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Streed CG, King D, Grasso C, Reisner SL, Mayer KH, Jasuja GK, Poteat T, Mukherjee M, Shapira-Daniels A, Cabral H, Tangpricha V, Paasche-Orlow MK, Benjamin EJ. Validation of an administrative algorithm for transgender and gender diverse persons against self-report data in electronic health records. J Am Med Inform Assoc 2023; 30:1047-1055. [PMID: 36921287 PMCID: PMC10198536 DOI: 10.1093/jamia/ocad039] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 02/19/2023] [Accepted: 02/25/2023] [Indexed: 03/17/2023] Open
Abstract
OBJECTIVE To adapt and validate an algorithm to ascertain transgender and gender diverse (TGD) patients within electronic health record (EHR) data. METHODS Using a previously unvalidated algorithm of identifying TGD persons within administrative claims data in a multistep, hierarchical process, we validated this algorithm in an EHR data set with self-reported gender identity. RESULTS Within an EHR data set of 52 746 adults with self-reported gender identity (gold standard) a previously unvalidated algorithm to identify TGD persons via TGD-related diagnosis and procedure codes, and gender-affirming hormone therapy prescription data had a sensitivity of 87.3% (95% confidence interval [CI] 86.4-88.2), specificity of 98.7% (95% CI 98.6-98.8), positive predictive value (PPV) of 88.7% (95% CI 87.9-89.4), and negative predictive value (NPV) of 98.5% (95% CI 98.4-98.6). The area under the curve (AUC) was 0.930 (95% CI 0.925-0.935). Steps to further categorize patients as presumably TGD men versus women based on prescription data performed well: sensitivity of 97.6%, specificity of 92.7%, PPV of 93.2%, and NPV of 97.4%. The AUC was 0.95 (95% CI 0.94-0.96). CONCLUSIONS In the absence of self-reported gender identity data, an algorithm to identify TGD patients in administrative data using TGD-related diagnosis and procedure codes, and gender-affirming hormone prescriptions performs well.
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Affiliation(s)
- Carl G Streed
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
- Center for Transgender Medicine and Surgery, Boston Medical Center, Boston, Massachusetts, USA
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Dana King
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Chris Grasso
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Sari L Reisner
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kenneth H Mayer
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Guneet K Jasuja
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Tonia Poteat
- Department of Social Medicine, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA
| | - Monica Mukherjee
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Howard Cabral
- Department of Biostatistics, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
| | | | - Emelia J Benjamin
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
- Boston University's and National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, Massachusetts, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
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Shapira-Daniels A, Kornej J, Spartano NL, Wang X, Zhang Y, Pathiravasan CH, Liu C, Trinquart L, Borrelli B, McManus DD, Murabito JM, Benjamin EJ, Lin H. Step Count, Self-reported Physical Activity, and Predicted 5-Year Risk of Atrial Fibrillation: Cross-sectional Analysis. J Med Internet Res 2023; 25:e43123. [PMID: 36877540 PMCID: PMC10028513 DOI: 10.2196/43123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/24/2022] [Accepted: 11/30/2022] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Physical inactivity is a known risk factor for atrial fibrillation (AF). Wearable devices, such as smartwatches, present an opportunity to investigate the relation between daily step count and AF risk. OBJECTIVE The objective of this study was to investigate the association between daily step count and the predicted 5-year risk of AF. METHODS Participants from the electronic Framingham Heart Study used an Apple smartwatch. Individuals with diagnosed AF were excluded. Daily step count, watch wear time (hours and days), and self-reported physical activity data were collected. Individuals' 5-year risk of AF was estimated, using the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE)-AF score. The relation between daily step count and predicted 5-year AF risk was examined via linear regression, adjusting for age, sex, and wear time. Secondary analyses examined effect modification by sex and obesity (BMI≥30 kg/m2), as well as the relation between self-reported physical activity and predicted 5-year AF risk. RESULTS We examined 923 electronic Framingham Heart Study participants (age: mean 53, SD 9 years; female: n=563, 61%) who had a median daily step count of 7227 (IQR 5699-8970). Most participants (n=823, 89.2%) had a <2.5% CHARGE-AF risk. Every 1000 steps were associated with a 0.08% lower CHARGE-AF risk (P<.001). A stronger association was observed in men and individuals with obesity. In contrast, self-reported physical activity was not associated with CHARGE-AF risk. CONCLUSIONS Higher daily step counts were associated with a lower predicted 5-year risk of AF, and this relation was stronger in men and participants with obesity. The utility of a wearable daily step counter for AF risk reduction merits further investigation.
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Affiliation(s)
- Ayelet Shapira-Daniels
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Jelena Kornej
- Boston University's Framingham Heart Study, National Heart, Lung, and Blood Institute, Framingham, MA, United States
| | - Nicole L Spartano
- Section of Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Xuzhi Wang
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | - Yuankai Zhang
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | | | - Chunyu Liu
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | - Ludovic Trinquart
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | - Belinda Borrelli
- Center for Behavioral Science Research, Henry M Goldman School of Dental Medicine, Boston University, Boston, MA, United States
| | - David D McManus
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
- Department of Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Joanne M Murabito
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
- Boston University's Framingham Heart Study, National Heart, Lung, and Blood Institute, Framingham, MA, United States
| | - Emelia J Benjamin
- Boston University's Framingham Heart Study, National Heart, Lung, and Blood Institute, Framingham, MA, United States
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States
- Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Honghuang Lin
- Boston University's Framingham Heart Study, National Heart, Lung, and Blood Institute, Framingham, MA, United States
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
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Ben-David EI, Blumenfeld O, Shapira-Daniels A, Shapira OM. Validation of the society of thoracic surgeons predicted risk of mortality score for long-term survival after cardiac surgery in Israel. J Cardiothorac Surg 2022; 17:68. [PMID: 35382843 PMCID: PMC8985317 DOI: 10.1186/s13019-022-01809-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 03/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background Long-term survival is an important metric in assessing procedural value. We previously confirmed that the Society of Thoracic Surgeons predicted risk of mortality score (PROM) accurately predicts 30-day mortality in Israeli patients. The present study investigated the ability of the PROM to reliably predict long-term survival. Methods Data on 1279 patients undergoing cardiac surgery were prospectively entered into our database and used to calculate PROM. Long-term mortality was obtained from the Israeli Social Security Database. Patients were stratified into five cohorts according to PROM (A: 0–0.99%, B: 1.0–1.99%, C: 2.0–2.99%, D: 3.0–4.99% and E: ≥ 5.0%). Kaplan–Meier estimates of survival were calculated for each cohort and compared by Wilcoxon signed-rank test. We used C-statistics to assess model discrimination. Cox regression analysis was performed to identify predictors of long-term survival. Results Follow-up was achieved for 1256 (98%) patients over a mean period of 62 ± 28 months (median 64, range 0–107). Mean survival of the entire cohort was 95 ± 1 (95% CI 93–96) months. Higher PROM was associated with reduced survival: A—104 ± 1 (103–105) months, B—96 ± 2 (93–99) months, C—93 ± 3 (88–98) months, D—89 ± 3 (84–94) months, E—74 ± 3 (68–80) months (p < 0.0001). The Area Under the Curve was 0.76 ± 0.02 indicating excellent model discrimination. Independent predictors of long-term mortality included advanced age, lower ejection fraction, reoperation, diabetes mellitus, dialysis and PROM. Conclusions The PROM was a reliable predictor of long-term survival in Israeli patients undergoing cardiac surgery. The PROM might be a useful metric for assessing procedural value and surgical decision-making.
