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Terrade G, Borenstein N, Chetboul V, Toma C, Guillaume E, Bruneval P, Fiette L, Carazo Arias LE, Morlet A, Le Dudal M. First reported long-term two- and three-dimensional echocardiographic follow-up with histopathological analysis of a transcatheter pulmonary valve implantation in a pet dog. J Vet Cardiol 2024; 53:52-59. [PMID: 38688090 DOI: 10.1016/j.jvc.2024.04.001] [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: 12/19/2023] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 05/02/2024]
Abstract
Transcatheter pulmonary valve implantation (TPVI) is indicated for use in the management of failing pulmonary valves in humans. We report here the long-term follow-up of the first documented transcatheter pulmonary valve implanted in a client-owned dog. A one-year-old Beagle dog with severe congenital type A valvular pulmonic stenosis first underwent percutaneous balloon pulmonary valvuloplasty, leading two years later to severe pulmonary regurgitation. A TPVI using a Melody™ bioprosthetic valve was then successfully performed, with normalization of the right heart cavities. Repeated two- and three-dimensional transthoracic echocardiographic examinations combined with Doppler modes confirmed the appropriate position and function of the valve for four years. Mitral myxomatous valvular degeneration led to refractory left-sided congestive heart failure, and the dog was humanely euthanized. After postmortem examination, X-ray imaging and histopathological evaluation of the stent and the valve were performed. Ex-vivo imaging of the implanted valve using a Faxitron® Path radiography system and microscopic evaluation of the implanted stent and bioprosthetic leaflets did not show any relevant leaflet or stent alterations. This case provides a proof of concept in interventional veterinary cardiology, showing that TPVI can be performed in dogs with subsequent long-term maintaining normal pulmonary valve function.
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Affiliation(s)
- G Terrade
- Veranex Preclinical Services, 42 Bd Jourdan, 75014 Paris, France; Ecole Nationale Vétérinaire d'Alfort, Unité d'Histologie et d'Anatomie-Pathologique, Biopôle Alfort, 7 Av. du Général de Gaulle, 94700 Maisons-Alfort, France
| | - N Borenstein
- Veranex Preclinical Services, 42 Bd Jourdan, 75014 Paris, France.
| | - V Chetboul
- Ecole Nationale Vétérinaire d'Alfort, Unité de Cardiologie d'Alfort (UCA), Centre Hospitalier Universitaire Vétérinaire d'Alfort (CHUVA), 7 Av. du Général de Gaulle, 94700 Maisons-Alfort, France; U955, Equipe 03, INSERM (Institut National de la santé et de la recherche médicale), 8 rue du Général Sarrail, 94010 Créteil, France
| | - C Toma
- Veranex Preclinical Services, 42 Bd Jourdan, 75014 Paris, France
| | - E Guillaume
- Veranex Preclinical Services, 42 Bd Jourdan, 75014 Paris, France
| | - P Bruneval
- Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Department of Pathology, 20 Rue Leblanc, 75015 Paris, France
| | - L Fiette
- Veranex Preclinical Services, 42 Bd Jourdan, 75014 Paris, France
| | - L E Carazo Arias
- Veranex Preclinical Services, 42 Bd Jourdan, 75014 Paris, France
| | - A Morlet
- Veranex Preclinical Services, 42 Bd Jourdan, 75014 Paris, France
| | - M Le Dudal
- Ecole Nationale Vétérinaire d'Alfort, Unité d'Histologie et d'Anatomie-Pathologique, Biopôle Alfort, 7 Av. du Général de Gaulle, 94700 Maisons-Alfort, France
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Leiva O, Alviar C, Khandhar S, Parikh SA, Toma C, Postelnicu R, Horowitz J, Mukherjee V, Greco A, Bangalore S. Catheter-based therapy for high-risk or intermediate-risk pulmonary embolism: death and re-hospitalization. Eur Heart J 2024:ehae184. [PMID: 38573048 DOI: 10.1093/eurheartj/ehae184] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 02/18/2024] [Accepted: 03/11/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND AND AIMS Catheter-based therapies (CBTs) have been developed as a treatment option in patients with pulmonary embolism (PE). There remains a paucity of data to inform decision-making in patients with intermediate-risk or high-risk PE. The aim of this study was to characterize in-hospital and readmission outcomes in patients with intermediate-risk or high-risk PE treated with vs. without CBT in a large retrospective registry. METHODS Patients hospitalized with intermediate-risk or high-risk PE were identified using the 2017-20 National Readmission Database. In-hospital outcomes included death and bleeding and 30- and 90-day readmission outcomes including all-cause, venous thromboembolism (VTE)-related and bleeding-related readmissions. Inverse probability of treatment weighting (IPTW) was utilized to compare outcomes between CBT and no CBT. RESULTS A total of 14 903 [2076 (13.9%) with CBT] and 42 829 [8824 (20.6%) with CBT] patients with high-risk and intermediate-risk PE were included, respectively. Prior to IPTW, patients with CBT were younger and less likely to have cancer and cardiac arrest, receive systemic thrombolysis, or be on mechanical ventilation. In the IPTW logistic regression model, CBT was associated with lower odds of in-hospital death in high-risk [odds ratio (OR) 0.83, 95% confidence interval (CI) 0.80-0.87] and intermediate-risk PE (OR 0.76, 95% CI 0.70-0.83). Patients with high-risk PE treated with CBT were associated with lower risk of 90-day all-cause [hazard ratio (HR) 0.77, 95% CI 0.71-0.83] and VTE (HR 0.46, 95% CI 0.34-0.63) readmission. Patients with intermediate-risk PE treated with CBT were associated with lower risk of 90-day all-cause (HR 0.75, 95% CI 0.72-0.79) and VTE (HR 0.66, 95% CI 0.57-0.76) readmission. CONCLUSIONS Among patients with high-risk or intermediate-risk PE, CBT was associated with lower in-hospital death and 90-day readmission. Prospective, randomized trials are needed to confirm these findings.
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Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY 10016, USA
| | - Carlos Alviar
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY 10016, USA
| | - Sameer Khandhar
- Division of Cardiology, Penn Presbyterian Medical Center, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sahil A Parikh
- Division of Cardiology, Columbia University Irving Medical School, New York-Presbyterian Hospital, New York, NY, USA
| | - Catalin Toma
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Radu Postelnicu
- Department of Medicine, Division of Pulmonology and Critical Care, New York University Grossman School of Medicine, New York, NY, USA
| | - James Horowitz
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY 10016, USA
| | - Vikramjit Mukherjee
- Department of Medicine, Division of Pulmonology and Critical Care, New York University Grossman School of Medicine, New York, NY, USA
| | - Allison Greco
- Department of Medicine, Division of Pulmonology and Critical Care, New York University Grossman School of Medicine, New York, NY, USA
| | - Sripal Bangalore
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY 10016, USA
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Ahmad D, Yousef S, Kliner D, Brown JA, Serna-Gallegos D, Toma C, Makani A, West D, Wang Y, Thoma FW, Sultan I. Outcomes of Valve-in-Valve Transcatheter Aortic Valve Replacement. Am J Cardiol 2024; 215:1-7. [PMID: 38232811 DOI: 10.1016/j.amjcard.2023.12.061] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 11/23/2023] [Accepted: 12/27/2023] [Indexed: 01/19/2024]
Abstract
Structural valve degeneration is increasingly seen given the higher rates of bioprosthetic heart valve use for surgical and transcatheter aortic valve replacement (TAVR). Valve-in-valve TAVR (VIV-TAVR) is an attractive alternate for patients who are otherwise at high risk for reoperative surgery. We compared patients who underwent VIV-TAVR and native valve TAVR through a retrospective analysis of our institutional transcatheter valve therapy (TVT) database from 2013 to 2022. Patients who underwent either a native valve TAVR or VIV-TAVR were included. VIV-TAVR was defined as TAVR in patients who underwent a previous surgical aortic valve replacement. Kaplan-Meier survival analysis was used to obtain survival estimates. A Cox proportional hazards regression model was used for the multivariable analysis of mortality. A total of 3,532 patients underwent TAVR, of whom 198 (5.6%) underwent VIV-TAVR. Patients in the VIV-TAVR cohort were younger than patients who underwent native valve TAVR (79.5 vs 84 years, p <0.001), with comparable number of women and a higher Society of Thoracic Surgeons risk score (6.28 vs 4.46, p <0.001). The VIV-TAVR cohort had a higher incidence of major vascular complications (2.5% vs 0.8%, p = 0.008) but lower incidence of permanent pacemaker placement (2.5% vs 8.1%, p = 0.004). The incidence of stroke was comparable between the groups (VIV-TAVR 2.5% vs native TAVR 2.4%, p = 0.911). The 30-day readmission rates (VIV-TAVR 7.1% vs native TAVR 9%, p = 0.348), as well as in-hospital (VIV-TAVR 2% vs native TAVR 1.4%, p = 0.46), and overall (VIV-TAVR 26.3% vs native TAVR 30.8%, p = 0.18) mortality at a follow-up of 1.8 years (0.83 to 3.5) were comparable between the groups. The survival estimates were also comparable between the groups (log-rank p = 0.27). On multivariable Cox regression analysis, VIV-TAVR was associated with decreased hazards of death (hazard ratio 0.68 [0.5 to 0.9], p = 0.02). In conclusion, VIV-TAVR is a feasible and safe strategy for high-risk patients with bioprosthetic valve failure. There may be potentially higher short-term morbidity with VIV-TAVR, with no overt impact on survival.
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Affiliation(s)
- Danial Ahmad
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dustin Kliner
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amber Makani
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David West
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Floyd W Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Sá MP, Jacquemyn X, Serna-Gallegos D, Makani A, Kliner D, Toma C, West D, Ahmad D, Yousef S, Brown JA, Yoon P, Kaczorowski D, Bonatti J, Chu D, Sultan I. Long-Term Outcomes of Valve-in-Valve Transcatheter Aortic Valve Implantation Versus Redo Surgical Aortic Valve Replacement: Meta-Analysis of Kaplan-Meier-Derived Data. Am J Cardiol 2024; 212:30-39. [PMID: 38070591 DOI: 10.1016/j.amjcard.2023.11.054] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 12/20/2023]
Abstract
Valve-in-valve (ViV) transcatheter aortic valve implantation (ViV-TAVI) in patients with failed bioprostheses arose as an alternative to redo surgical aortic valve replacement (SAVR). To evaluate all-cause mortality in ViV-TAVI versus redo-SAVR, we performed a study-level meta-analysis of reconstructed time-to-event data from Kaplan-Meier curves of nonrandomized studies published by August 2023. A total of 16 studies met our eligibility criteria, with a total of 4,373 patients (2,204 patients underwent ViV-TAVI and 2,169 patients underwent redo-SAVR). Pooling all the studies, ViV-TAVI showed a lower risk of all-cause mortality in the first 6 months (hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.46 to 0.73, p <0.001), with an HR reversal after this time point favoring redo-SAVR (HR 1.92, 95% CI 1.58 to 2.33, p <0.001). Pooling only the matched populations (which represented 64.6% of the overall population), ViV-TAVI showed a lower risk of all-cause mortality in the first 6 months (HR 0.56, 95% CI 0.43 to 0.73, p <0.001], with a reversal after 6 months favoring redo-SAVR (HR 1.55, 95% CI 1.25 to 1.93, p <0.001). The meta-regression analyses revealed a modulating effect of the following covariates: age, coronary artery disease, history of coronary artery bypass graft surgery, and implanted valves <25 mm. In conclusion, ViV-TAVI is associated with better survival immediately after the procedure than redo-SAVR; however, this primary advantage reverses over time, and redo-SAVR seems to offer better survival at a later stage. Because these results are pooled data from observational studies, they should be interpreted with caution, and randomized controlled trials are warranted.
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Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amber Makani
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Interventional Cardiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dustin Kliner
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Interventional Cardiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Catalin Toma
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Interventional Cardiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David West
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Danial Ahmad
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sarah Yousef
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James A Brown
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pyongsoo Yoon
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Johannes Bonatti
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Ogami T, Yousef S, Brown JA, Kliner DE, Toma C, Serna-Gallegos D, Doshi N, Wang Y, Sultan I. Readmission-related outcomes of surgical versus transcatheter aortic valve replacement in patients aged 65 or older with bicuspid aortic valve. Cardiovasc Revasc Med 2024:S1553-8389(24)00010-1. [PMID: 38233251 DOI: 10.1016/j.carrev.2024.01.009] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/20/2023] [Accepted: 01/10/2024] [Indexed: 01/19/2024]
Abstract
BACKGROUND There continues to be debate regarding the superiority of transcatheter (TAVR) over surgical aortic valve replacement (SAVR) in patients with bicuspid aortic valves (BAV). We aimed to compare outcomes during readmissions in elderly patients with BAV who underwent SAVR or TAVR. METHODS Patients 65 years or older with BAV who underwent TAVR or isolated SAVR were identified using the National Readmission Database from 2012 through 2018. We compared outcomes during readmissions within 90 days after discharge from the index surgery. Propensity score matching was performed to adjust the baseline differences. RESULTS During the study period, 8555 and 1081 elderly patients with BAV underwent SAVR and TAVR, respectively. The number of patients who underwent TAVR went up by 179 % from 2012 to 2018. Propensity score matching yielded 573 patients in each group. A total of 111 (19.4 %) in the SAVR group and 125 (21.8 %) in the TAVR group were readmitted within 90 days after the index surgery (p = .31). The mortality during the readmissions within 90 days was equivalent between the two groups (0.9 % in the SAVR group vs. 3.2 % in the TAVR group, p = .22). However, the median hospital cost was approximately doubled in the TAVR group during the readmission (18,250 dollars vs. 9310 dollars in the SAVR group, p < .001). CONCLUSIONS Readmission within 90 days was common in both groups. While the mortality during the readmissions after the surgery was equivalent between the two groups, hospital cost was significantly more expensive in the TAVR group.
