reasonably early would make a very big difference, and you developed a particular eye test, which can be used to potentially pinpoint people at higher risk of Alzheimer's or in subclinical state of Alzheimer's, up to 20 years before the clinical manifestations of dementia develop. Could you please talk a little bit more s about the eye test that you developed?

- Sure, so this is the DARC technology, Detection of Apoptosing Retinal Cells and it relies on the fact that you get cell death in the retina mimicking what's going on in the brain. So, at the moment we haven't done patients with Alzheimer's disease, but our Phase 2 trial, which is starting here, in fact, next month, does contain a group of patients who are at high risk of Alzheimer's and they will be having this test. So, these patients, interestingly, have Down's syndrome and in Down's syndrome, you know, you have an extra chromosome. What's believed to happen is, as Down's patients are living longer, it is known that they have a lot of beta amyloid, protein that is implicated in the plaques in the brain in Alzheimer's disease. They over-express this beta amyloid, and so there's a very high rate of dementia in Down's patients. So, what we are going to be doing is looking at this sample of patients and using DARC. So, DARC basically it involves an injection into the arm and then taking photographs, very similar to the sort of machines that you see being used to examine your eye when you go to optometrists and opticians. So, the importance of that is these are fairly cheap machines, when you compare it to an MRI or a PET scanner. But they allow you to pick up abnormality, because the dye that is injected into your arm, is a fluorescent dye that identifies those cells that are dying through apoptosis. So, we do know that from all our experimental data or the literature that apoptosis in itself is very important in Alzheimer's and in Parkinson's. And what we believe is that you see apoptosis as an early stage before you develop the full blown disease, obviously you need to prove this, and we will be doing that at the clinical trials going forward. But certainly, when go to our transgenic experimental [mouse] models there is very good evidence that this is a very early event, which mimics almost the changes you see in the synapses of the brain. At the same times you see a change in synapses in the brain, you're seeing apoptosis in the retina.

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Exclusive interview / Dr. Anton Titov MD and Professor Dr. Sebastian Brandner, expert in molecular and genetic brain tumor diagnosis and neurodegeneration.

Just to circle back to the concept of CJD, and also Alzheimer's disease, there is a genetic influence, but it can also arise spontaneously. The vast majority, 95% of cases are spontaneous.

- 95% [of Alzheimer's or CJD] cases are spontaneous, but once disease happens, it can be transmitted via the biological material... - Yes, that's right! I would say very clearly, via medical procedures where brain tissue is transmitted in some way. We don't yet know how risky that is, how common that is, whether it's easy or difficult. And we should also say, it's not that we can transmit Alzheimer's disease, we can transmit the protein that then deposits and amplifies in the recipient brain, and, it was established, this protein can cause some problems in the blood vessels, they then become more brittle and they start bleeding. We have seen a few examples, where the transmission without prion disease was also possible, and that leads young people to the potential development of these vascular problems, which we call cerebral amyloid angiopathy. This is a whole different concept of disease!

- Yes, that's right! - It's amazing, these diseases are not bacterial and not viral, but are caused by a protein that can precipitate intrinsic changes.
- Yes...
- Huge implications!

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Professor Dr. Paul Sugarbaker MD, abdominal peritoneal metastatic cancer treatment expert, co-author of The Sugarbaker Procedure - Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy CRS HIPEC, and Dr. Anton Titov MD PhD MBA / Exclusive interview