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Affiliation(s)
- Eyal I Ben-David
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel. .,St George's Hospital Medical School, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK.
| | - Orit Blumenfeld
- The Israel Center for Disease Control, Division of Medical Technologies and Research, Ministry of Health, Ramat Gan, Israel
| | - Ayelet Shapira-Daniels
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Oz M Shapira
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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Younis A, Yavin HD, Higuchi K, Zilberman I, Sroubek J, Tchou P, Bubar ZP, Barkagan M, Leshem E, Shapira-Daniels A, Kanj M, Cantillon DJ, Hussein AA, Tarakji KG, Saliba WI, Koruth JS, Anter E. Increasing Lesion Dimensions of Bipolar Ablation by Modulating the Surface Area of the Return Electrode. JACC Clin Electrophysiol 2022; 8:498-510. [PMID: 35450605 DOI: 10.1016/j.jacep.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/21/2021] [Accepted: 01/01/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study sought to examine the effect of the return electrode's surface area on bipolar RFA lesion size. BACKGROUND Bipolar radiofrequency ablation (RFA) is typically performed between 2 3.5-mm tip catheters serving as active and return electrodes. We hypothesized that increasing the surface area of the return electrode would increase lesion dimensions by reducing the circuit impedance, thus increasing the current into a larger tissue volume enclosed between the electrodes. METHODS In step 1, ex vivo bipolar RFA was performed between 3.5-mm and custom-made return electrodes with increasing surface areas (20, 80, 180 mm2). In step 2, ex vivo bipolar RFA was performed between 3.5-mm and 3.5-mm or 8-mm electrode catheters positioned perpendicular or parallel to the tissue. In step 3, in vivo bipolar RFA was performed between 3.5-mm and either 3.5-mm or 8-mm parallel electrode at the: 1) left ventricular summit; 2) interventricular septum; and 3) healed anterior infarction. RESULTS In step 1, increasing the surface area of the return electrode resulted in lower circuit impedance (R = -0.65; P < 0.001), higher current (R = +0.80; P < 0.001), and larger lesion volume (R = +0.88; P < 0.001). In step 2, an 8-mm return electrode parallel to tissue produced larger and deeper lesions compared with a 3.5-mm return electrode (P = 0.014 and P = 0.02). Similarly, in step 3, compared with a 3.5-mm, bipolar RFA with an 8-mm return electrode produced larger (volume: 1,525 ± 871 mm3 vs 306 ± 310 mm3, respectively; P < 0.001) and more transmural lesions (88% vs 0%; P < 0.001). CONCLUSIONS Bipolar RFA using an 8-mm return electrode positioned parallel to the tissue produces larger lesions in comparison with a 3.5-mm return electrode.
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Affiliation(s)
- Arwa Younis
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA; Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Lerner Research Institute, Cleveland, Ohio, USA
| | - Hagai D Yavin
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA; Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Lerner Research Institute, Cleveland, Ohio, USA
| | - Koji Higuchi
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Israel Zilberman
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA; Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Lerner Research Institute, Cleveland, Ohio, USA
| | - Jakub Sroubek
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Patrick Tchou
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Zachary P Bubar
- Biosense Webster of Johnson and Johnson, Irvine, California, USA
| | - Michael Barkagan
- Cardiac Electrophysiology Section, Assaf Harofeh Hospital, Be'er Ya'akov, Israel
| | - Eran Leshem
- Davidai Arrhythmia Center, Heart Institute, Sheba Medical Center, Ramat Gan, Israel
| | | | - Mohamad Kanj
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniel J Cantillon
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ayman A Hussein
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Khaldoun G Tarakji
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Walid I Saliba
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jacob S Koruth
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Elad Anter
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA; Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Lerner Research Institute, Cleveland, Ohio, USA.
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Shapira-Daniels A, Ingbir M, Shapira OM. In the Heart of the Ancient Silk Road: Fever of Unknown Origin, Right Ventricular Mass, and Systemic Vasculitis. Circulation 2021; 144:172-176. [PMID: 34251890 DOI: 10.1161/circulationaha.121.053389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ayelet Shapira-Daniels
- Department of Medicine, Boston Medical Center, MA (A.S.-D.).,Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel (A.S.-D., O.M.S.)
| | - Merav Ingbir
- Internal Medicine J, Tel Aviv Sourasky Medical Center, Israel (M.I.)
| | - Oz M Shapira
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel (A.S.-D., O.M.S.)