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Affiliation(s)
- Takuya Ogami
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dustin E Kliner
- Division of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Catalin Toma
- Division of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nandini Doshi
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Najarro M, Briceño W, Rodríguez C, Muriel A, González S, Castillo A, Jara I, Rali P, Toma C, Bikdeli B, Jiménez D. Shock score for prediction of clinical outcomes among stable patients with acute symptomatic pulmonary embolism. Thromb Res 2024; 233:18-24. [PMID: 37988846 DOI: 10.1016/j.thromres.2023.11.011] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/13/2023] [Accepted: 11/10/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND The Composite Pulmonary Embolism Shock (CPES) score has been developed to identify normotensive patients with acute pulmonary embolism (PE) and a low cardiac index (referred to as normotensive shock). We aimed to externally assess the validity of this model for predicting a complicated course among hemodynamically stable patients with acute PE. METHODS Using prospectively collected data from the PROgnosTic valuE of Computed Tomography scan (PROTECT) study, we calculated the CPES score for each patient and the proportion of patients with a score > 3. We calculated the test performance characteristics to predict a complicated course (i.e., death from any cause, hemodynamic collapse, or recurrent PE) and the discriminatory power using the area under the receiver operating characteristic curve. RESULTS Sixty-three of the 848 (7.4 %) patients had a complicated course during the 30-day follow-up period. Of the 848 enrolled patients, the CPES score was positive (i.e., score > 3) in 78 (9.2 %). The specificity was 92.1 % (723/785), the positive predictive value was 20.5 % (16/78), and the positive likelihood ratio was 3.22 for a complicated course. The areas under the receiver operating characteristic curve for a complicated course were 0.71 (95 % confidence interval [CI], 0.65-0.78). With the higher score risk classification threshold (cutoff score > 4), the proportion of patients designated as positive was 2.1 %, and the specificity was 98.1 %. When echocardiographic right ventricle (RV) dysfunction was replaced by computed tomographic RV enlargement, the specificity was 85.4 %, the positive predictive value was 14.2 %, and the positive likelihood ratio was 2.06 for a complicated course. When analyses were restricted to the subgroup of patients with intermediate-risk PE, the specificity and the positive predictive value for a complicated course were identical to the overall cohort. CONCLUSIONS The CPES score has acceptable C-statistic, excellent specificity, and low positive predictive value for identification of hemodynamic deterioration in normotensive patients with PE. CLINICALTRIALS gov number: NCT02238639.
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Affiliation(s)
- Marta Najarro
- Emergency Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Winnifer Briceño
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Alfonso Muriel
- Biostatistics Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Sara González
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Ana Castillo
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Ignacio Jara
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Catalin Toma
- Division of Cardiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, CT, USA.; Cardiovascular Research Foundation, New York, USA
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain; Medicine Department, Universidad de Alcalá, Madrid, Spain.
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Gonsalves CF, Gibson CM, Stortecky S, Alvarez RA, Beam DM, Horowitz JM, Silver MJ, Toma C, Rundback JH, Rosenberg SP, Markovitz CD, Tu T, Jaber WA. Randomized controlled trial of mechanical thrombectomy vs catheter-directed thrombolysis for acute hemodynamically stable pulmonary embolism: Rationale and design of the PEERLESS study. Am Heart J 2023; 266:128-137. [PMID: 37703948 DOI: 10.1016/j.ahj.2023.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND The identification of hemodynamically stable pulmonary embolism (PE) patients who may benefit from advanced treatment beyond anticoagulation is unclear. However, when intervention is deemed necessary by the PE patient's care team, data to select the most advantageous interventional treatment option are lacking. Limiting factors include major bleeding risks with systemic and locally delivered thrombolytics and the overall lack of randomized controlled trial (RCT) data for interventional treatment strategies. Considering the expansion of the pulmonary embolism response team (PERT) model, corresponding rise in interventional treatment, and number of thrombolytic and nonthrombolytic catheter-directed devices coming to market, robust evidence is needed to identify the safest and most effective interventional option for patients. METHODS The PEERLESS study (ClinicalTrials.gov identifier: NCT05111613) is a currently enrolling multinational RCT comparing large-bore mechanical thrombectomy (MT) with the FlowTriever System (Inari Medical, Irvine, CA) vs catheter-directed thrombolysis (CDT). A total of 550 hemodynamically stable PE patients with right ventricular (RV) dysfunction and additional clinical risk factors will undergo 1:1 randomization. Up to 150 additional patients with absolute thrombolytic contraindications may be enrolled into a nonrandomized MT cohort for separate analysis. The primary end point will be assessed at hospital discharge or 7 days post procedure, whichever is sooner, and is a composite of the following clinical outcomes constructed as a hierarchal win ratio: (1) all-cause mortality, (2) intracranial hemorrhage, (3) major bleeding, (4) clinical deterioration and/or escalation to bailout, and (5) intensive care unit admission and length of stay. The first 4 components of the win ratio will be adjudicated by a Clinical Events Committee, and all components will be assessed individually as secondary end points. Other key secondary end points include all-cause mortality and readmission within 30 days of procedure and device- and drug-related serious adverse events through the 30-day visit. IMPLICATIONS PEERLESS is the first RCT to compare 2 different interventional treatment strategies for hemodynamically stable PE and results will inform strategy selection after the physician or PERT determines advanced therapy is warranted.
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Affiliation(s)
| | | | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | | | - Daren M Beam
- Indiana University Health University Hospital, Indianapolis, IN
| | | | | | - Catalin Toma
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John H Rundback
- Advanced Interventional & Vascular Services, LLP, Teaneck, NJ
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Brown JA, Yousef S, Toma C, Kliner D, Serna-Gallegos D, Makani A, West D, Wang Y, Thoma F, Pompeu Sá M, Sultan I. Self-Expanding Transcatheter Aortic Valves Optimize Transvalvular Hemodynamics Independent of Intra- Versus Supra-Annular Design. Am J Cardiol 2023; 207:48-53. [PMID: 37722201 DOI: 10.1016/j.amjcard.2023.08.120] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/14/2023] [Accepted: 08/20/2023] [Indexed: 09/20/2023]
Abstract
This study sought to characterize transvalvular hemodynamics during the first 30 days after transcatheter aortic valve implantation (TAVI) across various transcatheter heart valves (THVs), while adjusting for annular dimensions. This was an observational study of TAVIs from September 2021 to October 2022. The primary outcome was mean transvalvular pressure gradient (TVPG), measured using transthoracic echocardiography at day 0, day 1, and day 30 post-TAVI, and were compared across 3 THV, including the self-expandable intra-annular Portico (Abbott Vascular, Santa Clara, California) valve, the balloon-expandable SAPIEN 3 Ultra (Edwards Lifesciences, Irvine, California), and the self-expandable supra-annular Evolut Pro+ (Medtronic, Minneapolis, Minnesota). A total of 560 patients who underwent TAVI were identified, of which 106 (18.9%) received a Portico THV, 176 (31.4%) received a SAPIEN THV, and 278 (49.6%) received an Evolut THV. For Portico THV, the TVPG on day 0 increased from 6.0 (4.7 to 9.0) to 7.0 (6.0 to 10.0) by day 30 (p = 0.009). For SAPIEN THV, the TVPG on day 0 increased from 6.5 (5.0 to 8.0) to 12.0 (9.0 to 15.0) by day 30 (p <0.001). For Evolut THV, the TVPG on day 0 increased from 6.0 (5.0 to 9.0) to 7.2 (5.0 to 10.0) by day 30 (p = 0.001). Adjusting for time and annular diameter in a multivariable mixed effects model, the SAPIEN group had a significantly greater increase in TVPG over time than the Evolut reference group (p <0.001), while there was no difference in the change of TVPG over time for the Portico group vs. the Evolut group (p = 0.874). In conclusion, compared with balloon-expandable valves, self-expanding THV may optimize transvalvular hemodynamics across all annular diameters, independent of their supra-annular and intra-annular design.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dustin Kliner
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amber Makani
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David West
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michel Pompeu Sá
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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9
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Yousef S, Bianco V, Kliner D, Toma C, Serna-Gallegos D, West D, Makani A, Zhu J, Thoma FW, Brown JA, Ogami T, Sultan I. Outcomes of Transcatheter Aortic Valve Replacement in Patients With Concomitant Aortic Regurgitation. Ann Thorac Surg 2023; 116:728-734. [PMID: 36791833 DOI: 10.1016/j.athoracsur.2023.02.008] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/12/2023] [Accepted: 02/06/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND This study sought to evaluate outcomes of transcatheter aortic valve replacement (TAVR) in patients with moderate or greater aortic regurgitation (AR). METHODS This was an observational study using an institutional database of TAVRs from November 2012 to April 2022. The study compared outcomes of TAVR in patients with isolated aortic stenosis (AS) vs patients with AS and concomitant AR (moderate or greater). Those patients with trace or mild AR were excluded. Clinical and echocardiographic outcomes were compared, with end points established by the Valve Academic Research Consortium 3. Kaplan-Meier survival estimation and Cox regression for mortality were performed. Competing-risk cumulative incidence estimates for heart failure readmissions were also compared. RESULTS Of 3295 patients, 605 (53.4%) had severe AS with no AR and 529 (46.6%) had severe AS with moderate or severe AR. There were no significant differences in in-hospital mortality, length of stay, stroke, myocardial infarction, permanent pacemaker requirement, transfusion requirement, minor or major vascular complications, or 30-day readmissions between the 2 groups (P > .05). There were also no significant differences in annular dissection or rupture, coronary obstruction, or device embolization. Mean gradient and paravalvular leak rates at 30 days and 1 year were similar between the groups. Survival estimates were comparable, and, on multivariable Cox regression, mixed aortic valvular disease was not associated with an increased hazard of death as compared with isolated AS (hazard ratio, 1.01; 95% CI, 0.81-1.25; P = .962). Cumulative incidence estimates for heart failure readmissions were comparable between groups. CONCLUSIONS TAVR can be safely performed in patients with mixed valvular disease, with outcomes comparable to those in isolated AS.
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Affiliation(s)
- Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dustin Kliner
- Heart and Vascular Institute, University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| | - David West
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| | - Amber Makani
- Heart and Vascular Institute, University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| | - Jianhui Zhu
- Heart and Vascular Institute, University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| | - Floyd W Thoma
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Takuya Ogami
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center Pittsburgh, Pennsylvania.
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10
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Silver MJ, Gibson CM, Giri J, Khandhar S, Jaber W, Toma C, Mina B, Bowers T, Greenspon L, Kado H, Zlotnick DM, Chakravarthy M, DuCoffe AR, Butros P, Horowitz JM. Outcomes in High-Risk Pulmonary Embolism Patients Undergoing FlowTriever Mechanical Thrombectomy or Other Contemporary Therapies: Results From the FLAME Study. Circ Cardiovasc Interv 2023; 16:e013406. [PMID: 37847768 PMCID: PMC10573120 DOI: 10.1161/circinterventions.123.013406] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/14/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Hemodynamically unstable high-risk, or massive, pulmonary embolism (PE) has a reported in-hospital mortality of over 25%. Systemic thrombolysis is the guideline-recommended treatment despite limited evidence. The FLAME study (FlowTriever for Acute Massive PE) was designed to generate evidence for interventional treatments in high-risk PE. METHODS The FLAME study was a prospective, multicenter, nonrandomized, parallel group, observational study of high-risk PE. Eligible patients were treated with FlowTriever mechanical thrombectomy (FlowTriever Arm) or with other contemporary therapies (Context Arm). The primary end point was an in-hospital composite of all-cause mortality, bailout to an alternate thrombus removal strategy, clinical deterioration, and major bleeding. This was compared in the FlowTriever Arm to a prespecified performance goal derived from a contemporary systematic review and meta-analysis. RESULTS A total of 53 patients were enrolled in the FlowTriever Arm and 61 in the Context Arm. Context Arm patients were primarily treated with systemic thrombolysis (68.9%) or anticoagulation alone (23.0%). The primary end point was reached in 9/53 (17.0%) FlowTriever Arm patients, significantly lower than the 32.0% performance goal (P<0.01). The primary end point was reached in 39/61 (63.9%) Context Arm patients. In-hospital mortality occurred in 1/53 (1.9%) patients in the FlowTriever Arm and in 18/61 (29.5%) patients in the Context Arm. CONCLUSIONS Among patients selected for mechanical thrombectomy with the FlowTriever System, a significantly lower associated rate of in-hospital adverse clinical outcomes was observed compared with a prespecified performance goal, primarily driven by low all-cause mortality of 1.9%. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04795167.
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Affiliation(s)
| | - C. Michael Gibson
- Department of Cardiovascular Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (C.M.G.)
| | - Jay Giri
- Cardiovascular Medicine Division, Perelman School of Medicine at University of Pennsylvania, Philadelphia (J.G., S.K.)
| | - Sameer Khandhar
- Cardiovascular Medicine Division, Perelman School of Medicine at University of Pennsylvania, Philadelphia (J.G., S.K.)
| | - Wissam Jaber
- Division of Cardiology, Emory University Hospital, Atlanta, GA (W.J.)
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, PA (C.T.)
| | - Bushra Mina
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, Northwell Health, New York (B.M.)
| | - Terry Bowers
- Department of Cardiovascular Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, MI (T.B., H.K.)
| | - Lee Greenspon
- Pulmonary Critical Care Division, Lankenau Medical Center, Wynnewood, PA (L.G.)
| | - Herman Kado
- Department of Cardiovascular Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, MI (T.B., H.K.)