- Dr. Sugarbaker, this is an opportunity to talk not only about the Sugarbaker Procedure that you and your colleagues have developed and pioneered - but also about you - because I think it's very important. In modern age, the public starts to view medicine as a "technology play" - as a collection of gadgets, algorithms, beeping sounds and various technological developments. But we have to remember that it is humans who are dedicated to the lives of patients. They drive medicine forward - physicians, nurses, other health care professionals I think that your career and your life exemplifies this dedication. So I would like to ask you, What drives you in life? Maybe you can share a little bit about your upbringing, about your values and your dedication. What gets you going when the going gets tough? That's a difficult question - to try and figure yourself out. Why you do things? Why you don't do other things? My father was a surgical oncologist. And I used to operate with him when I was in medical school, even before I went to medical school. So in some respects I was brought up in the operating room. And I got a feeling for what was a really high quality surgical procedure, and what didn't turn out well during an operation. I began to develop a feeling for it. Somehow, when you start very young with some things, you get a perspective on things that you otherwise wouldn't have. So I got to credit my father, who was a really groundbreaking surgical oncologist trained at Memorial Hospital. My father was the founding member of the James Ewing society. [Now it is American Cancer Society] My father was definitely a guiding force in my life. My professor at Harvard Medical School, Dr. Francis Moore, used to have this saying: "The best way to care for a patient is to care for the patient". And that's really I think very true. If you are really concerned about this person, who's entrusted their life to you, If you are really concerned, then you give them absolutely the best result possible. And you do that one patient at a time. Then you are going to have a superior result of treatment. I think that "one patient at a time" concept is now not so popular. They would like us to see 20 patients in an afternoon.

- Especially in modern medicine!

- Yes, that's right! "One patient at a time" was a motto during classical days of surgery at Peter Bent Brigham Hospital in Boston. [Now Brigham & Women's Hospital] That's correct! So perhaps that has lingered on throughout my career. And now, being in the position that I am in, I have the luxury of still evaluating every patient extremely carefully prior to surgery. to make sure that my patients have a real good chance, a real good possibility to benefit from treatment, before we take them to the operating room for a procedure that could potentially cost them their life.

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Professor Dr. Aric Parnes MD, hematologist-oncologist, expert in anemia, blood clots, myelodysplastic syndrome, MDS, leukemia and lymphoma treatment, and Dr. Anton Titov MD / Exclusive interview

- We started the conversation with disorders of abnormal bleeding, when blood does not have enough ability to form clots. But blood clots sometimes form where they should not form - a thrombosis. Blood clot causes and treatment is one of your clinical and research interests. Thrombosis is a large problem. When clots break from the leg veins, they travel to lungs and cause pulmonary embolism. It has a 30% death rate. When blood clots form in a coronary artery, this causes myocardial infarction. These are all very serious problems. Please talk about causes of thrombosis. How to diagnose blood clots properly? What are the best treatment methods for thrombosis? We divide thrombosis into venous thrombosis or arterial thrombosis. Hematologist deals primarily with venous thrombosis. The arterial thrombosis is the realm of cardiologists when it causes myocardial infarction, heart attack, Thrombosis in the brain causes strokes. This is in the realm of neurologists. There is an overlap with cardiology and neurology, but hematologist works with venous thrombosis. for example, clots in the legs [deep venous thrombosis]. Blood clots can break off from leg veins and travel up to the lungs. This causes pulmonary embolism. Cancer can also cause blood clots, a so-called "hypercoagulable state", when blood has increased propensity to form clots. Deep venous thrombosis could be the first sign of cancer. That is correct. Blood clots in veins can often be a first sign of cancer in the body. This brings us to "hypercoagulable state" [increased risk of blood clotting]. Who are the patients that get thrombosis? Cancer patients are certainly at risk of venous thrombosis, People who cannot move well and who are in a hospital, patients with bone fractures are all also at risk of thrombosis because they cannot be as active as they had been. Elderly and obese people are at risk of venous thrombosis for similar reasons. Pregnancy also leads to increased risk of vein thrombosis. Recently we discovered genetic predispositions to venous thrombosis. Factor V Leiden thrombophilia is a gene polymorphism that is common in people of Northern European ancestry. Factor V Leiden increases risk of deep venous thrombosis and pulmonary embolism. There is also the prothrombin gene mutationthat can predispose people to blood clots in legs and to pulmonary embolism. There are other mutations in clotting cascade that increase risk of venous thromboembolism, If Protein C or Protein S, or antithrombin III are missing, it also causes increased risk of abnormal clotting of blood. Most of the time we don't know what causes blood clots to form. So we call these unexplained blood clots "unprovoked clots" or idiopathic clots. In contrast, provoked blood clots happen after operation or a period of immobility. Cancer treatment can cause blood clots. Birth control pills increase risk of clots. Estrogen increases thrombosis risks. Estrogen is a female sex hormone contained in birth control pills. That's right. One of the most important risks of birth control pills is blood clots. So anybody with known hypercoagulable state should not get any kind of estrogen supplementation. But birth control pills are a very common medication. If a woman takes birth control pills and then develops a blood clot, then we can recognize that risk and stop that medication. Is smoking an additional risk factor for venous thrombosis for women on oral contraceptives? Yes, it is. We can think about risk for blood clot formation as a concept of threshold. A person can accumulate different risk factors for increased blood clotting: smoking, oral contraception, obesity. Eventually risk factors add up and blood clot is formed. When we see several risk factors for thrombosis, we try to minimize them. For example, a woman might have a known Protein C deficiency diagnosed because her mother had a blood clot and daughter had genetic tests done. I'd make sure that patient is never given oral contraceptive pills. Is there a test for Protein C deficiency? - Yes, there is. We typically don't test for these risks of thrombosis unless there is a family history of blood clots, or multiple clots already happened. Treatment of deep vein thrombosis and other hypercoagulable states is very similar. We prescribe blood thinners, there are many options, including a new recent class [NOACs]. Warfarinand heparin are classic anticoagulant medications.