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Barkagan M, Sroubek J, Shapira-Daniels A, Yavin H, Jang J, Nezafat R, Anter E. A novel multielectrode catheter for high-density ventricular mapping: electrogram characterization and utility for scar mapping. Europace 2021; 22:440-449. [PMID: 31985784 DOI: 10.1093/europace/euz364] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/02/2019] [Accepted: 12/19/2019] [Indexed: 01/11/2023] Open
Abstract
AIMS Multielectrode mapping catheters can be advantageous for identifying surviving myocardial bundles in scar. This study aimed to evaluate the utility of a new multielectrode catheter with increased number of small and closely spaced electrodes for mapping ventricles with healed infarction. METHODS AND RESULTS In 12 swine (four healthy and eight with infarction), the left ventricle was mapped with investigational (OctarayTM) and standard (PentarayTM) multielectrode mapping catheters. The investigational catheter has more electrodes (48 vs. 20), each with a smaller surface area (0.9 vs. 2.0 mm2) and spacing is fixed at 2 mm (vs. 2-6-2 mm). Electrogram (EGM) characteristics, mapping efficiency and scar description were compared between the catheters and late gadolinium enhancement (LGE). Electrogram acquisition rate was faster with the investigational catheter (814 ± 126 vs. 148 ± 58 EGM/min, P = 0.02) resulting in higher density maps (38 ± 10.3 vs. 10.1 ± 10.4 EGM/cm2, P = 0.02). Bipolar voltage amplitude was similar between the catheters in normal and infarcted myocardium (P = 0.265 and P = 0.44) and the infarct surface area was similar between the catheters (P = 0.12) and corresponded to subendocardial LGE. The investigational catheter identified a higher proportion of near-field local abnormal ventricular activities within the low-voltage area (53 ± 16% vs. 34 ± 16%, P = 0.03) that were considered far-field EGMs by the standard catheter. The investigational catheter was also advantageous for mapping haemodymically non-tolerated ventricular tachycardias due to its higher acquisition rate (P < 0.001). CONCLUSION A novel multielectrode mapping catheter with higher number of small, and closely spaced electrodes increases the mapping speed, EGM density and the ability to recognize low amplitude near-field EGMs in ventricles with healed infarction.
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Affiliation(s)
- Michael Barkagan
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard-Thorndike Electrophysiology Institute, 185 Pilgrim Road, Baker 4, Boston, MA 02215, USA
| | - Jakub Sroubek
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard-Thorndike Electrophysiology Institute, 185 Pilgrim Road, Baker 4, Boston, MA 02215, USA
| | - Ayelet Shapira-Daniels
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard-Thorndike Electrophysiology Institute, 185 Pilgrim Road, Baker 4, Boston, MA 02215, USA
| | - Hagai Yavin
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard-Thorndike Electrophysiology Institute, 185 Pilgrim Road, Baker 4, Boston, MA 02215, USA
| | - Jihye Jang
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Reza Nezafat
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Department of Medicine, Cancer Research Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Elad Anter
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard-Thorndike Electrophysiology Institute, 185 Pilgrim Road, Baker 4, Boston, MA 02215, USA
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Yavin H, Brem E, Zilberman I, Shapira-Daniels A, Datta K, Govari A, Altmann A, Anic A, Wazni O, Anter E. Circular Multielectrode Pulsed Field Ablation Catheter Lasso Pulsed Field Ablation: Lesion Characteristics, Durability, and Effect on Neighboring Structures. Circ Arrhythm Electrophysiol 2021; 14:e009229. [PMID: 33417475 DOI: 10.1161/circep.120.009229] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pulsed field ablation (PFA) is a nonthermal energy with potential safety advantages over radiofrequency ablation. This study investigated a novel PFA system-a circular multielectrode catheter (PFA lasso) and a multichannel generator designed to work with Carto 3 mapping system. METHODS A 7.5F bidirectional circular catheter with 10 electrodes and variable expansion was designed for PFA (biphasic, 1800 Volts). This study included a total of 16 swine used to investigate the following 3 experimental aims: Aim 1 examined the feasibility to create a right atrial ablation line of block from the superior vena cava to the inferior vena cava. Aim 2 examined the effect of PFA on lesion maturation including durability after a 30-day survival period. Aim 3 examined the effect of high-intensity PFA (10 applications) on esophageal and phrenic nerve tissue in comparison to normal intensity radiofrequency ablation (1-2 applications). Histopathologic analysis of all cardiac, esophageal, and phrenic nerve tissue was performed. RESULTS Acute line of block was achieved in 12/12 swine (100%) and required a total PFA time of 14 seconds (interquartile range [IQR], 9-24.5) per line. Ablation line durability after 28±3 days was maintained in 11/12 (91.7%) swine. PFA resulted in transmural lesions in 179/183 (97.8%) sections and a median lesion width of 14.2 mm. High-intensity PFA (9 [IQR, 8-14] application) had no effect on the esophagus while standard intensity radiofrequency ablation (1.5 [IQR, 1-2] applications) resulted in deep esophageal tissue injury involving the muscularis propria and adventitia layers. High-intensity PFA (16 [IQR, 10-28] applications) has no effect on phrenic nerve function and structure while standard dose radiofrequency ablation (1.5 [IQR, 1-2] applications) resulted in acute phrenic nerve paralysis. CONCLUSIONS In this preclinical model, a multielectrode circular catheter and multichannel generator produced durable atrial lesions with lower vulnerability to esophageal or phrenic nerve damage.
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Affiliation(s)
- Hagai Yavin
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, OH (H.Y., O.W., E.A.)
| | - Erez Brem
- Research and Development Division, Biosense Webster, Johnson and Johnson, Irwindale, CA (E.B., K.D.)
| | - Israel Zilberman
- Advanced Research and Development Biosense Webster, Johnson and Johnson, Yokneam, Israel (I.Z., A.G., A.A.)
| | - Ayelet Shapira-Daniels
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (A.S.-D.)
| | - Keshava Datta
- Research and Development Division, Biosense Webster, Johnson and Johnson, Irwindale, CA (E.B., K.D.)
| | - Assaf Govari
- Advanced Research and Development Biosense Webster, Johnson and Johnson, Yokneam, Israel (I.Z., A.G., A.A.)
| | - Andres Altmann
- Advanced Research and Development Biosense Webster, Johnson and Johnson, Yokneam, Israel (I.Z., A.G., A.A.).,University Clinical Hospital Split, Croatia (A.A.)
| | | | - Oussama Wazni
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, OH (H.Y., O.W., E.A.)
| | - Elad Anter
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, OH (H.Y., O.W., E.A.)