- Ascension Providence Hospital, Southfield, MI (H.K.)
| | - David M. Zlotnick
- Division of Cardiovascular Medicine, University at Buffalo, Gates Vascular Institute, Buffalo General Medical Center, NY (D.M.Z.)
| | - Mithun Chakravarthy
- Department of Cardiology, AHN Cardiovascular Institute at Allegheny General Hospital, Pittsburgh, PA (M.C.)
| | - Aaron R. DuCoffe
- Inova Health Systems Heart and Vascular Institute, Fairfax Hospital, VA (A.R.D., P.B.)
| | - Paul Butros
- Inova Health Systems Heart and Vascular Institute, Fairfax Hospital, VA (A.R.D., P.B.)
| | - James M. Horowitz
- Division of Cardiology, New York University Grossman School of Medicine, NY (J.M.H.)
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11
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Chiarito M, Cao D, Sartori S, Zhang Z, Vogel B, Spirito A, Smith KF, Weintraub W, Strauss C, Toma C, DeFranco A, Effron MB, Stefanini G, Keller S, Kapadia S, Rao SV, Henry TD, Pocock S, Sharma S, Dangas G, Kini A, Baber U, Mehran R. Thrombotic risk in patients with acute coronary syndromes discharged on prasugrel or clopidogrel: results from the PROMETHEUS study. Eur Heart J Acute Cardiovasc Care 2023; 12:594-603. [PMID: 37459570 DOI: 10.1093/ehjacc/zuad083] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 05/21/2023] [Accepted: 06/02/2023] [Indexed: 09/27/2023]
Abstract
AIMS Based on recent clinical data, the 2020 ESC guidelines on non-ST-elevation acute coronary syndrome (NSTE-ACS) suggest to tailor antithrombotic strategy on individual thrombotic risk. Nonetheless, prevalence and prognostic impact of the high thrombotic risk (HTR) criteria proposed are yet to be described. In this analysis from the PROMETHEUS registry, we assessed prevalence and prognostic impact of HTR, defined according to the 2020 ESC NSTE-ACS guidelines, and if the benefits associated with prasugrel vs. clopidogrel vary with thrombotic risk. METHODS AND RESULTS PROMETHEUS was a multicentre prospective study comparing prasugrel vs. clopidogrel in ACS patients undergoing percutaneous coronary intervention (PCI). Patients were at HTR if presenting with one clinical plus one procedural risk feature. The primary endpoint was major adverse cardiac events (MACE), composite of death, myocardial infarction, stroke, or unplanned revascularization, at 1 year. Adjusted hazard ratio (adjHR) and 95% confidence intervals (CIs) were calculated with propensity score stratification and multivariable Cox regression. Among 16 065 patients, 4293 (26.7%) were at HTR and 11 772 (73.3%) at low-to-moderate thrombotic risk. The HTR conferred increased incidence of MACE (23.3 vs. 13.6%, HR 1.85, 95% CI 1.71-2.00, P < 0.001) and its single components. Prasugrel was prescribed in patients with less comorbidities and risk factors and was associated with reduced risk of MACE (HTR: adjHR 0.83, 95% CI 0.68-1.02; low-to-moderate risk: adjHR 0.75, 95% CI 0.64-0.88; pinteraction = 0.32). CONCLUSION High thrombotic risk, as defined by the 2020 ESC NSTE-ACS guidelines, is highly prevalent among ACS patients undergoing PCI. The HTR definition had a strong prognostic impact, as it successfully identified patients at increased 1 year risk of ischaemic events.
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Affiliation(s)
- Mauro Chiarito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
- Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Via Alessandro Manzoni, 56, 20089 Rozzano, Milan, Italy
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele, Milan, Italy
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Kenneth F Smith
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - William Weintraub
- Division of Cardiology, Christiana Care Health System, 313 W Main St, Newark, DE 19711, USA
| | - Craig Strauss
- Division of Cardiology, Minneapolis Heart Institute, 920 E 28th St #100, Minneapolis, MN 55407, USA
| | - Catalin Toma
- Division of Cardiology, University of Pittsburgh Medical Center, 200 Meyran Ave # 318, Pittsburgh, PA 15213, USA
| | - Anthony DeFranco
- Division of Cardiology, Aurora Cardiovascular Services, 2801 W Kinnickinnic River Pkwy. Ste 777. Milwaukee, WI 53215, USA
| | - Mark B Effron
- Division of Cardiology, John Ochsner Heart and Vascular Institute, 1514 Jefferson Hwy, New Orleans, LA 70121, USA
| | - Giulio Stefanini
- Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Via Alessandro Manzoni, 56, 20089 Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele, Milan, Italy
| | - Stuart Keller
- Eli Lilly and Company, Sam Jones Expy, Indianapolis, IN 46241, USA
| | - Samir Kapadia
- Division of Cardiology, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Sunil V Rao
- Division of Cardiology, NYU Langone Health System, Skirball 9N, 530 1st Ave., New York, NY 10016, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, 2123 Auburn Ave # 424, Cincinnati, OH 45219, USA
- The Christ Hospital Heart and Vascular Institute, The Christ Hospital, 2139 Auburn Ave, Cincinnati, OH 45219, USA
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine,15-17 Tavistock Pl, London WC1H 9SH, UK
| | - Samin Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Annapoorna Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Usman Baber
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
- Division of Cardiology, University of Oklahoma Health Sciences Center, 1100 N Lindsay Ave, Oklahoma City, OK 73104, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
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12
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Aranda-Michel E, Kilner D, Toma C, Serna-Gallegos D, Yousef S, Brown J, Diaz-Castrillon CE, Makani A, Sultan I. A Readmission Risk Score for Transcatheter Aortic Valve Replacement: An Analysis of 200,000 Patients. Cardiovasc Revasc Med 2023; 53:8-12. [PMID: 36907697 DOI: 10.1016/j.carrev.2023.02.025] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/23/2023] [Accepted: 02/23/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE The objective of this study was to leverage a national database of TAVR procedures to create a risk model for 30-day readmissions. METHODS The National Readmissions Database was reviewed for all TAVR procedures from 2011 to 2018. Previous ICD coding paradigms created comorbidity and complication variables from the index admission. Univariate analysis included any variables with a P-value of ≤0.2. A bootstrapped mixed-effects logistic regression was run using the hospital ID as a random effect variable. By bootstrapping, a more robust estimate of the variables' effect can be generated, reducing the risk of model overfitting. The odds ratio of variables with a P-value <0.1 was turned into a risk score following the Johnson scoring method. A mixed-effect logistic regression was run using the total risk score, and a calibration plot of the observed to expected readmission was generated. RESULTS A total of 237,507 TAVRs were identified, with an in-hospital mortality of 2.2 %. A total of 17.4 % % of TAVR patients were readmitted within 30 days. The median age was 82 with 46 % of the population being women. The risk score values ranged from -3 to 37 corresponding to a predicted readmission risk between 4.6 % and 80.4 %, respectively. Discharge to a short-term facility and being a resident of the hospital state were the most significant predictors of readmission. The calibration plot shows good agreement between the observed and expected readmission rates with an underestimation at higher probabilities. CONCLUSION The readmission risk model agrees with the observed readmissions throughout the study period. The most significant risk factors were being a resident of the hospital state and discharge to a short-term facility. This suggests that using this risk score in conjunction with enhanced post-operative care in these patients could reduce readmissions and associated hospital costs, improving outcomes.
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Affiliation(s)
- Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, PA, United States of America
| | - Dustin Kilner
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, PA, United States of America; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, PA, United States of America
| | - James Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, PA, United States of America
| | - Carlos E Diaz-Castrillon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, PA, United States of America
| | - Amber Makani
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, PA, United States of America; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America.
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13
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Yousef S, Serna-Gallegos D, Iyanna N, Kliner D, Brown JA, Toma C, Makani A, West D, Wang Y, Thoma FW, Ahmad D, Yoon P, Chu D, Kaczorowski D, Bonatti J, Sultan I. Valve-in-valve Transcatheter Aortic Valve Replacement versus isolated redo Surgical Aortic Valve Replacement. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00541-X. [PMID: 37399942 DOI: 10.1016/j.jtcvs.2023.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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] [Received: 04/03/2023] [Revised: 06/05/2023] [Accepted: 06/24/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE To compare outcomes of patients undergoing valve-in-valve transcatheter aortic valve replacement (ViV TAVR) versus redo surgical aortic valve replacement (SAVR). METHODS This was a retrospective study using institutional databases of transcatheter (2013-2022) and surgical (2011-2022) aortic valve replacements. Patients who underwent ViV TAVR were compared to patients who underwent redo isolated SAVR. Clinical and echocardiographic outcomes were analyzed. Kaplan-Meier survival estimation and Cox regression were performed. Cumulative incidence functions were generated for heart failure readmissions. RESULTS A total of 4,200 TAVRs and 2,306 isolated SAVRs were performed. Of these, there were 198 patients who underwent ViV TAVR and 147 patients who underwent redo SAVR. Operative mortality was 2% in each group, but observed to expected (O:E) operative mortality in the redo SAVR group was higher than in the ViV TAVR group (1.2 vs 0.32). Those who underwent redo SAVR were more likely to require transfusions and reoperation for bleeding, to have new-onset renal failure requiring dialysis, and to require a permanent pacemaker postoperatively than those in the ViV group. Mean gradient was significantly lower in the redo SAVR group than in the ViV group at 30 days and 1 year. Kaplan-Meier survival estimates at 1 year were comparable, and on multivariable Cox regression, ViV TAVR was not significantly associated with an increased hazard of death as compared to redo SAVR (HR 1.39, 95% CI 0.65-2.99, p=0.40). Competing-risk cumulative incidence estimates for heart-failure readmissions were higher in the ViV cohort. CONCLUSIONS ViV TAVR and redo SAVR were associated with comparable mortality. Patients who underwent redo SAVR had lower postoperative mean gradients and greater freedom from heart failure readmissions, but they also had more postoperative complications than the VIV group, despite their lower baseline risk profiles.
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Affiliation(s)
- Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh; Heart and Vascular Institute, University of Pittsburgh Medical Center
| | | | - Dustin Kliner
- Heart and Vascular Institute, University of Pittsburgh Medical Center
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh; Heart and Vascular Institute, University of Pittsburgh Medical Center
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center
| | - Amber Makani
- Heart and Vascular Institute, University of Pittsburgh Medical Center
| | - David West
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh; Heart and Vascular Institute, University of Pittsburgh Medical Center
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center
| | - Floyd W Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center
| | - Danial Ahmad
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh
| | - Pyongsoo Yoon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh; Heart and Vascular Institute, University of Pittsburgh Medical Center
| | - Danny Chu
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh; Heart and Vascular Institute, University of Pittsburgh Medical Center
| | - David Kaczorowski
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh; Heart and Vascular Institute, University of Pittsburgh Medical Center
| | - Johannes Bonatti
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh; Heart and Vascular Institute, University of Pittsburgh Medical Center
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh; Heart and Vascular Institute, University of Pittsburgh Medical Center.
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14
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Bangalore S, Horowitz JM, Beam D, Jaber WA, Khandhar S, Toma C, Weinberg MD, Mina B. Prevalence and Predictors of Cardiogenic Shock in Intermediate-Risk Pulmonary Embolism: Insights From the FLASH Registry. JACC Cardiovasc Interv 2023; 16:958-972. [PMID: 37100559 DOI: 10.1016/j.jcin.2023.02.004] [Citation(s) in RCA: 9] [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] [Received: 09/27/2022] [Revised: 01/31/2023] [Accepted: 02/07/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Patients with acute pulmonary embolism (PE) and hypotension (high-risk PE) have high mortality. Cardiogenic shock can also occur in nonhypotensive or normotensive patients (intermediate-risk PE) but is less well characterized. OBJECTIVES The authors sought to evaluate the prevalence and predictors of normotensive shock in intermediate-risk PE. METHODS Intermediate-risk PE patients in the FLASH (FlowTriever All-Comer Registry for Patient Safety and Hemodynamics) registry undergoing mechanical thrombectomy with the FlowTriever System (Inari Medical) were included. The prevalence of normotensive shock (systolic blood pressure ≥90 mm Hg but cardiac index ≤2.2 L/min/m2) was assessed. A composite shock score consisting of markers of right ventricular function and ischemia (elevated troponin, elevated B-type natriuretic peptide, moderately/severely reduced right ventricular function), central thrombus burden (saddle PE), potential additional embolization (concomitant deep vein thrombosis), and cardiovascular compensation (tachycardia) was prespecified and assessed for its ability to identify normotensive shock patients. RESULTS Over one-third of intermediate-risk PE patients in FLASH (131/384, 34.1%) were in normotensive shock. The normotensive shock prevalence was 0% in patients with a composite shock score of 0 and 58.3% in those with a score of 6 (highest score). A score of 6 was a significant predictor of normotensive shock (odds ratio: 5.84; 95% CI: 2.00-17.04). Patients showed significant on-table improvements in hemodynamics post-thrombectomy, including normalization of the cardiac index in 30.5% of normotensive shock patients. Right ventricular size, function, dyspnea, and quality of life significantly improved at the 30-day follow-up. CONCLUSIONS Although hemodynamically stable, over one-third of intermediate-risk FLASH patients were in normotensive shock with a depressed cardiac index. A composite shock score effectively further risk stratified these patients. Mechanical thrombectomy improved hemodynamics and functional outcomes at the 30-day follow-up.