Professor Dr. Kent Yucel MD, prominent MRI and CT expert and interventional radiologist with particular focus on heart disease diagnosis by MRI and CT Angiography, and treatments by minimally invasive interventional radiology methods, and Dr. Anton Titov MD / Exclusive interview

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- Hello! Today we are meeting with Dr. Kent Yucel, who is Radiologist-in-Chief, and Ettinger Dreyfus Chair at Tufts Medical Center and Professor of Radiology, Tufts University School of Medicine. Dr. Yucel previously held leadership positions in radiology and cardiovascular imaging at Brigham and Women's Hospital and Massachusetts General Hospital. Dr. Yucel is a graduate of Harvard College and Harvard Medical School. He completed his post-graduate training at Yale New Haven Hospital, Tufts Medical Center and Massachusetts General Hospital. Dr. Yucel's clinical specialties include angiography, peripheral vascular intervention, computed tomography and cardiovascular MRI imaging.

- Professor Yucel, thank you very much and welcome! - Thank you!

Exclusive interview / Professor Dr. Lawrence Cohn MD, eminent heart surgeon and medical educator, pioneer in minimally invasive heart valve surgery and Dr. Anton Titov MD

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- I understand that you use a particular mitral valve repair algorithm that works in more than 90% of all heart valve surgeries that you do. What are the techniques for mitral valve repair that you favor in your surgical practice? The most common problem in patients with mitral valve prolapse is located in a posterior leaflet of the mitral valve. Oftentimes the chords are ruptured. [Chords attach mitral valve leaflet to papillary muscles] Often the middle part of posterior leaflet becomes loose and billowy, and leaking. Mitral valve prolapse is a genetic disease and patients have a genetic predisposition to weakness in mitral valve tissue. We have done a classic operation, when we resect that little section of mitral valve and bring two edges of the mitral valve leaflet together. All patients had a ring to strengthen the mitral valve. Recently we started to use technique called foldoplasty. We fold over the area in posterior leaflet of mitral valve, which is causing leakage of blood. We place a ring inside heart valve to strengthen it. We suture the leaflet to underside of the annulus of mitral valve. This operation is much much faster than classical technique. And we have same patient results as with classical operation. Can cardiac surgeons read about this new mitral valve repair technique in published articles? Yes, this work was published.

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Professor Dr. Dale Adler MD, prominent cardiologist and medical heart disease treatment expert, and Dr. Anton Titov MD PhD MBA / Exclusive interview on medical therapy for coronary heart disease, high cholesterol and hypertension treatment, and sudden death prevention and treatment.