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Kucukseymen S, Yavin H, Barkagan M, Jang J, Shapira-Daniels A, Rodriguez J, Shim D, Pashakhanloo F, Pierce P, Botzer L, Manning WJ, Anter E, Nezafat R. Discordance in Scar Detection Between Electroanatomical Mapping and Cardiac MRI in an Infarct Swine Model. JACC Clin Electrophysiol 2020; 6:1452-1464. [DOI: 10.1016/j.jacep.2020.08.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/29/2020] [Accepted: 08/11/2020] [Indexed: 12/18/2022]
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Shapira-Daniels A, Katz D, Aviel G, Meirovitz A, Gilon D, Shapira OM. Multimodality Treatment for Advanced Cervical Cancer With Isolated Metastasis to Interventricular Septum of the Heart. JACC CardioOncol 2020; 2:519-522. [PMID: 34396262 PMCID: PMC8352254 DOI: 10.1016/j.jaccao.2020.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/08/2020] [Accepted: 06/10/2020] [Indexed: 11/18/2022] Open
Affiliation(s)
- Ayelet Shapira-Daniels
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Daniela Katz
- Department of Oncology, Shamir Medical Center, Beer Yaacov, Israel
| | - Gal Aviel
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Amichay Meirovitz
- Department of Oncology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Dan Gilon
- Department of Cardiology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Department of Cardiology, Shamir Medical Center, Beer Yaacov, Israel
| | - Oz M. Shapira
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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Shapira-Daniels A, Mohanty S, Contreras-Valdes FM, Tieu H, Thomas RJ, Natale A, Anter E. Prevalence of Undiagnosed Sleep Apnea in Patients With Atrial Fibrillation and its Impact on Therapy. JACC Clin Electrophysiol 2020; 6:1499-1506. [PMID: 33213809 DOI: 10.1016/j.jacep.2020.05.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/25/2020] [Accepted: 05/25/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES This study sought to evaluate the proportion of patients with atrial fibrillation (AF) who also have undiagnosed sleep apnea and examine the impact of its diagnosis on adherence to sleep apnea therapies. BACKGROUND Sleep apnea is a modifiable risk factor for AF. However, the proportion of patients with AF who also have undiagnosed sleep apnea and the impact of its diagnosis on therapy have not been well studied. METHODS This prospective study included 188 consecutive patients with AF without a prior diagnosis of sleep apnea who were scheduled to undergo AF ablation. Participants underwent home sleep apnea testing, completed a sleep apnea screening questionnaire (STOP-BANG [Snoring; Tiredness, Fatigue, or Sleepiness During the Daytime; Observation of Apnea and/or Choking During Sleep; Hypertension; Body Mass Index >35 kg/m2; Age >50 Years; Neck Circumference >40 cm; and Male Sex]) and were followed for ≥2 years to evaluate the impact of diagnosis on therapy. RESULTS Home sleep apnea testing was positive in 155 of 188 patients (82.4%); among those 155, 127 (82%) had a predominant obstructive component and 28 (18%) had mixed sleep apnea with a 15.2 ± 7.4% central component. Sleep apnea severity was mild in 43.8%, moderate in 32.9%, and severe in 23.2%. The sensitivity and specificity of a STOP-BANG questionnaire were 81.2% and 42.4%, respectively. In a multivariate analysis, STOP-BANG was not predictive for sleep apnea (odds ratio: 0.54; 95% confidence interval: 0.17 to 1.76; p = 0.31). Therapy with continuous positive airway pressure ventilators was initiated in 73 of 85 patients (85.9%) with moderate or severe sleep apnea, and 68 of the 73 patients (93.1%) remained complaint after a mean follow-up period of 21 ± 6.2 months. CONCLUSIONS Sleep apnea is exceedingly prevalent in patients with AF who are referred for ablation, with a large proportion being undiagnosed due the limited predictive value of sleep apnea symptoms in this AF population. Screening for sleep apnea resulted in high rate of long-term continuous positive airway pressure adherence.
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Affiliation(s)
- Ayelet Shapira-Daniels
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA
| | - Fernando M Contreras-Valdes
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Hieu Tieu
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert J Thomas
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA
| | - Elad Anter
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA.
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11
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Yavin HD, Leshem E, Shapira-Daniels A, Sroubek J, Barkagan M, Haffajee CI, Cooper JM, Anter E. Impact of High-Power Short-Duration Radiofrequency Ablation on Long-Term Lesion Durability for Atrial Fibrillation Ablation. JACC Clin Electrophysiol 2020; 6:973-985. [DOI: 10.1016/j.jacep.2020.04.023] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 01/20/2023]
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12
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Yavin H, Shapira-Daniels A, Barkagan M, Sroubek J, Shim D, Melidone R, Anter E. Pulsed Field Ablation Using a Lattice Electrode for Focal Energy Delivery: Biophysical Characterization, Lesion Durability, and Safety Evaluation. Circ Arrhythm Electrophysiol 2020; 13:e008580. [PMID: 32372696 PMCID: PMC7338046 DOI: 10.1161/circep.120.008580] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Pulsed field ablation (PFA) is a nonthermal energy that may provide safety advantages over radiofrequency ablation (RFA). One-shot PFA catheters have been developed for pulmonary vein isolation, but they do not permit flexible lesion sets. This study investigated a novel lattice-tip catheter designed for focal RFA or PFA ablation. METHODS The effects of PFA (biphasic, 24 amperes) were investigated in 25 swine using a lattice-tip catheter and system (Affera Inc). Step 1 (n=14) examined the feasibility to create atrial line of block and described its acute effects on the phrenic nerve and esophagus. Step 2 (n=7) examined the subacute effects of PFA on block durability, phrenic nerve, and esophagus ≥2 weeks. Step 3 compared the effects of PFA and RFA on the esophagus using a mechanical deviation model approximating the esophagus to the right atrium (n=4) and by direct ablation within its lumen (n=4). The effects of endocardial PFA and RFA on the phrenic nerve were also compared (n=10). Histological analysis was performed. RESULTS PFA produced acute block in 100% of lines, achieved with 2.1 (1.3-3.2) applications/cm line. Histological analysis following (35 [18-37]) days showed 100% transmurality (thickness range 0.4-3.4 mm) with a lesion width of 19.4 (10.9-27.4 mm). PFA selectively affected cardiomyocytes but spared blood vessels and nervous tissue. PFA applied from the posterior atria (23 [21-25] applications) to the approximated esophagus (6 [4.5-14] mm) produced transmural lesions without esophageal injury. PFA (16.5 [15-18] applications) applied inside the esophageal lumen produced mild edema compared with RFA (13 [12-14] applications) which produced epithelial ulcerations. PFA resulted in no or transient stunning of the phrenic nerve (<5 minutes) without histological changes while RFA produced paralysis. CONCLUSIONS PFA using a lattice-tip ablation catheter for focal ablation produced durable atrial lesions and showed lower vulnerability to esophageal or phrenic nerve damage compared with RFA.