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Affiliation(s)
- Sripal Bangalore
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA.
| | - James M Horowitz
- Division of Cardiology, New York University Grossman School of Medicine, New York, New York, USA
| | - Daren Beam
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Wissam A Jaber
- Division of Cardiology, Emory University Hospital, Atlanta, Georgia
| | - Sameer Khandhar
- Division of Cardiology at Penn Presbyterian Medical Center, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mitchell D Weinberg
- Department of Cardiology, Northwell Health, Zucker School of Medicine at Hofstra/Northwell Health, Staten Island University Hospital, Staten Island, New York, USA
| | - Bushra Mina
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, Northwell Health, New York, New York, USA
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Ogami T, Kliner DE, Toma C, Sanon S, Smith AJC, Serna-Gallegos D, Wang Y, Makani A, Doshi N, Brown JA, Yousef S, Sultan I. Acute Coronary Syndrome After Transcatheter Aortic Valve Implantation (Results from Over 40,000 Patients). Am J Cardiol 2023; 193:126-132. [PMID: 36905688 DOI: 10.1016/j.amjcard.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 01/28/2023] [Accepted: 02/06/2023] [Indexed: 03/13/2023]
Abstract
Acute coronary syndrome (ACS) encompasses a broad category of presentations from unstable angina to ST-elevation myocardial infarctions. Most patients undergo coronary angiography upon presentation for diagnosis and treatment. However, the ACS management strategy after transcatheter aortic valve implantation (TAVI) may be complicated because of challenging coronary access. The National Readmission Database was reviewed to identify all patients who were readmitted with ACS within 90 days after TAVI between 2012 and 2018. Their outcomes were described between patients who were readmitted with ACS (ACS group) and without (non-ACS group). A total of 44,653 patients were readmitted within 90 days after TAVI. Among them, 1,416 patients (3.2%) were readmitted with ACS. The ACS group had a higher prevalence of men, diabetes, hypertension, congestive heart failure, peripheral vascular disease, and a history of percutaneous coronary intervention (PCI). In the ACS group, 101 patients (7.1%) developed cardiogenic shock, whereas 120 patients (8.5%) developed ventricular arrhythmias. Overall, 141 patients (9.9%) in the ACS group died during readmissions (vs 3.0% in the non-ACS group, p <0.001). Among the ACS group, PCI was performed in 33 (5.9%), whereas coronary bypass grafting was performed in 12 (0.82%). The factors associated with ACS readmission included a history of diabetes, congestive heart failure, chronic kidney disease, and PCI, and nonelective TAVI. Coronary artery bypass grafting was an independent factor related to in-hospital mortality during ACS readmission (odds ratio 11.9, 95% confidence interval 2.18 to 65.4, p = 0.004), whereas PCI was not (odds ratio 0.19, 95% confidence interval 0.03 to 1.44, p = 0.11). In conclusion, patients readmitted with ACS have significantly higher mortality compared with those readmitted without ACS. History of PCI is an independent factor associated with ACS after TAVI.
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Affiliation(s)
- Takuya Ogami
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsubrgh, Pennsylvania
| | - Dustin E Kliner
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsubrgh, Pennsylvania
| | - Catalin Toma
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsubrgh, Pennsylvania
| | - Saurabh Sanon
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsubrgh, Pennsylvania
| | - Anson J Conrad Smith
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsubrgh, Pennsylvania
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsubrgh, Pennsylvania; Department of Cardiothoracic Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Yisi Wang
- Department of Cardiothoracic Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amber Makani
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsubrgh, Pennsylvania
| | - Nandini Doshi
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsubrgh, Pennsylvania
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsubrgh, Pennsylvania
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsubrgh, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsubrgh, Pennsylvania; Department of Cardiothoracic Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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16
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Toma C, Jaber WA, Weinberg MD, Bunte MC, Khandhar S, Stegman B, Gondi S, Chambers J, Amin R, Leung DA, Kado H, Brown MA, Sarosi MG, Bhat AP, Castle J, Savin M, Siskin G, Rosenberg M, Fanola C, Horowitz JM, Pollak JS. Acute outcomes for the full US cohort of the FLASH mechanical thrombectomy registry in pulmonary embolism. EUROINTERVENTION 2023; 18:1201-1212. [PMID: 36349702 PMCID: PMC9936254 DOI: 10.4244/eij-d-22-00732] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 09/09/2022] [Indexed: 02/19/2023]
Abstract
BACKGROUND Evidence supporting interventional pulmonary embolism (PE) treatment is needed. AIMS We aimed to evaluate the acute safety and effectiveness of mechanical thrombectomy for intermediate- and high-risk PE in a large real-world population. METHODS FLASH is a multicentre, prospective registry enrolling up to 1,000 US and European PE patients treated with mechanical thrombectomy using the FlowTriever System. The primary safety endpoint is a major adverse event composite including device-related death and major bleeding at 48 hours, and intraprocedural adverse events. Acute mortality and 48-hour outcomes are reported. Multivariate regression analysed characteristics associated with pulmonary artery pressure and dyspnoea improvement. RESULTS Among 800 patients in the full US cohort, 76.7% had intermediate-high risk PE, 7.9% had high-risk PE, and 32.1% had thrombolytic contraindications. Major adverse events occurred in 1.8% of patients. All-cause mortality was 0.3% at 48-hour follow-up and 0.8% at 30-day follow-up, with no device-related deaths. Immediate haemodynamic improvements included a 7.6 mmHg mean drop in mean pulmonary artery pressure (-23.0%; p<0.0001) and a 0.3 L/min/m2 mean increase in cardiac index (18.9%; p<0.0001) in patients with depressed baseline values. Most patients (62.6%) had no overnight intensive care unit stay post-procedure. At 48 hours, the echocardiographic right ventricle/left ventricle ratio decreased from 1.23±0.36 to 0.98±0.31 (p<0.0001 for paired values) and patients with severe dyspnoea decreased from 66.5% to 15.6% (p<0.0001). Conclusions: Mechanical thrombectomy with the FlowTriever System demonstrates a favourable safety profile, improvements in haemodynamics and functional outcomes, and low 30-day mortality for intermediate- and high-risk PE.
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Affiliation(s)
- Catalin Toma
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, PA, USA
| | | | - Mitchell D Weinberg
- Department of Cardiology, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, Staten Island University Hospital, Staten Island, NY, USA
| | - Matthew C Bunte
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Sameer Khandhar
- Division of Cardiology, Penn Presbyterian Medical Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Brian Stegman
- CentraCare Heart and Vascular Center, St. Cloud, MN, USA
| | | | - Jeffrey Chambers
- Interventional Cardiology, Metropolitan Heart and Vascular Institute, Minneapolis, MN, USA
| | - Rohit Amin
- Ascension Sacred Heart Hospital Pensacola, Pensacola, FL, USA
| | | | - Herman Kado
- Ascension Providence Hospital, Southfield, MI, USA
| | | | | | - Ambarish P Bhat
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, Columbia, MO, USA
| | - Jordan Castle
- Inland Imaging, Providence Sacred Heart, Spokane, WA, USA
| | - Michael Savin
- Department of Radiology, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Gary Siskin
- Department of Radiology, Albany Medical Center, Albany, NY, USA
| | - Michael Rosenberg
- Department of Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Christina Fanola
- Department of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - James M Horowitz
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Jeffrey S Pollak
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
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17
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Bianco V, Mulukutla S, Aranda-Michel E, Chu D, Kaczorowski D, Bonatti J, Yoon P, Kliner D, Toma C, Wang Y, Koscumb S, Thoma F, Navid F, Serna-Gallegos D, Sultan I. Coronary Artery Bypass With Multiarterial Grafting vs Percutaneous Coronary Intervention. Ann Thorac Surg 2023; 115:404-410. [PMID: 35835208 DOI: 10.1016/j.athoracsur.2022.06.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/01/2022] [Accepted: 06/13/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Data comparing patients who undergo multiarterial grafting during coronary artery bypass grafting (CABG) vs percutaneous coronary intervention (PCI) in patients with multivessel coronary disease are scarce. This study addresses the relevance of using multiple arterial conduits vs PCI for appropriate patients. METHODS This retrospective study included all patients with coronary artery disease who underwent CABG with multiple arterial conduits or PCI. Propensity score matching was performed for baseline characteristics. Kaplan-Meier estimates, cumulative incidence, and freedom from major adverse cardiac and cerebrovascular events (MACCE) curves were performed. RESULTS The total patient population consisted of 3648 patients from 2011 to 2018 divided into 902 CABG patients and 2746 PCI patients. Patients were propensity matched (PCI, n = 838; CABG, n = 838). In the CABG cohort the left internal mammary artery was used in 837 patients (99.9%), the right internal mammary artery in 770 patients (92%), and radial arteries in 108 patients (12.9%). Patients in the PCI cohort had significantly higher 30-day mortality (24 [2.9%] vs 7 [0.8%], P < .01). Survival over follow-up (median, 4.9 years; range, 3.3-6.8) was better for the CABG cohort (730 [87.1%] vs 625 [74.6%], P < .01). Patients in the CABG cohort had greater freedom from MACCE (607 [72.4%] vs 339 [40.5%], P < .01). Cox multivariable regression showed that patients who underwent CABG had a significantly reduced risk of mortality (hazard ratio, 0.49; 95% confidence interval, 0.39-0.61; P < .01) and of MACCE (hazard ratio, 0.33; 95% confidence interval, 0.28-0.38; P < .01). CONCLUSIONS Patients with coronary artery disease who undergo CABG with multiple arterial conduits have significantly fewer major adverse events, improved survival, and reduced hospital readmissions.
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Affiliation(s)
- Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Suresh Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Danny Chu
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David Kaczorowski
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Johannes Bonatti
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pyongsoo Yoon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Dustin Kliner
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Steve Koscumb
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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18
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Brown J, Yousef S, Kliner D, Toma C, Serna-Gallegos D, Makani A, West D, Thoma F, Wang Y, Sultan I. CRT-700.39 Transcatheter Aortic Valve Implantation With a Self-Expanding Intra-Annular Valve: Institutional Experience With Over 100 Patients. JACC Cardiovasc Interv 2023. [DOI: 10.1016/j.jcin.2023.01.294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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Kostantinis S, Simsek B, Karacsonyi J, Alaswad K, Jaffer FA, Khatri JJ, Choi JW, Jaber WA, Rinfret S, Nicholson W, Patel MP, Mahmud E, Toma C, Davies RE, Kerrigan JL, Haddad EV, Gorgulu S, Abi-Rafeh N, ElGuindy AM, Goktekin O, Allana S, Burke MN, Mastrodemos OC, Rangan BV, Brilakis E. Development and validation of a scoring system for predicting clinical coronary artery perforation during percutaneous coronary intervention of chronic total occlusions: the PROGRESS-CTO perforation score. EUROINTERVENTION 2023; 18:1022-1030. [PMID: 36281650 PMCID: PMC9853034 DOI: 10.4244/eij-d-22-00593] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/12/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Coronary artery perforation is a feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) and often leads to serious adverse clinical events. AIMS We sought to develop a risk score to predict clinical coronary artery perforation in patients undergoing CTO PCI. METHODS We analysed clinical and angiographic parameters from 9,618 CTO PCIs in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO). Logistic regression prediction modelling was used to identify variables independently associated with clinical perforation, and the model was internally validated with bootstrapping. Clinical coronary artery perforation was defined as any perforation requiring treatment. RESULTS The incidence of clinical coronary perforation was 3.8% (n=367). Five factors were independently associated with perforation and were included in the score: patient age ≥65 years +1 point (odds ratio [OR] 1.79, 95% confidence interval [CI]: 1.37-2.33), moderate/severe calcification +1 point (OR 1.85, 95% CI: 1.41-2.42), blunt/no stump +1 point (OR 1.45, 95% CI: 1.10-1.92), use of antegrade dissection and re-entry +1 point (OR 2.43, 95% CI: 1.61-3.69), and use of the retrograde approach +2 points (OR 4.02, 95% CI: 2.95-5.46). The resulting score showed acceptable performance on receiver operating characteristic (ROC) curve (area under the curve [AUC]: 0.741, 95% CI: 0.712-0.773). The Hosmer-Lemeshow test indicated a good fit (p=0.991), and internal validation with bootstrapping demonstrated good agreement with the model with observed AUC: 0.736 (95% bias-corrected CI: 0.706-0.767). CONCLUSIONS The PROGRESS-CTO perforation score may be a useful tool for predicting clinical coronary perforation during CTO PCI.
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Affiliation(s)
- Spyridon Kostantinis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Bahadir Simsek
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Judit Karacsonyi
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | | | | | | | - James W Choi
- Texas Health Presbyterian Hospital, Dallas, TX, USA
| | | | | | | | | | | | - Catalin Toma
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | - Elias V Haddad
- Ascension Saint Thomas Heart Hospital, Nashville, TN, USA
| | | | | | | | | | - Salman Allana
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - M Nicholas Burke
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Olga C Mastrodemos
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Bavana V Rangan
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Emmanouil Brilakis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
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20
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Inci EK, Khandhar S, Toma C, Licitra G, Brown MJ, Herzig M, Matthai W, Palevsky H, Schwartz A, Wight JA, McDaniel M, Kumar G, Devireddy C, Baumgartner S, Bashline M, Jaber WA. Mechanical thrombectomy versus catheter directed thrombolysis in patients with pulmonary embolism: A multicenter experience. Catheter Cardiovasc Interv 2023; 101:140-146. [PMID: 36448401 DOI: 10.1002/ccd.30505] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 11/05/2022] [Accepted: 11/19/2022] [Indexed: 12/02/2022]
Abstract
OBJECTIVES Compare in-hospital outcomes of patients treated with either mechanical thrombectomy (MT) or catheter directed lysis (CDL) in treatment of acute pulmonary embolism (PE). METHODS This is a multicenter, retrospective cohort study of patients undergoing MT or CDL for acute PE between 2014 and 2021. The primary outcome was the composite of in-hospital death, significant bleed, vascular complication, or need for mechanical support post-procedure. Secondary outcomes included the individual components of the composite outcome in addition to blood transfusions, invasive hemodynamics, echocardiographic data, and intensive care unit (ICU) utilization. RESULTS 458 patients were treated for PE with 266 patients in the CDL arm and 192 patients in the MT arm. The primary composite endpoint was not significantly different between the two groups with CDL 12% versus MT 11% (p = 0.5). There was a significant difference in total length of ICU time required with more in the CDL group versus MT (3.8 ± 2.0 vs. 2.8 ± 3.0 days, p = 0.009). All other secondary end points showed no significant difference between the groups. CONCLUSIONS In patients undergoing catheter directed treatment of PE, there was no difference between MT and CDL in terms of in-hospital mortality, bleeds, catheter-related complications, and hemodynamics.