- How to lower cholesterol? Let's discuss treatment of high cholesterol. High cholesterol level is a major risk factor for coronary heart disease. Recently the clinical guidelines for use of statins have changed. Statins are major drugs to lower cholesterol. Revision of statin use guidelines generated controversy in medical community. Under the new guidelines a number of people who should use statins to lower cholesterol have increased. But many people do not make full use of non-pharmacologic methods for lower cholesterol: the lifestyle changes, better food, and dietary changes. How do you approach the management of risk factors for coronary heart disease in your practice? Since early 1980s we have learned that LDL cholesterol is the bad cholesterol Any lifestyle modifications and any medications that specifically lower the level of LDL cholesterol - almost always there is a benefit to the patient. It seems that the lower you make LDL cholesterol level - the lower the risk of coronary artery disease. Can LDL cholesterol be too low? If LDL cholesterol is too low - can this create a problem? This has been a controversial issue. Probably too low level of LDL cholesterol is not really in issue for most people. We are not so worried that LDL cholesterol is going to be too low. For patients who do not have very high risks for coronary heart disease, we would love to see them work on improving their lifestyle. No questions about that. Who has low risk profile for coronary heart disease? #1: Those people who do not have a family history of very premature coronary artery disease. #2: Those who do not have diabetes. #3: Those who never had any heart-related health event whatsoever. But lifestyle change is a tough proposition. Relatively few people can keep their weight just where it should be. Few people can exercise on a regular basis and have very good diet. Let's now look at people who have already had a heart-related health problem, who have diabetes, who have a strong family history of premature coronary artery disease. In my clinical practice I support healthy diet and lifestyle changes. This is all terrific. But diet and lifestyle lowers LDL cholesterol in these people by only about 5%. Medications, the statins, often lower cholesterol by 20% to 40%. Medications and lifestyle / dietary changes are synergistic. So it's wonderful to put them together. So I say to my patients: "Let's make it very low. Let's drive it down." The recent clinical guidelines on the use of statins to lower cholesterol are controversial in several areas. One controversy is about the dose of statins to treat patients. Also there is controversy about evidence Dr. Dale Adler, MD: I agree very much with the guidelines when they say: "If you're going to use the statin to lower cholesterol, use statin in a dose that was used in the clinical trial". For example, simvastatin is a very nice medication to lower cholesterol. In the clinical trials simvastatin was used at 40 milligrams But a lot of physicians prescribe simvastatin at 5 milligrams or 10 milligrams per day. I say: "If it's worth treating a patient with a statin medication, then start medication in a dose that was established and shown to make a big difference." If the patient has trouble tolerating statin at that dose, then you may have to decrease the dose of medication. That even occurred in some of the clinical trials.

Exclusive interview / Professor Dr. Lawrence Cohn MD, eminent heart surgeon and medical educator, pioneer in minimally invasive heart valve surgery and Dr. Anton Titov MD

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- Even as heart surgery becomes minimally invasive, it remains a major surgery. - Sure! How can patients prepare psychologically for the major surgery? What are the ways in which patients can relieve the anxiety that all patients have before the surgery? If the person isn't anxious, there's something wrong with the patient. That's normal behavior. First of all, the patient should ask the doctor every question on their mind. Or they should ask all questions the physician assistant, whoever sees the patient. And there are counselling services to help people prepare for surgery. There are also books been written about how to prepare yourself for surgery. Sometimes these are very, very good. Patient who had been drinking a lot of alcohol should reduce that. They should try to lose some weight. They should stop smoking. Smoking is the worst thing you can do. That's just common sense. I think the major question is to ask the doctor - do not hesitate, do not be afraid or shy - to ask the doctor every single question in your mind. Find out what the basic routine is going to be after the surgery. It all has to be asked. You cannot hold back. How can a surgeon apply the power of suggestion or any other psychological methods to decrease the patient's anxiety and improve surgical outcomes? Again, if the patient does not ask all the questions that they should ask, the surgeon has to say, "You never asked the following questions, what you really need to know." Most patients, for example, ask me, "How many days I have to stay in hospital?" But a lot of them don't ask, "What's the risk of this operation? What is the risk I might die or risk of having a stroke or heart attack?" The surgeon should have predictable numbers based on his or her own experience. And that's important to relate to the patient. It could really reassure them. A lot of times the stress of just getting those decisions made is more stress than the operation itself. So patients should have a good understanding. It is very important part of the preparation of patient for surgery. Surgeon should answer all the questions the patient needs to know. Even if the patient did not ask that question. Because same questions come up again and again. And the surgeon often knows which questions the patient should ask

- better than the patient does.

- Of course, yes.