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Affiliation(s)
- Hagai Yavin
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Ayelet Shapira-Daniels
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Michael Barkagan
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Jakub Sroubek
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - David Shim
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | | | - Elad Anter
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
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13
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Shapira-Daniels A, Barkagan M, Rottmann M, Sroubek J, Tugal D, Carlozzi MA, McConville JW, Buxton AE, Anter E. Modulating the Baseline Impedance: An Adjunctive Technique for Maximizing Radiofrequency Lesion Dimensions in Deep and Intramural Ventricular Substrate: An Adjunctive Technique for Maximizing Radiofrequency Lesion Dimensions in Deep and Intramural Ventricular Substrate. Circ Arrhythm Electrophysiol 2020; 12:e007336. [PMID: 31113232 DOI: 10.1161/circep.119.007336] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Radiofrequency ablation of intramural ventricular substrate is often limited by insufficient tissue penetration despite high energy settings. As lesion dimensions have a direct and negative relationship to impedance, reducing the baseline impedance may increase the ablation effect on deep ventricular tissue. Methods This study included 16 patients with ventricular tachycardia or frequent ventricular premature complexes refractory to ablation with irrigated catheters. After a failed response to radiofrequency ablation, impedance was modulated by adding or repositioning return patches in an attempt to decrease the circuit impedance. Ablation was repeated at a similar location and power settings, and the effect on arrhythmia suppression and adverse effects were evaluated. Results Six patients with idiopathic ventricular premature complexes originating from the left ventricular summit (n=4) or papillary muscles (n=2), 6 patients with noninfarct related ventricular tachycardia and 4 patients with infarct-related ventricular tachycardia had unsuccessful response to radiofrequency ablation at critical sites (number of applications: 10.4±3.1, power: 42.3±2.9 W, duration: 55.3±25.5 seconds, impedance reduction: 14.6±3.5 Ω, low-ionic solution was used in 81.25%). Modulating the return patches resulted in reduced baseline impedance (111.7±8.2 versus 134.7±6.6 Ω, P<0.0001), increased current output (0.6±0.02 versus 0.56±0.02 Amp; P<0.0001) and greater impedance drop (16.8±3.0 Ω, P<0.001). Repeat ablation at similar locations had a successful effect in 12 out of 16 (75.0%) patients. During a follow-up duration of 13±5 months, 10 out of 12 (83.3%) patients remained free of arrhythmia recurrence. The frequency of steam pops was similar between the higher and lower baseline impedance settings (7.1 versus 8.2%; P=0.74). Conclusions In patients with deep ventricular substrate, reducing the baseline impedance is a simple, safe, and effective technique for increasing the effect of radiofrequency ablation. However, its combination with low-ionic solutions may increase the risk for steam pops and neurological events.
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Affiliation(s)
- Ayelet Shapira-Daniels
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Michael Barkagan
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Markus Rottmann
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jakub Sroubek
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Derin Tugal
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Michael A Carlozzi
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - James W McConville
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Alfred E Buxton
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Elad Anter
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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14
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Barkagan M, Leshem E, Rottmann M, Sroubek J, Shapira-Daniels A, Anter E. Expandable Lattice Electrode Ablation Catheter: A Novel Radiofrequency Platform Allowing High Current at Low Density for Rapid, Titratable, and Durable Lesions. Circ Arrhythm Electrophysiol 2020; 12:e007090. [PMID: 30943762 DOI: 10.1161/circep.118.007090] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND High-current short-duration radiofrequency energy delivery has potential advantages for cardiac ablation. However, this strategy is limited by high current density and narrow safety-to-efficacy window. The objective of this study was to examine a novel strategy for radiofrequency energy delivery using a new electrode design capable of delivering high power at a low current density to increase the therapeutic range of radiofrequency ablation. METHODS The Sphere9 is an expandable spheroid-shaped lattice electrode design with an effective surface area 10-fold larger than standard irrigated electrodes (lattice catheter). It incorporates 9 surface temperature sensors with ablation performed in a temperature-controlled mode. Phase I: in 6 thigh muscle preparations, 2 energy settings for atrial ablation were compared between the lattice and irrigated-tip catheters (low-energy: Tmax75°C/5 s versus 25 W/20 s; high-energy: Tmax75°C/7 s versus 30 W/20 s). Phase II: in 8 swine, right atrial lines were created in the posterior and lateral walls using low- and high-energy settings, respectively. Phase III: the safety, efficacy, and durability at 30 days were evaluated by electroanatomical mapping and histopathologic analysis. RESULTS In the thigh model, the lattice catheter resulted in wider lesions at both low- and high-energy settings (18.7±3.3 versus 12.2±1.7 mm, P<0.0001; 19.4±2.4 versus 12.3±1.7 mm, P<0.0001). Atrial lines created with the lattice were wider (posterior: 14.7±3.4 versus 9.2±4.0 mm, P<0.0001; lateral: 15.8±4.2 versus 5.7±4.2 mm, P<0.0001) and required 85% shorter ablation time (12.4 versus 79.8 s/cm-line). While current squared (I2) was higher with Sphere9 (7.0±0.04 versus 0.2±0.002 A2; P<0.0001), the current density was lower (9.6±0.9 versus 16.9±0.09 mA/mm2; P<0.0001). At 30 days, 100% of ablation lines created with the lattice catheter remained contiguous compared with only 14.3% lines created with a standard irrigated catheter. This was achieved without steam pops or collateral tissue damage. CONCLUSIONS In this preclinical model, a novel, high-current low-density radiofrequency ablation strategy created contiguous and durable ablation lines in significantly less ablation time and a comparable safety profile.