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Affiliation(s)
- Errol K Inci
- Emory University Hospital, Atlanta, Georgia, USA
| | - Sameer Khandhar
- PENN Presbyterian Medical Center, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsyvlanvia, USA
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | - Matthew Herzig
- PENN Presbyterian Medical Center, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsyvlanvia, USA
| | - William Matthai
- PENN Presbyterian Medical Center, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsyvlanvia, USA
| | - Harold Palevsky
- PENN Presbyterian Medical Center, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsyvlanvia, USA
| | | | - John A Wight
- Emory University Hospital, Atlanta, Georgia, USA
| | | | - Gautam Kumar
- Emory University Hospital, Atlanta, Georgia, USA
| | | | - Scott Baumgartner
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael Bashline
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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21
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Ogami T, Kliner DE, Toma C, Serna-Gallegos D, Wang Y, Brown JA, Yousef S, Sultan I. Readmission with infective endocarditis within 90 days following transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2023; 101:170-177. [PMID: 36478377 DOI: 10.1002/ccd.30508] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 11/18/2022] [Accepted: 11/20/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Transcatheter aortic valve implantation (TAVI) continues to be the most common modality of treating aortic stenosis in the United States. While infective endocarditis (IE) and its outcomes have been well documented after surgical aortic valve replacement, the incidence and outcomes of early IE after TAVI have not been well described. METHODS All patients who underwent TAVI from 2012 through 2018 were identified using the National Readmission Database. Among them, patients who underwent TAVI at the index admission and readmitted within 90 days were included. Patients who died or had IE during the index admission were excluded. Clinical outcomes were compared between patients readmitted with IE (IE group) and those without (non-IE group). RESULTS A total of 168,283 patients were readmitted to a hospital within 90 days after TAVI. The median age of the IE group and non-IE group were 81 and 82 years old, respectively (p = 0.21). Of those, 525 (0.3%) were readmitted with IE. The median time from TAVI to readmission was 20 days. During readmissions, 11.6% of the IE group died while only 3.15% of the non-IE group experienced death (p < 0.001). The most common causative organism of IE was enterococcus (22.1%). Multivariable analysis revealed that congestive heart failure, cerebrovascular disease, dialysis, concomitant valve disease, Medicaid, and discharge to a facility were independently associated with readmission with IE within 90 days. CONCLUSION The incidence of readmission with IE is low after TAVI. However, the mortality was markedly high during readmissions. Surgical intervention was rarely performed for IE during the first admission. Enterococcus was the most common organism observed in IE after TAVI. DISCLOSURE IS receives institutional research support from Abbott, Atricure, cryolife, and Medtronic. None related to this manuscript. CLINICAL TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Takuya Ogami
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dustin E Kliner
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Catalin Toma
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Cardiothoracic Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yisi Wang
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Cardiothoracic Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Kostantinis S, Simsek B, Karacsonyi J, Alaswad K, Krestyaninov O, Khelimskii D, Karmpaliotis D, Jaffer FA, Khatri JJ, Poommipanit P, Choi JW, Jaber WA, Rinfret S, Nicholson W, Patel MP, Mahmud E, Dattilo P, Gorgulu S, Koutouzis M, Tsiafoutis I, Elbarouni B, Sheikh AM, Uretsky BF, ElGuindy AM, Jefferson BK, Patel TN, Wollmuth J, Riley RF, Benton SM, Davies RE, Chandwaney RH, Toma C, Yeh RW, Schimmel DR, Abi Rafeh N, Goktekin O, Kerrigan JL, Mastrodemos OC, Rangan BV, Garcia S, Sandoval Y, Burke MN, Brilakis E. In-hospital outcomes and temporal trends of percutaneous coronary interventions for chronic total occlusion. EUROINTERVENTION 2022; 18:e929-e932. [PMID: 36065983 PMCID: PMC9743233 DOI: 10.4244/eij-d-22-00599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/02/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Spyridon Kostantinis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Bahadir Simsek
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Judit Karacsonyi
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Khaldoon Alaswad
- Cardiovascular Division, Henry Ford Hospital Cardiology Heart Care, Detroit, MI, USA
| | | | | | | | | | | | - Paul Poommipanit
- University Hospitals, Case Western Reserve University, Cleveland, OH, USA
| | - James W Choi
- Texas Health Presbyterian Hospital, Dallas, TX, USA
| | | | | | | | | | | | - Philip Dattilo
- UC Health Medical Center of the Rockies, Loveland, CO, USA
| | | | | | | | - Basem Elbarouni
- St. Boniface General Hospital, Winnipeg, Manitoba, MB, Canada
| | | | - Barry F Uretsky
- Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
| | | | | | - Taral N Patel
- Tristar Centennial Medical Center, Nashville, TN, USA
| | - Jason Wollmuth
- Providence Heart and Vascular Institute, Portland, OR, USA
| | | | | | | | | | - Catalin Toma
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert W Yeh
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Olga C Mastrodemos
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Bavana V Rangan
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Santiago Garcia
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Yader Sandoval
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - M Nicholas Burke
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Emmanouil Brilakis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
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Kostantinis S, Simsek B, Karacsonyi J, Alaswad K, Megaly M, Jaffer FA, Khatri JJ, Poommipanit P, Davies RE, Rinfret S, Elbarouni B, Ybarra LF, Sheikh AM, Toma C, Chandwaney R, Abi Rafeh N, Goktekin O, El Guindy AM, Allana S, Mastrodemos OC, Rangan BV, Sandoval Y, Burke MN, Brilakis ES. Saphenous Vein Graft Occlusion Following Native Vessel Chronic Total Occlusion Percutaneous Coronary Intervention. J Invasive Cardiol 2022; 34:E836-E840. [PMID: 36416903] [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] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Whether saphenous vein grafts (SVGs) should be occluded after successful chronic total occlusion (CTO) percutaneous coronary intervention (PCI) of the corresponding native vessel remains controversial. METHODS We analyzed the clinical and angiographic characteristics and procedural outcomes of 51 patients who underwent SVG occlusion following successful CTO-PCI of the corresponding native vessel between 2015 and 2022 at 14 centers. RESULTS Mean patient age was 71 ± 8 years and 80% were men. The most common CTO target vessel was the right coronary artery (41%), followed by the left circumflex (37%). Retrograde crossing through the SVG was the successful crossing strategy in 40 cases (78%). SVG occlusion was achieved with coils (1.9 ± 1.0) in 35 of 51 patients (69%) and vascular plugs in the other 16 cases (31%). All procedures were technically successful and the SVG was occluded completely (TIMI 0 flow) in 38 of the cases (75%), with the remaining cases having TIMI 1 flow. Follow-up was available for 37 patients (73%); during a mean follow-up of 312 days from CTO-PCI, the incidence of target-lesion failure due to restenosis was 5.4% (n = 2) with no other major events reported. CONCLUSION Following native vessel CTO-PCI, SVG occlusion is often performed and is associated with favorable mid-term outcomes.
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Hasan I, Brown JA, Aranda-Michel E, Serna-Gallegos D, Gada H, Kliner D, Toma C, Sanon S, Wang Y, Sultan I. Outcomes of transcatheter aortic valve replacement at teaching versus nonteaching hospitals. J Card Surg 2022; 37:3550-3555. [PMID: 36073067 DOI: 10.1111/jocs.16833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 06/28/2022] [Accepted: 07/11/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Prior studies have demonstrated that outcomes of invasive cardiac interventions may vary by hospital teaching status and volume. As transcatheter aortic valve replacement (TAVR) rapidly expands from teaching to nonteaching hospitals across the country, the clinical impact of hospital teaching status has not been clearly established. This study aimed to compare TAVR outcomes between nonteaching and teaching hospitals. METHODS An observational study was conducted using the Nationwide Readmission Database (NRD). Patients undergoing TAVR from 2011 to 2018 were included. Data was analyzed using multivariable logistic regression to determine outcomes of 30-day mortality and readmission between nonteaching and teaching hospitals. RESULTS A total of 235,321 patients underwent TAVR during the study period. Patients undergoing TAVR at teaching hospitals presented with a higher frequency of baseline comorbidities compared to nonteaching hospitals. Postprocedure complications such as myocardial infarction, arrhythmia, pneumonia, acute kidney injury, sepsis, stroke, and hemorrhage occurred more often at teaching centers (p < 0.001); translating to a higher rate of in-hospital mortality (2.27% vs. 1.99%, p = 0.006) and hospital cost ($48,300 vs. $44,900, p < 0.001) in teaching versus nonteaching hospitals. After adjusting for baseline characteristics and postoperative morbidity, in-hospital mortality (p = 0.095) and readmission rate (p = 0.420) on multivariable analysis were not statistically different between centers. CONCLUSION With the evolution and expansion of TAVR to nonteaching centers, mortality, and readmission rates are not significantly different between nonteaching and teaching hospitals. Higher unadjusted in-hospital mortality at teaching centers suggest these centers more often treat high risk patients with associated increased complications.
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Affiliation(s)
- Irsa Hasan
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James A Brown
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Edgar Aranda-Michel
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hemal Gada
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dustin Kliner
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Saurabh Sanon
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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25
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Toma C. Impact of a blood return system on mechanical thrombectomy-associated blood loss and hemodynamic outcomes in a pulmonary embolism registry. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Mechanical thrombectomy can treat pulmonary embolism (PE) while eliminating the bleeding risks associated with thrombolytic-based therapies. In longer and more complex procedures, however, blood loss from aspiration-based mechanical thrombectomy can potentially limit thrombus removal.
Purpose
Assess a blood return system's ability to reduce mechanical thrombectomy procedure blood loss and characterize hemodynamic outcomes post-procedure.
Methods
This retrospective analysis of a prospective, multicentre, real-world registry enrolling intermediate- and high-risk PE patients treated with mechanical thrombectomy compared all patients enrolled prior to the availability of a blood return system with all patients whose treatment included use of a blood return system. Linear regression was used to model the blood return system's effect on estimated blood loss. The model was adjusted for patient characteristics and disease factors that may have been different between the treatment groups or related to blood loss.
Results
Complete case analysis was used to identify 319 patients prior to the availability of a blood return system (no blood return), and 50 patients who were treated using a blood return system through January 2022 (blood return). As shown in Table 1, the only significant differences in the summary statistics for the blood return group were 160 ml decreased estimated blood loss (292.5 to 132.5 ml; p<0.01) and a 13.1 minute increase in thrombectomy time (47.9 to 61.0 minutes; p<0.01).
Linear regression modeling revealed that use of a blood return system was associated with a 200 ml (69%) reduction (p<0.01) in blood loss for the average patient and thrombectomy time (Figure 1A). Importantly, the addition of an interaction term between thrombectomy time and blood return showed blood loss reduction increased with thrombectomy time (Figure 1B). Post-procedure mean pulmonary arterial pressure decreased by 7.0 mmHg (33.0 to 26.0 mmHg) in the blood return group and 7.9 mmHg (32.1 to 24.2 mmHg) in the no blood return group. In patients with depressed baseline cardiac index (CI) <2, CI improved by 0.3 L/min/m2 (1.8 to 2.1 L/min/m2) in the blood return group and 0.4 L/min/m2 (1.6 to 2.0 L/min/m2) in the no blood return group, demonstrating normalization of depressed CI in both groups. No hemodynamic outcomes differed significantly between groups (p>0.05).
Conclusions
Treatment with aspiration mechanical thrombectomy in combination with a blood return system achieved equivalent hemodynamic outcomes compared with mechanical thrombectomy alone, while reducing 69% of procedure blood loss. The fact that blood return patients had equivalent hemodynamic improvements suggests these improvements are related to thrombus removal rather than aspiration-related blood loss. The association identified between blood loss and thrombectomy time indicates that thrombus removal is not limited by blood loss when a blood return system is used.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Inari Medical
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Affiliation(s)
- C Toma
- University of Pittsburgh Medical Centre , Pittsburgh , United States of America
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26
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Ogami T, Ridgley J, Serna-Gallegos D, Kliner DE, Toma C, Sanon S, Brown JA, Yousef S, Sultan I. Outcomes of Surgical Aortic Valve Replacement After Transcatheter Aortic Valve Implantation. Am J Cardiol 2022; 182:63-68. [PMID: 36075751 DOI: 10.1016/j.amjcard.2022.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 07/10/2022] [Accepted: 07/18/2022] [Indexed: 12/01/2022]
Abstract
Few studies have reported their experience in explantation of a transcatheter heart valve. We found 2,100 patients who underwent transcatheter aortic valve implantation (TAVI) from 2013 through 2021. Of 2,100, a total of 17 patients underwent surgical aortic valve replacement after TAVI, including surgical bailout. The mean age was 78.3 years. Co-morbidities were very frequent, including coronary artery disease (70.6%), atrial fibrillation (52.9%), cerebrovascular disease (47.1%), and pulmonary hypertension (41.2%). A history of cardiac surgery was observed in 6 patients (35.3%). The mean predicted risk of mortality at the time of TAVI was 7.7%. Surgical bailout was the most common indication of valve explantation (n = 8, 47.1%), followed by infective endocarditis (n = 4, 23.5%) and paravalvular leak (n = 2, 11.8%). The valve-in-valve TAVI was not feasible because of endocarditis, paravalvular leak, and history of valve-in-valve TAVI. Overall, 13 (76.5%) were performed urgently or emergently, and 10 (58.9%) required aortic root reconstruction. The mean cardiopulmonary bypass time was 158.5 minutes. In-hospital mortality was 41.2%. Transcatheter heart valve explantation continues to be rare; however, these data will continue to be informative as TAVI explantations will become more common with time.