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Affiliation(s)
- Michael Barkagan
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Eran Leshem
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Markus Rottmann
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jakub Sroubek
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ayelet Shapira-Daniels
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Elad Anter
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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15
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Shapira-Daniels A, Barkagan M, Yavin H, Sroubek J, Reddy VY, Neuzil P, Anter E. Novel Irrigated Temperature-Controlled Lattice Ablation Catheter for Ventricular Ablation: A Preclinical Multimodality Biophysical Characterization. Circ Arrhythm Electrophysiol 2019; 12:e007661. [PMID: 31707809 DOI: 10.1161/circep.119.007661] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ventricular tachycardia ablation is often limited by insufficient lesion creation. A novel radiofrequency catheter with an expandable lattice electrode has a larger surface area capable of delivering higher currents at a lower density to potentially increase lesion dimensions without overheating. METHODS This 8F bidirectional irrigated catheter (Sphere-9, Affera Inc) has a 9 mm spherical lattice tip ("lattice") with an effective surface area 10-fold larger than standard linear catheters. Nine surface thermocouples provide temperature feedback to a proprietary high-current generator operating in a temperature-controlled mode. Ex vivo phase: in 11 bovine hearts, unipolar ablation at 30, 60, and 120 seconds was compared between the lattice (Tmax60°C) and a standard linear irrigated-tip catheter (40 W) at contact force of 10 g. In 5 porcine hearts, bipolar ablation was compared between the catheters (Tmax60°C versus 40 W; 60 seconds). In vivo phase: in 9 swine, ventricular ablation at Tmax60°C versus 40 W was performed for 60 seconds. In addition, direct tissue temperature at 3- and 7-mm tissue depth was measured in a thigh muscle preparation. RESULTS Ex vivo: lattice produced deeper lesions at 30, 60, and 120 seconds application duration (6.7±1.3 versus 4.8±1.2 mm; 8.3±1.4 versus 5.4±0.8 mm; 10.0±1.6 versus 6.1±1.6 mm, respectively, P≤0.001 for all). Bipolar lesions were deeper (15.8±4.1 versus 10.5±1.4 mm, P<0.001) and more likely to be transmural (80% versus 0%, P=0.002). In vivo: lattice produced deeper lesions (10.5±1.4 versus 6.5±0.8 mm, P≤0.001). Tissue temperature at 7 mm was higher with the lattice (+15.1±2.4°C; P<0.001). The steam-pop occurrence was lower with the lattice (total: 4% versus 18%, P=0.02; in vivo 0% versus 14.2%, P=0.13). CONCLUSIONS This novel radiofrequency system produces larger ventricular lesions compared with standard irrigated catheters and at a lower risk of tissue overheating. This may improve the efficacy of ventricular tachycardia ablation procedures while reducing the number of applications and procedural duration.
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Affiliation(s)
- Ayelet Shapira-Daniels
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (A.S.-D., M.B., H.Y., J.S., E.A.)
| | - Michael Barkagan
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (A.S.-D., M.B., H.Y., J.S., E.A.)
| | - Hagai Yavin
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (A.S.-D., M.B., H.Y., J.S., E.A.)
| | - Jakub Sroubek
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (A.S.-D., M.B., H.Y., J.S., E.A.)
| | - Vivek Y Reddy
- Helmsley Center for Electrophysiology, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (V.Y.R.).,Department of Cardiology, Hamolka Hospital, Prague, Czech Republic (V.Y.R., P.N.)
| | - Petr Neuzil
- Department of Cardiology, Hamolka Hospital, Prague, Czech Republic (V.Y.R., P.N.)
| | - Elad Anter
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (A.S.-D., M.B., H.Y., J.S., E.A.)
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16
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Barkagan M, Shapira-Daniels A, Leshem E, Shen C, Anter E. Pseudoblock of the Posterior Mitral Line With Epicardial Bridging Connections Is a Frequent Cause of Complex Perimitral Tachycardias. Circ Arrhythm Electrophysiol 2019; 12:e006933. [PMID: 30606034 DOI: 10.1161/circep.118.006933] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The mitral isthmus is the critical element of perimitral reentrant tachycardias. Prolongation in transisthmus conduction time and differential pacing techniques are commonly used to determine block. However, these may not distinguish block from slow conduction or conduction via epicardial bridging connections. The aim of this study was to examine these standard criteria for mitral line block with endocardial and epicardial activation mapping. METHODS In 56 patients, posterior mitral line was performed using radiofrequency ablation. Conduction block was defined as transisthmus time (≥100 ms) and reversal of coronary sinus activation during pacing from the left atrial appendage. These results were compared with high-resolution activation mapping (Rhythmia) of the endocardium and epicardium via the coronary sinus. RESULTS Mitral block determined by pacing was achieved in 51 out of 56 (91%) patients. In 11 out of 51 (21.6%), activation mapping demonstrated residual endocardial (3/11; 27.2%) or epicardial (8/11; 72.7%) connections. Epicardial bridging connections were distant from the line (2.4±1.6 cm), inserting laterally at the proximal-middle coronary sinus and septally at the left atrial ridge. Patients with residual conduction were prone to complex circuits involving the epicardium (7/11; 63.6%). Mitral line block was achieved in 75% by targeting these insertion site(s). The transisthmus conduction time had limited predictive value for distinguishing block from pseudoblock. CONCLUSIONS Standard criteria for posterior mitral line block may not distinguish block from pseudoblock. In particular, epicardial bridging connections can result in prolonged transisthmus conduction time and reversal in coronary sinus activation to falsely suggest block. These connections are a frequent cause for complex circuits, and their insertion site(s) can be targeted for ablation.
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Affiliation(s)
- Michael Barkagan
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.B., A.S.-D., E.L., C.S., E.A.)
| | - Ayelet Shapira-Daniels
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.B., A.S.-D., E.L., C.S., E.A.)
| | - Eran Leshem
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.B., A.S.-D., E.L., C.S., E.A.)
| | - Changyu Shen
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.B., A.S.-D., E.L., C.S., E.A.).,Division of Cardiovascular Medicine, Richard A. and Susan F. Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA (C.S.)
| | - Elad Anter
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.B., A.S.-D., E.L., C.S., E.A.)