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Affiliation(s)
- Takuya Ogami
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - Jacqueline Ridgley
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - Dustin E Kliner
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh
| | - Catalin Toma
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh
| | - Saurabh Sanon
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh
| | - James A Brown
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - Sarah Yousef
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - Ibrahim Sultan
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh.
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27
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Castrillon CD, Kliner D, Serna-Gallegos D, Toma C, Sanon S, Smith AC, Yousef S, Brown J, Wang Y, Makani A, Sultan I. TCT-477 Household Income and Readmissions After TAVR. J Am Coll Cardiol 2022. [DOI: 10.1016/j.jacc.2022.08.563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Kostantinis S, Simsek B, Karacsonyi J, Alaswad K, Megaly M, Jaffer F, Khatri J, Poommipanit P, Davies R, Rinfret S, Elbarouni B, Ybarra L, Sheikh A, Toma C, Chandwaney R, Goktekin O, ElGuindy A, Mastrodemos O, Rangan B, Burke MN, Brilakis E. TCT-128 Saphenous Vein Graft Occlusion Following Native Vessel Chronic Total Occlusion Percutaneous Coronary Intervention. J Am Coll Cardiol 2022. [DOI: 10.1016/j.jacc.2022.08.732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Kostantinis S, Simsek B, Karacsonyi J, Alaswad K, Jaffer F, Khatri J, Choi J, Jaber W, Rinfret S, Nicholson W, Patel M, Mahmud E, Toma C, Davies R, Kerrigan J, Haddad E, Gorgulu S, ElGuindy A, Goktekin O, Allana S, Burke MN, Mastrodemos O, Rangan B, Brilakis E. TCT-170 Development and Validation of a Scoring System for Predicting Clinical Coronary Artery Perforation During Percutaneous Coronary Interventions of Chronic Total Occlusions: The PROGRESS-CTO Perforation Score. J Am Coll Cardiol 2022. [DOI: 10.1016/j.jacc.2022.08.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Brown J, Toma C, Kliner D, Serna-Gallegos D, Yousef S, Makani A, Smith AC, Wang Y, Sultan I. TCT-468 Electrocardiographic Risk Factors for the Implantation of a Permanent Pacemaker Within 1 Year of Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2022. [DOI: 10.1016/j.jacc.2022.08.552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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31
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Kostantinis S, Simsek B, Karacsonyi J, Alaswad K, Krestyaninov O, Khelimskii D, Karmpaliotis D, Jaffer FA, Khatri JJ, Poommipanit P, Jaber WA, Rinfret S, Nicholson W, Patel MP, Mahmud E, Koutouzis M, Tsiafoutis I, Benton SM, Davies RE, Toma C, Kerrigan JL, Haddad EV, Abi-Rafeh N, ElGuindy AM, Goktekin O, Mastrodemos OC, Rangan BV, Burke MN, Brilakis ES. Incidence, Mechanisms, Treatment, and Outcomes of Coronary Artery Perforation During Chronic Total Occlusion Percutaneous Coronary Intervention. Am J Cardiol 2022; 182:17-24. [PMID: 36028387 DOI: 10.1016/j.amjcard.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 11/28/2022]
Abstract
Coronary artery perforation is a feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Our objective was to describe the incidence, mechanisms, treatment, and outcomes of coronary artery perforation during CTO PCI. We analyzed the baseline clinical and angiographic characteristics and procedural outcomes of 10,454 CTO PCIs performed in 10,219 patients between 2012 and 2022. The incidence of coronary perforation was 4.9% (n = 503). Patients who experienced coronary perforation were older and were more likely to have had previous coronary artery bypass graft surgery. Procedures that resulted in perforation were more complex, with higher Japanese CTO and Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) scores. Technical (66% vs 87%, p <0.001) and procedural (55% vs 87%, p <0.001) success rates were lower in perforation cases. The CTO target vessel was the most common perforation site (66%). The retrograde approach was responsible for the perforation in 47% of cases, and guidewire exit was the most common perforation mechanism. The proportion of Ellis class 1, 2, 3, and 3 -"cavity spilling" coronary perforations was 20%, 41%, 28%, and 11%, respectively. In 52% of perforations, 1 or more interventions were required: prolonged balloon inflation (23%), covered stent deployment (21%), coil embolization (6%), and/or autologous fat embolization (4%). Tamponade requiring pericardiocentesis occurred in 69 patients (14%). The incidence of major adverse cardiovascular events was higher in perforation cases (18% vs 1.3%, p <0.001). In conclusion, coronary artery perforation occurred in 4.9% of CTO PCIs performed by experienced operators and was associated with lower technical success and higher in-hospital major adverse cardiovascular events.
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Affiliation(s)
- Spyridon Kostantinis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Bahadir Simsek
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Judit Karacsonyi
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Khaldoon Alaswad
- Division of Cardiology, Henry Ford Cardiovascular Division, Detroit, Michigan
| | - Oleg Krestyaninov
- Department of Invasive Cardiology, Meshalkin Novosibirsk Research Institute, Novosibirsk, Russia
| | - Dmitrii Khelimskii
- Department of Invasive Cardiology, Meshalkin Novosibirsk Research Institute, Novosibirsk, Russia
| | - Dimitri Karmpaliotis
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
| | - Farouc A Jaffer
- Cardiovascular Research Center and Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Paul Poommipanit
- Section of Cardiology, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Wissam A Jaber
- Emory Heart and Vascular Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Stephane Rinfret
- Emory Heart and Vascular Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - William Nicholson
- Emory Heart and Vascular Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Mitul P Patel
- Division of Cardiovascular Medicine, University of California San Diego Medical Center, San Diego, California
| | - Ehtisham Mahmud
- Division of Cardiovascular Medicine, University of California San Diego Medical Center, San Diego, California
| | - Michael Koutouzis
- Department of Cardiology, Red Cross Hospital of Athens, Athens, Greece
| | | | - Stewart M Benton
- Department of Cardiology, Wellspan York Hospital, York, Pennsylvania
| | - Rhian E Davies
- Department of Cardiology, Wellspan York Hospital, York, Pennsylvania
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jimmy L Kerrigan
- Department of Cardiology, Saint Thomas Heart Hospital, Nashville, Tennessee
| | - Elias V Haddad
- Department of Cardiology, Saint Thomas Heart Hospital, Nashville, Tennessee
| | - Nidal Abi-Rafeh
- Department of Cardiology, North Oaks Health System, Hammond, Louisiana
| | | | - Omer Goktekin
- Department of Cardiology, Memorial Bahcelievler Hospital, Istanbul, Turkey
| | - Olga C Mastrodemos
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Bavana V Rangan
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - M Nicholas Burke
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota.
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Romeo JD, Bashline MJ, Fowler JA, Kliner DE, Toma C, Smith AJC, Sultan I, Sanon S. Current Status of Transcatheter Tricuspid Valve Therapies. Heart Int 2022; 16:49-58. [PMID: 36275351 PMCID: PMC9524678 DOI: 10.17925/hi.2022.16.1.49] [Citation(s) in RCA: 3] [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: 10/18/2021] [Accepted: 01/10/2022] [Indexed: 01/04/2024] Open
Abstract
Tricuspid regurgitation is a complex disease that carries a poor prognosis, and surgical repair is associated with high mortality. In light of the success of other transcatheter-based valve interventions, transcatheter tricuspid therapy has recently seen exponential use both clinically and in innovation. Given the rapid development of many tricuspid systems and multiple on-going clinical trials, the aim of this review is to highlight the current state of transcatheter tricuspid therapeutics and to provide an up-to-date view of their clinical use, outcomes and future directions.
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Affiliation(s)
- Jared D Romeo
- Division of Cardiology, Department of Medicine, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael J Bashline
- Division of Cardiology, Department of Medicine, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeffrey A Fowler
- Division of Cardiology, Department of Medicine, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Dustin E Kliner
- Division of Cardiology, Department of Medicine, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Catalin Toma
- Division of Cardiology, Department of Medicine, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - AJ Conrad Smith
- Division of Cardiology, Department of Medicine, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ibrahim Sultan
- Division of Cardiology, Department of Medicine, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Saurabh Sanon
- Division of Cardiology, Department of Medicine, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Broughton ST, Aranda-Michel E, Sezer A, Mulukutla SR, Toma C, Kliner DE, Chu D, Sultan I. Long-term Outcomes of Percutaneous Coronary Intervention in Patients with Prior Coronary Artery Bypass Grafting. Heart Surg Forum 2022; 25:E232-E240. [DOI: 10.1532/hsf.4457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/02/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients with a prior coronary artery bypass graft (CABG) may have a need for repeat revascularization, which is typically attempted first via percutaneous coronary intervention (PCI) of either a bypass graft or native vessel. Long-term outcomes of native vessel compared to graft PCI after CABG have not yet been explored in a large institution study.
METHODS Patients with history of prior CABG who underwent PCI at our institution during 2010-2018 were included. Baseline characteristics and long-term outcomes of up to 5 years were compared between native vessel and bypass graft PCI groups. Cox regression was used to adjust for significant covariates in estimation of risk and calculation of hazard ratios.
RESULTS During the study, 4,251 patients with a prior CABG underwent PCI. Native vessel PCI represented 67.1% (n=2,851) of the cohort. After adjusting for significant covariates, bypass graft PCI compared to native vessel PCI had a higher risk of overall mortality (HR 1.15; 95% CI, 1.04-1.29; p<0.05), all-cause readmission (HR 1.16; 95% CI, 1.1-1.3; p<0.05), readmission for PCI (HR 1.25; 95% CI, 1.13-1.38; p<0.05), readmission for heart failure (HR 1.16; 95% CI, 1.06-1.26; p<0.05), and composite of myocardial infarction and revascularization (HR 1.23; 95% CI, 1.12-1.35; p<0.05).
CONCLUSIONS Among patients with prior CABG, bypass graft PCI compared to native vessel PCI was associated with higher risk of adverse long-term outcomes.
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Yousef S, Brown JA, Kliner D, Serna-Gallegos D, Toma C, Sanon S, Mulukutla S, Wang Y, Thoma FW, Sultan I. Transfemoral Versus Subclavian Access for Transcatheter Aortic Valve Replacement. Innovations (Phila) 2022; 17:95-101. [PMID: 35243929 DOI: 10.1177/15569845221079623] [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] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This study sought to compare outcomes of transcatheter aortic valve replacement (TAVR) performed through subclavian access with those performed through transfemoral access. METHODS This was an observational study utilizing an institutional TAVR database from 2010 to 2018. All patients undergoing a TAVR via a transfemoral (TF-TAVR) or subclavian (SC-TAVR) approach were included in the study. The groups were analyzed for differences in operative mortality and postoperative outcomes. Multivariable Cox analysis was performed to identify variables associated with long-term survival after TAVR. RESULTS Of the 1,095 patients identified, 133 patients underwent SC-TAVR and 962 patients underwent TF-TAVR. Patients who underwent SC-TAVR were younger, more likely to have chronic lung disease and peripheral vascular disease, had higher Society of Thoracic Surgeons predicted risk of mortality scores, and were more likely to have self-expanding valves placed (P < 0.05). Operative mortality was similar between the TF-TAVR (2.7%) and SC-TAVR (3.8%) groups. There were no significant differences in stroke, length of stay, 30-day readmission, blood transfusions, acute kidney injury, need for permanent pacemaker, paravalvular leak, or major vascular complications between the groups (P > 0.05). The unadjusted Kaplan-Meier survival estimate for TF-TAVR was significantly higher than for SC-TAVR (P = 0.009, log-rank). However, on multivariable Cox analysis, subclavian access was not significantly associated with an increased hazard of death as compared with transfemoral access (P = 0.21). CONCLUSIONS Outcomes of SC-TAVR are comparable to those of TF-TAVR. Subclavian access may be a favorable alternative approach when TF-TAVR is contraindicated.