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17
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Leshem E, Zilberman I, Barkagan M, Shapira-Daniels A, Sroubek J, Govari A, Buxton AE, Anter E. Temperature-Controlled Radiofrequency Ablation Using Irrigated Catheters: Maximizing Ventricular Lesion Dimensions While Reducing Steam-Pop Formation. JACC Clin Electrophysiol 2019; 6:83-93. [PMID: 31971910 DOI: 10.1016/j.jacep.2019.08.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/19/2019] [Accepted: 08/20/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The goal of this study was to examine the safety and efficacy of radiofrequency ablation (RFA) with irrigated catheters operated in a temperature-controlled mode for ventricular ablation. BACKGROUND Techniques to increase RFA dimensions are associated with higher risk for steam-pops. A novel irrigated catheter with circumferential thermocouples embedded in its ablation surface provides real-time surface temperature data. This study hypothesized that RFA operated in a temperature-controlled mode may allow maximizing lesion dimensions while reducing the occurrence of steam-pops. METHODS RFA with an irrigated catheter incorporating surface thermocouples was examined in 6 swine thigh muscle preparations and 15 beating ventricles at higher (50 W/60 s, Tmax50oC) and lower (50 W/60 s, Tmax45oC) temperature limits. Biophysical properties, lesion dimensions, and steam-pop occurrence were compared versus RFA with a standard catheter operated in power-control mode at higher (50 W/60 s) and lower (40W/60 s) power, and additionally at high power with half-normal saline (50 W/60 s). RESULTS In the thigh muscle preparation, lesion depth and width were similar between all groups (p = 0.90 and p = 0.17, respectively). Steam-pops were most frequent with power-controlled ablation at 50 W/60 s (82%) and least frequent with temperature-controlled ablation at 50 W/60 s, Tmax45oC (0%; p < 0.001). In the beating ventricle, lesion depth was comparable between all RFA settings (p = 0.09). Steam-pops were most frequent using power-controlled ablation at 50 W/60 s (37%) and least frequent with temperature-controlled ablation at 50 W/60 s, Tmax45oC (7%; p < 0.001). Half-normal saline had no incremental effect on lesion dimensions at 50 W in either the thigh muscle or the beating heart. CONCLUSIONS RFA using a novel irrigated catheter with surface thermocouples operated in a temperature-controlled mode can maximize lesion dimensions while reducing the risk for steam-pops.
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Affiliation(s)
- Eran Leshem
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Israel Zilberman
- Biosense Webster, Advanced Research and Development, Haifa, Israel
| | - Michael Barkagan
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ayelet Shapira-Daniels
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jakub Sroubek
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Assaf Govari
- Biosense Webster, Advanced Research and Development, Haifa, Israel
| | - Alfred E Buxton
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Elad Anter
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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18
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Rottmann M, Kleber AG, Barkagan M, Sroubek J, Leshem E, Shapira-Daniels A, Buxton AE, Anter E. Activation During Sinus Rhythm in Ventricles With Healed Infarction: Differentiation Between Arrhythmogenic and Nonarrhythmogenic Scar. Circ Arrhythm Electrophysiol 2019; 12:e007879. [PMID: 31597477 DOI: 10.1161/circep.119.007879] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In infarct-related ventricular tachycardia (VT), the circuit often corresponds to a location characterized by activation slowing during sinus rhythm (SR). However, the relationship between activation slowing during SR and vulnerability for reentry and correlation to components of the VT circuit are unknown. This study examined the relationship between activation slowing during SR and vulnerability for reentry and correlated these areas with components of the circuit. METHODS In a porcine model of healed infarction, the spatial distribution of endocardial activation velocity was compared between SR and VT. Isthmus sites were defined using activation and entrainment mapping as areas exhibiting diastolic activity within the circuit while bystanders were defined as areas displaying diastolic activity outside the circuit. RESULTS Of 15 swine, 9 had inducible VT (5.2±3.0 per animal) while in 6 swine VT could not be induced despite stimulation from 4 RV and LV sites at 2 drive trains with 6 extra-stimuli down to refractoriness. Infarcts with VT had a greater magnitude of activation slowing during SR. A minimal endocardial activation velocity cutoff ≤0.1 m/s differentiated inducible from noninducible infarctions (P=0.015). Regions of maximal endocardial slowing during SR corresponded to the VT isthmus (area under curve=0.84 95% CI, 0.78-0.90) while bystander sites exhibited near-normal activation during SR. VT circuits were complex with 41.7% exhibiting discontinuous propagation with intramural bridges of slow conduction and delayed quasi-simultaneous endocardial activation. Regions forming the VT isthmus borders had faster activation during SR while regions forming the inner isthmus were activated faster during VT. CONCLUSIONS Endocardial activation slowing during SR may differentiate infarctions vulnerable for VT from those less vulnerable for VT. Sites of slow activation during SR correspond to sites forming the VT isthmus but not to bystander sites.
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Affiliation(s)
- Markus Rottmann
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Andre G Kleber
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Michael Barkagan
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jakub Sroubek
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Eran Leshem
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ayelet Shapira-Daniels
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Alfred E Buxton
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Elad Anter
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Shapira-Daniels A, Blumenfeld O, Korach A, Rudis E, Izhar U, Shapira OM. The American Society of Thoracic Surgery Score versus EuroSCORE I and EuroSCORE II in Israeli Patients Undergoing Cardiac Surgery. Isr Med Assoc J 2019; 21:671-675. [PMID: 31599509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Recently, Israel established the first national-level adult cardiac surgery database, which was linked to the Society of Thoracic Surgeons (STS). OBJECTIVES To validate and compare the STS predicted risk of mortality (PROM) to logistic EuroSCORE I (LESI) and EuroSCORE II (ESII) in Israeli patients undergoing cardiac surgery. METHODS We retrospectively studied 1279 consecutive patients who underwent cardiac surgeries with a calculable PROM. Data were prospectively entered into our database and used to calculate PROM, LESI, and ESII. Scores were normalized and correlated using linear regression and Pearson's test. To examine model calibration, we plotted the total observed versus expected mortality for each score and across five risk-score subgroups. Model discrimination was assessed by measuring the area under the receiver operating curves. RESULTS The observed 30-day operative mortality was 1.95%. The median (IQ1; IQ3) PROM, LESI, and the ESII scores were 1.45% (0.69; 3.22), 4.54% (2.28; 9.27), and 1.88% (1.18; 3.54), respectively, with observed over expected ratios of 0.63 (95% confidence interval [95%CI] 0.42-0.93), 0.59 (95%CI 0.40-0.87), and 0.24 (95%CI 0.17-0.36), respectively, (STS vs. ESII P = 0.36, STS vs. LESI P = 0.0001). There was good correlation among all scores. All models overestimated mortality. Model discrimination was high and similar for all three scores. Model calibration of the STS, PROM, and ESII were more accurate than the LESI, particularly in higher risk subgroups. CONCLUSIONS All scores overestimated mortality. In Israeli patients, the STS, PROM, and ESII risk-scores were more reliable metrics than LESI, particularly in higher risk patients.