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Affiliation(s)
- Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, 6614University of Pittsburgh, PA, USA
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, 6614University of Pittsburgh, PA, USA
| | - Dustin Kliner
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, 6614University of Pittsburgh, PA, USA
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, 6614University of Pittsburgh, PA, USA.,Heart and Vascular Institute, 6595University of Pittsburgh Medical Center, PA, USA
| | - Catalin Toma
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, 6614University of Pittsburgh, PA, USA
| | - Saurabh Sanon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, 6614University of Pittsburgh, PA, USA
| | - Suresh Mulukutla
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, 6614University of Pittsburgh, PA, USA
| | - Yisi Wang
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, 6614University of Pittsburgh, PA, USA.,Heart and Vascular Institute, 6595University of Pittsburgh Medical Center, PA, USA
| | - Floyd W Thoma
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, 6614University of Pittsburgh, PA, USA.,Heart and Vascular Institute, 6595University of Pittsburgh Medical Center, PA, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, 6614University of Pittsburgh, PA, USA.,Heart and Vascular Institute, 6595University of Pittsburgh Medical Center, PA, USA
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Abou Ali AN, Cherfan P, Zaghloul MS, Sridharan N, Lebron BR, Toma C, Chaer RA, Avgerinos ED. Institutional trends over a decade in catheter-directed interventions for pulmonary embolism. Eur J Vasc Endovasc Surg 2022. [DOI: 10.1016/j.ejvs.2022.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Toma C, Bunte MC, Cho KH, Jaber WA, Chambers J, Stegman B, Gondi S, Leung DA, Savin M, Khandhar S, Kado H, Koenig G, Weinberg M, Beasley RE, Roberts J, Angel W, Sarosi MG, Qaqi O, Veerina K, Brown MA, Pollak JS. Percutaneous mechanical thrombectomy in a real-world pulmonary embolism population: Interim results of the FLASH registry. Catheter Cardiovasc Interv 2022; 99:1345-1355. [PMID: 35114059 PMCID: PMC9542558 DOI: 10.1002/ccd.30091] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [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] [Received: 09/23/2021] [Revised: 11/15/2021] [Accepted: 01/09/2022] [Indexed: 11/30/2022]
Abstract
Objectives The FlowTriever All‐Comer Registry for Patient Safety and Hemodynamics (FLASH) is a prospective multi‐center registry evaluating the safety and effectiveness of percutaneous mechanical thrombectomy for treatment of pulmonary embolism (PE) in a real‐world patient population (NCT03761173). This interim analysis reports outcomes for the first 250 patients enrolled in FLASH. Background High‐ and intermediate‐risk PEs are characterized by high mortality rates, frequent readmissions, and long‐term sequelae. Mechanical thrombectomy is emerging as a front‐line therapy for PE that enables immediate thrombus reduction while avoiding the bleeding risks inherent with thrombolytics. Methods The primary endpoint is a composite of major adverse events (MAE) including device‐related death, major bleeding, and intraprocedural device‐ or procedure‐related adverse events at 48 h. Secondary endpoints include on‐table changes in hemodynamics and longer‐term measures including dyspnea, heart rate, and cardiac function. Results Patients were predominantly intermediate‐risk per ESC guidelines (6.8% high‐risk, 93.2% intermediate‐risk). There were three MAEs (1.2%), all of which were major bleeds that resolved without sequelae, with no device‐related injuries, clinical deteriorations, or deaths at 48 h. All‐cause mortality was 0.4% at 30 days, with a single death that was unrelated to PE. Significant on‐table improvements in hemodynamics were noted, including an average reduction in mean pulmonary artery pressure of 7.1 mmHg (22.2%, p < 0.001). Patient symptoms and cardiac function improved through follow‐up. Conclusions These interim results provide preliminary evidence of excellent safety in a real‐world PE population. Reported outcomes suggest that mechanical thrombectomy can result in immediate hemodynamic improvements, symptom reduction, and cardiac function recovery.
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Affiliation(s)
- Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Matthew C Bunte
- Vascular Medicine and Interventional Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Kenneth H Cho
- Interventional Radiology, Albert Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Wissam A Jaber
- Division of Cardiology, Emory University Hospital, Atlanta, Georgia, USA
| | - Jeffrey Chambers
- Interventional Cardiology, Metropolitan Heart and Vascular Institute, Minneapolis, Minnesota, USA
| | - Brian Stegman
- Interventional Cardiology, CentraCare Heart and Vascular Center, St. Cloud, Minnesota, USA
| | - Sreedevi Gondi
- Interventional Cardiology, Baptist Health, Louisville, Kentucky, USA
| | - Daniel A Leung
- Vascular Interventional Radiology, Christiana Care Health System, Newark, Delaware, USA
| | - Michael Savin
- Interventional Radiology, Beaumont Health, Royal Oak, Michigan, USA
| | - Sameer Khandhar
- Division of Cardiology, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Herman Kado
- Interventional Cardiology, Ascension Providence Hospital, Southfield, Michigan, USA
| | - Gerald Koenig
- Interventional Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - Mitchell Weinberg
- Interventional Cardiology, Staten Island University Hospital, Northwell Health, New York, New York, USA
| | - Robert E Beasley
- Vascular Interventional Radiology, Palm Vascular Centers, Miami Beach, Florida, USA
| | - Jon Roberts
- Interventional Radiology, Methodist Healthcare Foundation, Germantown, Tennessee, USA
| | - Wesley Angel
- Interventional Radiology, Methodist Healthcare Foundation, Germantown, Tennessee, USA
| | - Michael G Sarosi
- Interventional Radiology, St. Joseph Mercy Hospital, Ann Arbor, Michigan, USA
| | - Osama Qaqi
- Interventional Cardiology, Ascension Providence Rochester Hospital, Rochester, Michigan, USA
| | - Kalyan Veerina
- Interventional Cardiology, Opelousas General Health System, Opelousas, Louisiana, USA
| | - Michael A Brown
- Interventional Cardiology, Boone Hospital Center, Columbia, Missouri, USA
| | - Jeffrey S Pollak
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
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Popa R, Negoescu A, Ciobanu L, Taulescu M, Marica R, Toma C. Differential Immunoexpression of Thyroid Transcription Factor-1 in Classical Versus Atypical Ovine Pulmonary Adenocarcinoma. J Comp Pathol 2022. [DOI: 10.1016/j.jcpa.2021.11.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Xenogiannis I, Alaswad K, Krestyaninov O, Khelimskii D, Khatri JJ, Choi JW, Jaffer FA, Patel M, Mahmud E, Doing AH, Dattilo P, Koutouzis M, Tsiafoutis I, Uretsky B, Jefferson BK, Patel T, Jaber W, Samady H, Sheikh AM, Yeh RW, Tamez H, Elbarouni B, Love MP, Abi Rafeh N, Maalouf A, Fadi AJ, Toma C, Shah AR, Chandwaney RH, Omer M, Megaly MS, Vemmou E, Nikolakopoulos I, Rangan BV, Garcia S, Abdullah S, Banerjee S, Burke MN, Karmpaliotis D, Brilakis ES. Impacto de la adherencia a un algoritmo híbrido para la selección de la estrategia inicial de cruce en la intervención coronaria percutánea de oclusiones crónicas. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Brown J, Sultan I, Lewis J, Thoma F, Kliner D, Serna-Gallegos D, Sanon S, Mulukutla S, Navid F, Toma C. TCT-44 The Impact of Transcatheter Aortic Valve Replacement on Gastrointestinal Bleeding in Aortic Stenosis. J Am Coll Cardiol 2021. [DOI: 10.1016/j.jacc.2021.09.894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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40
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Toma C. TCT-12 Acute and Long-Term Improvements Following FlowTriever Mechanical Thrombectomy in Patients With Pulmonary Embolism: Six-Month Results From the FLASH Registry. J Am Coll Cardiol 2021. [DOI: 10.1016/j.jacc.2021.09.871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Asif A, Sezer A, Thoma F, Toma C, Schindler J, Fowler J, Smith C, Marroquin OC, Mulukutla SR. Relationship between predicting bleeding complication in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score and mortality among patients with atrial fibrillation undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2021; 98:838-845. [PMID: 33300267 DOI: 10.1002/ccd.29399] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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] [Received: 05/31/2020] [Revised: 10/11/2020] [Accepted: 11/09/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The predicting bleeding complication in patients undergoing stent implantation and subsequent dual antiplatelet therapy, PRECISE-DAPT (P-DAPT) score has been validated in large cohorts as an effective tool in predicting bleeding complication after dual antiplatelet therapy (DAPT) as well as in predicting in-hospital mortality. The implication of using this score to predict outcomes, including mortality in patients with atrial fibrillation (AF) undergoing PCI is unknown. OBJECTIVE Role of P-DAPT score to study clinical outcomes, including mortality, hospitalization, and major bleeding, particularly among patients with AF. METHODS This is a retrospective observational study of 18,850 consecutive patients who underwent percutaneous coronary intervention (PCI) across a large multihospital healthcare system from 2010 to 2019. Patients were stratified into four groups depending on the presence or absence of AF and P-DAPT score, with score ≥ 25 defined as high risk. The primary outcome was all-cause mortality. The secondary outcomes evaluated were hospitalization and major bleeding. RESULTS In the unadjusted analyses, a P-DAPT score ≥ 25, in both AF and non-AF population, was associated with increased mortality, hospitalization, and bleeding. After adjusting for baseline covariates, no significant differences in major bleeding risk were found across the four groups. However, a P-DAPT score of ≥25 in AF patients was associated with a higher risk for hospitalizations related to cardiovascular causes (HR: 2.15 95% CI 2.00-2.3, p < .0001). Among AF patients, P-DAPT score ≥ 25 was found to be strongly associated with mortality (HR 3.5; 95% CI 2.95-4.25, p < .0001) as compared with AF patients with score < 25 (HR 1.18, 95% CI 0.88-1.54, p = .26). CONCLUSION In this large cohort of patients undergoing PCI, the P-DAPT score can help to identify patients at high risk for long-term mortality, particularly among those with atrial fibrillation.
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Affiliation(s)
- Anum Asif
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ahmet Sezer
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John Schindler
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jeffrey Fowler
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Conrad Smith
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Oscar C Marroquin
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Suresh R Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Nikolakopoulos I, Patel T, Jefferson BK, Sheikh AM, Jaber W, Samady H, Khatri JJ, Yeh RW, Tamez H, Koutouzis M, Tsiafoutis I, Jaffer FA, Doing AH, Dattilo P, Uretsky BF, Toma C, Elbarouni B, Alaswad K, Choi JW, Lembo NJ, Parikh M, Kirtane AJ, Ali ZA, Omer M, Vemmou E, Xenogiannis I, Karacsonyi J, Rangan BV, Abdullah S, Banerjee S, Garcia S, Burke MN, Brilakis ES, Karmpaliotis D. Distal Radial Access in Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From the PROGRESS-CTO Registry. J Invasive Cardiol 2021; 33:E717-E722. [PMID: 34433693] [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] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND The outcomes of distal radial access (dRA) in chronic total occlusion percutaneous coronary intervention (CTO-PCI) have received limited study. METHODS We compared the clinical, angiographic, and procedural characteristics of 120 CTO-PCIs performed via dRA access with 2625 CTO-PCIs performed via proximal radial access (pRA) in a large, multicenter registry. RESULTS The dRA group had lower mean PROGRESS-CTO score than the pRA group (1.0 ± 1 vs 1.2 ± 1, respectively; P=.05), while J-CTO score (2.4 ± 1.2 vs 2.3 ± 1.3; P=.43) and PROGRESS-CTO Complications score (2.8 ± 1.8 vs 2.6 ± 1.9; P=.16) were similar in the dRA vs pRA groups, respectively. Technical success was similar in the 2 groups (90% dRA vs 86% pRA; P=.14). Concomitant use of femoral access did not alter procedural success. The incidence of major periprocedural adverse cardiac events was similar in the 2 groups (0.8% dRA vs 2.4% pRA; P=.26), whereas the incidence of tamponade requiring pericardiocentesis was lower with dRA (0% dRA vs 4.69% pRA; P<.001), as was air kerma radiation dose (median, 1.7 Gy; interquartile range [IQR], 0.97-2.63 Gy in the dRA group vs median, 2.27 Gy; IQR, 1.2-3.9 Gy in the pRA group; P<.001). CONCLUSIONS Use of dRA in CTO-PCI is associated with similar procedural success and risk of complications as compared with pRA.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Emmanouil S Brilakis
- Minneapolis Heart Institute, 920 E. 28th Street #300, Minneapolis, MN 55407 USA.
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Abou Ali AN, Cherfan P, Zaghloul MS, Sridharan N, Rivera Lebron B, Toma C, Chaer RA, Avgerinos ED. Catheter Directed Interventions for pulmonary embolism: Institutional Trends over a Decade 2010-2019. J Vasc Surg Venous Lymphat Disord 2021; 10:287-292. [PMID: 34352422 DOI: 10.1016/j.jvsv.2021.06.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/16/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Catheter Directed Interventions (CDIs) are commonly performed for acute Pulmonary Embolism (PE). The evolving catheter types and treatment algorithms impact the utilization and outcomes of these interventions. This study aimed to investigate the changes in CDI practice and their impact on outcomes. METHODS Patients who underwent CDIs for PE between 2010 and 2019 at a single institution were identified from a prospectively maintained database. A PE team was launched in 2012, and in 2014 was established as an official Pulmonary Embolism Response Team (PERT). CDI annual usage trends and clinical failures were recorded. Clinical success was defined as physiologic improvement in the absence of major bleeding, perioperative stroke or other procedure-related adverse event, decompensation for sub-massive or persistent shock for massive PE, need for surgical thromboembolectomy or death. Major bleeding was defined as requiring a blood transfusion, a surgical intervention, or suffering from an intracranial hemorrhage. RESULTS 372 patients received a CDI for acute PE during the study period: age 58.9±15.4 years, males 187 (50.3%), sub-massive PE 340 (91.4%). CDI showed a steep increase in the early PERT years, peaking in 2016 with a subsequent decline. Ultrasound-assisted thrombolysis was the predominant CDI technique peaking at 84% of all CDI in 2014. Suction thrombectomy utilization peaked at 15.2% of CDI in 2019. Mean alteplase dose with catheter thrombolysis techniques decreased from 26.8±12.5mg in 2013 to 13.9±7.5mg in 2019 (P<.001). Mean lysis time decreased from 17.2±8.3 hours in 2013 to 11.3±8.2 hours in 2019 (P<.001). Clinical success for the massive and the submassive PE cohorts was 58.1% and 91.2% respectively; the major bleed rate was 25.0% and 5.3%. There were two major clinical success peaks, one in 2015 mirroring our technical learning curve and one in 2019 mirroring our patient selection learning curve. The clinical success drop in 2018 was primarily derived from blood transfusions due to acute blood loss during suction thrombectomy. CONCLUSIONS CDIs for acute PE have rapidly evolved with high success rates. Multidisciplinary approaches amongst centers with appropriate expertise are advisable for the safe and successful implementation of catheter interventions.