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Affiliation(s)
- Ayelet Shapira-Daniels
- Department of Cardiothoracic Surgery, Hadassah-Hebrew University Medical Center, Ein Kerem Campus, Jerusalem, Israel
| | - Orit Blumenfeld
- Israel Center for Disease Control, Division of Medical Technologies and Research, Ministry of Health, Sheba Medical Center, Tel Hashomer, Israel
| | - Amit Korach
- Department of Cardiothoracic Surgery, Hadassah-Hebrew University Medical Center, Ein Kerem Campus, Jerusalem, Israel
| | - Ehud Rudis
- Department of Cardiothoracic Surgery, Hadassah-Hebrew University Medical Center, Ein Kerem Campus, Jerusalem, Israel
| | - Uzi Izhar
- Department of Cardiothoracic Surgery, Hadassah-Hebrew University Medical Center, Ein Kerem Campus, Jerusalem, Israel
| | - Oz M Shapira
- Department of Cardiothoracic Surgery, Hadassah-Hebrew University Medical Center, Ein Kerem Campus, Jerusalem, Israel
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20
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Barkagan M, Leshem E, Shapira-Daniels A, Sroubek J, Buxton AE, Saffitz JE, Anter E. Histopathological Characterization of Radiofrequency Ablation in Ventricular Scar Tissue. JACC Clin Electrophysiol 2019; 5:920-931. [PMID: 31439293 DOI: 10.1016/j.jacep.2019.05.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/09/2019] [Accepted: 05/13/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This study sought to characterize the histopathological features of radiofrequency ablation (RFA) in heterogeneous ventricular scar in comparison to those in healthy myocardium. BACKGROUND The histopathological features of RFA have been studied largely in normal myocardium. However, its effect on clinically relevant heterogeneous scar is not well understood. METHODS Five swine with chronic infarction underwent RFA using 35-W, 45-s, 10-20 g (Biosense Webster, Irwindale, California) in heterogenous scar tissue (voltage ≤1.5 mV) and healthy myocardium (≥3.0 mV). The location of each application was marked using the electroanatomical mapping system. Histological sections at intervals of 0.5 mm with hematoxylin and eosin and Masson's trichrome stained intervals were created. A pathologist blinded to the myocardium type characterized the extent of RF injury in cellular, extracellular, and vascular structures. RESULTS In healthy myocardium, 23 of 23 lesions (100%) were well demarcated and could be precisely measured (width: 11.3 ± 3.3 mm; depth: 7.3 ± 2.0 mm). In scar tissue, only 3 of 30 lesions (10%) were identified, and none could be measured due to a lack of defined borders. Lesions in healthy myocardium had a distinctive architecture showing a coagulative necrosis core surrounded by an outer rim of contraction band necrosis. Lesions in scar had ill-defined tissue injury without a distinct architecture. In all ablated regions, viable myocytes remained interspersed between necrotic myocytes exhibiting characteristics of both coagulative and contraction band necrosis. Connective tissue was more resistant to thermal injury in comparison to cardiomyocytes. CONCLUSIONS RFA in scarred myocardium results in irregular tissue injury and unpredictable effect on surviving cardiomyocytes. This may be related to biophysical differences between healthy and scarred myocardium.
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Affiliation(s)
- Michael Barkagan
- Division of Cardiovascular Medicine, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Eran Leshem
- Division of Cardiovascular Medicine, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ayelet Shapira-Daniels
- Division of Cardiovascular Medicine, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jakub Sroubek
- Division of Cardiovascular Medicine, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alfred E Buxton
- Division of Cardiovascular Medicine, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey E Saffitz
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Elad Anter
- Division of Cardiovascular Medicine, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
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Blumenfeld O, Na'amnih W, Shapira-Daniels A, Lotan C, Shohat T, Shapira OM. Trends in Coronary Revascularization and Ischemic Heart Disease-Related Mortality in Israel. J Am Heart Assoc 2017; 6:JAHA.116.004734. [PMID: 28213569 PMCID: PMC5523769 DOI: 10.1161/jaha.116.004734] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We investigated national trends in volume and outcomes of percutaneous coronary angioplasty (PCI), coronary artery bypass grafting (CABG), and ischemic heart disease-related mortality in Israel. METHODS AND RESULTS Using International Classification of Diseases 9th and 10th revision codes, we linked 5 Israeli national databases, including the Israel Center for Disease Control National PCI and CABG Registries, the Ministry of Health Hospitalization Report, the Center of Bureau of Statistics, and the Ministry of Interior Mortality Report, to assess the annual PCI and CABG volume, procedural mortality, comorbidities, and ischemic heart disease-related mortality between 2002 and 2014. Trends over time were analyzed using linear regression, assuming a Poisson distribution. A total of 298 390 revascularization procedures (PCI: 255 724, CABG: 42 666) were performed during the study period. PCI volume increased by 9% from 2002 to 2008 (387.4/100 000 to 423.2/100 000), steadily decreasing by 10.5% to 378.5/100 000 in 2014 (P=0.70 for the trend). CABG volume decreased by 59% (109.0/100 000 to 45.2/100 000) from 2002 to 2013, leveling at 46.4/100 000 (P<0.0001). PCI/CABG ratio increased from 3.6 in 2002 to 8.5 in 2013, slightly decreasing to 8.2 by 2014 (P<0.0001). In-hospital procedural mortality remained stable (PCI: 1.2-1.6%, P=0.34, CABG: 3.7-4.4%, P=0.29) despite a significant change in patient clinical profile. During the course of the study, ischemic heart disease-related mortality decreased by 46% (84.6-46/100 000, P<0.001). CONCLUSIONS We observed a dramatic change in coronary revascularization procedures type and volume, and a marked decrease in ischemic heart disease-related mortality in Israel. The reasons for the observed changes remain unclear and need to be further investigated.
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Affiliation(s)
- Orit Blumenfeld
- Israel Centers for Disease Control, Ministry of Health, Ramat Gan, Israel
| | - Wasef Na'amnih
- Israel Centers for Disease Control, Ministry of Health, Ramat Gan, Israel
| | - Ayelet Shapira-Daniels
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Chaim Lotan
- Department of Cardiology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Tamy Shohat
- Israel Centers for Disease Control, Ministry of Health, Ramat Gan, Israel.,Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Oz M Shapira
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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