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Affiliation(s)
- Adham N Abou Ali
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Patrick Cherfan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mohamed S Zaghloul
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Natalie Sridharan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Belinda Rivera Lebron
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Catalin Toma
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
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Fabrizio C, Levito MN, Rivosecchi R, Bashline M, Slocum B, Kilic A, Toma C, Murray H, Ramanan R, Fowler J, Hickey GW, Horn ET. Outcomes of systemic anticoagulation with bivalirudin for Impella 5.0. Int J Artif Organs 2021; 44:681-686. [PMID: 34250827 DOI: 10.1177/03913988211032238] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Temporary mechanical circulatory support (tMCS) devices are used for the management of cardiogenic shock. The Impella 5.0 (Abiomed; Danvers, MA) (IMP5) is a commonly used, surgically implanted, tMCS device that requires systemic anticoagulation and purge solution to avoid pump failure. To avoid heparin-induced thrombocytopenia (HIT) from unfractionated heparin (UFH) use, our program has explored the utility of bivalirudin (BIV) for systemic anticoagulation in IMP5. This single center, retrospective study included patients supported on IMP5 with BIV based AC. The efficacy and safety end points were recovery, bridge to left ventricular assist device (LVAD), cardiac transplant (HTX), or death as well as clinically significant bleeding, incidence of Tissue Plasminogen Activator (tPA) use for suspected pump thrombosis, stroke, and device failure. There were 31 patients included, and 26 (84%) received BIV purge solutions. The median duration of IMP5 was 6 (IQR 4-10) days. Most patients were bridged to LVAD (39%, 12); 16% (5) were bridged to HTX, 16% (5) recovered, and 29% (9) died. One patient (3%) suffered from ischemic stroke and 12% (4) patients developed clinically significant bleeding. tPA was administered to 8 (26%) patients. Logistic regression analysis demonstrated that duration of IMP5 was a significant predictor of tPA use (OR 1.28; 95% Confidence Interval 1.04-1.56). There were no cases of pump failure. Our experience highlights the feasibility of utilizing BIV for routine AC use in IMP5.
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Affiliation(s)
- Carly Fabrizio
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Marissa N Levito
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ryan Rivosecchi
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael Bashline
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Brittany Slocum
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arman Kilic
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Holt Murray
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeffrey Fowler
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gavin W Hickey
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Edward T Horn
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Tefas C, Ciobanu L, Berce C, Meșter A, Onica S, Toma C, Tanțău M, Taulescu M. Beneficial effect of oral administration of zinc sulfate on 5-fluorouracil-induced gastrointestinal mucositis in rats. Eur Rev Med Pharmacol Sci 2021; 24:11365-11373. [PMID: 33215457 DOI: 10.26355/eurrev_202011_23628] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE This experimental study explored the potential of oral zinc sulfate to protect the gut mucosa from 5-fluorouracil (5-FU)-induced degenerative lesions in Wistar rats. MATERIALS AND METHODS Female Wistar rats were used and divided into 2 interventional groups (Z with 6 animals and F with 5 animals) and one control group (M with 5 rats). After 2 hours of fasting, group Z received via oral gavage 1.5 ml of solution, corresponding to 15 mg zinc sulfate for 9 consecutive days. Groups F and M received only the vehicles. On day 3, 400 mg/kg of 5-FU was administered intraperitoneally to groups Z and F. Tissue samples were collected from the duodenum, jejunum, colon and liver. Histological assessment for each gastrointestinal tract segment was determined semi-quantitatively by rating 11 histological features from normal (0) to severe (3). The independent groups were analyzed using the Kruskal-Wallis test and the Mann-Whitney U-test, with a Bonferroni correction for alpha (p ≤ 0.016). RESULTS In group F the jejunum was the most affected area with a mean histological score of 27 (25-32). In the Z group, significantly lower histological scores were obtained compared with group F (duodenum Z vs. F: U = 0, p = 0.004; jejunum Z vs. F: U = 0, p = 0.006 and colon: Z vs. F: U = 0, p = 0.005). Graded liver necro-inflammatory lesions were significantly lower in group Z compared with group F (U = 0, p = 0.004), suggesting fewer bacterial intestinal translocation processes. CONCLUSIONS Zinc sulfate has a beneficial role, decreasing the severity of gut mucosal injuries induced by 5-FU in Wistar rats.
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Affiliation(s)
- C Tefas
- Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
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Routh S, Fabrizio C, Sciortino CM, Kilic A, Toma C, Ramanan R, Fowler JA, Randhawa PS, Hickey GW. Acute right ventricular failure in a patient with nonischemic cardiogenic shock on left-sided mechanical circulatory support. J Card Surg 2021; 36:3884-3888. [PMID: 34148246 DOI: 10.1111/jocs.15756] [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: 04/06/2021] [Revised: 06/04/2021] [Accepted: 06/07/2021] [Indexed: 11/28/2022]
Abstract
We report a case of acute right ventricular failure in a patient with cardiogenic shock on left-sided mechanical circulatory support with Impella 5.0. The patient was successfully bridged to heart transplantation using additional right-sided support with Protek Duo. Key learning points of the case include prompt recognition of acute right ventricular failure in patients on left-sided support, early consideration of right-ventricular mechanical support platforms, and timely deployment of right-sided mechanical support.
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Affiliation(s)
- Shuvodra Routh
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carly Fabrizio
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Arman Kilic
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Catalin Toma
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Raj Ramanan
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jeffrey A Fowler
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Gavin W Hickey
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Avgerinos ED, Jaber W, Lacomis J, Markel K, McDaniel M, Rivera-Lebron BN, Ross CB, Sechrist J, Toma C, Chaer R. Randomized Trial Comparing Standard Versus Ultrasound-Assisted Thrombolysis for Submassive Pulmonary Embolism: The SUNSET sPE Trial. JACC Cardiovasc Interv 2021; 14:1364-1373. [PMID: 34167677 DOI: 10.1016/j.jcin.2021.04.049] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The aim of this trial was to determine whether ultrasound-assisted thrombolysis (USAT) is superior to standard catheter-directed thrombolysis (SCDT) in pulmonary arterial thrombus reduction for patients with submassive pulmonary embolism (sPE). BACKGROUND Catheter-directed therapy has been increasingly used in sPE and massive pulmonary embolism as a decompensation prevention and potentially lifesaving procedure. It is unproved whether USAT is superior to SCDT using traditional multiple-side-hole catheters in the treatment of patients with pulmonary embolism. METHODS Adults with sPE were enrolled. Participants were randomized 1:1 to USAT or SCDT. The primary outcome was 48-hour clearance of pulmonary thrombus assessed by pre- and postprocedural computed tomographic angiography using a refined Miller score. Secondary outcomes included improvement in right ventricular-to-left ventricular ratio, intensive care unit and hospital stay, bleeding, and adverse events up to 90 days. RESULTS Eighty-one patients with acute sPE were randomized and were available for analysis. The mean total dose of alteplase for USAT was 19 ± 7 mg and for SCDT was 18 ± 7 mg (P = 0.53), infused over 14 ± 6 and 14 ± 5 hours, respectively (P = 0.99). In the USAT group, the mean raw pulmonary arterial thrombus score was reduced from 31 ± 4 at baseline to 22 ± 7 (P < 0.001). In the SCDT group, the score was reduced from 33 ± 4 to 23 ± 7 (P < 0.001). There was no significant difference in mean thrombus score reduction between the 2 groups (P = 0.76). The mean reduction in right ventricular/left ventricular ratio from baseline (1.54 ± 0.30 for USAT, 1.69 ± 0.44 for SCDT) to 48 hours was 0.37 ± 0.34 in the USAT group and 0.59 ± 0.42 in the SCDT group (P = 0.01). Major bleeding (1 stroke and 1 vaginal bleed requiring transfusion) occurred in 2 patients, both in the USAT group. CONCLUSIONS In the SUNSET sPE (Standard vs. Ultrasound-Assisted Catheter Thrombolysis for Submassive Pulmonary Embolism) trial, patients undergoing USAT had similar pulmonary arterial thrombus reduction compared with those undergoing SCDT, using comparable mean lytic doses and durations of lysis.
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Affiliation(s)
- Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Wissam Jaber
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Joan Lacomis
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kyle Markel
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael McDaniel
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Belinda N Rivera-Lebron
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Charles B Ross
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jacob Sechrist
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Rabih Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Karacsonyi J, Tsiafoutis I, Alaswad K, Khatri J, Choi J, Karmpaliotis D, ElGuindy A, Sheikh AM, Jaber W, Elbarouni B, Jaffer F, Poomipanit P, Chandwaney R, Krestianinov O, Uretsky B, Patel M, Toma C, Yeh R, Vemmou E, Nikolakopoulos I, Xenogiannis I, Rangan B, Ungi I, Brilakis E, Koutouzis M. THE IMPACT OF ANNUAL OPERATOR VOLUME ON THE OUTCOMES OF CHRONIC TOTAL OCCLUSION PERCUTANEOUS CORONARY INTERVENTION. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)02317-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vemmou E, Alaswad K, Khatri J, Karmpaliotis D, Mahmud E, Doing A, Dattilo P, Koutouzis M, Tsiafoutis I, Uretsky B, Toma C, Elbarouni B, Love M, Jaber W, Samady H, Jefferson B, Patel T, Abi-Rafeh N, Rangan B, Nikolakopoulos I, Karacsonyi J, Garcia S, Burke MN, Baechler C, Brilakis E. CHARACTERISTICS AND OUTCOMES OF CHRONIC TOTAL OCCLUSION (CTO) PERCUTANEOUS CORONARY INTERVENTION (PCI) ACCORDING TO RACE, INSIGHTS FROM THE PROGRESS-CTO REGISTRY. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)02554-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Supady A, DellaVolpe J, Taccone FS, Scharpf D, Ulmer M, Lepper PM, Halbe M, Ziegeler S, Vogt A, Ramanan R, Boldt D, Stecher SS, Montisci A, Spangenberg T, Marggraf O, Kunavarapu C, Peluso L, Muenz S, Buerle M, Nagaraj NG, Nuding S, Toma C, Gudzenko V, Stemmler HJ, Pappalardo F, Trummer G, Benk C, Michels G, Duerschmied D, von zur Muehlen C, Bode C, Kaier K, Brodie D, Wengenmayer T, Staudacher DL. Outcome Prediction in Patients with Severe COVID-19 Requiring Extracorporeal Membrane Oxygenation-A Retrospective International Multicenter Study. Membranes (Basel) 2021; 11:membranes11030170. [PMID: 33673615 PMCID: PMC7997249 DOI: 10.3390/membranes11030170] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/22/2021] [Accepted: 02/24/2021] [Indexed: 02/06/2023]
Abstract
The role of veno-venous extracorporeal membrane oxygenation therapy (V-V ECMO) in severe COVID-19 acute respiratory distress syndrome (ARDS) is still under debate and conclusive data from large cohorts are scarce. Furthermore, criteria for the selection of patients that benefit most from this highly invasive and resource-demanding therapy are yet to be defined. In this study, we assess survival in an international multicenter cohort of COVID-19 patients treated with V-V ECMO and evaluate the performance of several clinical scores to predict 30-day survival. Methods: This is an investigator-initiated retrospective non-interventional international multicenter registry study (NCT04405973, first registered 28 May 2020). In 127 patients treated with V-V ECMO at 15 centers in Germany, Switzerland, Italy, Belgium, and the United States, we calculated the Sequential Organ Failure Assessment (SOFA) Score, Simplified Acute Physiology Score II (SAPS II), Acute Physiology And Chronic Health Evaluation II (APACHE II) Score, Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) Score, Predicting Death for Severe ARDS on V-V ECMO (PRESERVE) Score, and 30-day survival. Results: In our study cohort which enrolled 127 patients, overall 30-day survival was 54%. Median SOFA, SAPS II, APACHE II, RESP, and PRESERVE were 9, 36, 17, 1, and 4, respectively. The prognostic accuracy for all these scores (area under the receiver operating characteristic—AUROC) ranged between 0.548 and 0.605. Conclusions: The use of scores for the prediction of mortality cannot be recommended for treatment decisions in severe COVID-19 ARDS undergoing V-V ECMO; nevertheless, scoring results below or above a specific cut-off value may be considered as an additional tool in the evaluation of prognosis. Survival rates in this cohort of COVID-19 patients treated with V-V ECMO were slightly lower than those reported in non-COVID-19 ARDS patients treated with V-V ECMO.
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Affiliation(s)
- Alexander Supady
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany; (D.D.); (C.v.z.M.); (C.B.); (T.W.); (D.L.S.)
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, 79106 Freiburg, Germany;
- Heidelberg Institute of Global Health, University of Heidelberg, 69120 Heidelberg, Germany
- Correspondence:
| | - Jeff DellaVolpe
- Methodist Hospital, San Antonio, TX 78229, USA; (J.D.); (C.K.)
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium; (F.S.T.); (L.P.)
| | - Dominik Scharpf
- SLK-Hospital Heilbronn, 74078 Heilbronn, Germany; (D.S.); (S.M.)
| | - Matthias Ulmer
- RKH Hospital Ludwigsburg, 71640 Ludwigsburg, Germany; (M.U.); (M.B.)
| | - Philipp M. Lepper
- Department of Internal Medicine V—Pneumology, Allergology and Critical Care Medicine, Saarland University Medical Center and University of Saarland, D-66421 Homburg, Germany;
| | - Maximilian Halbe
- Heart Center, University Hospital Zurich, 8006 Zurich, Switzerland; (M.H.); (N.G.N.)
| | - Stephan Ziegeler
- Department of Anesthesiology, Intensive Care Medicine and Pain Management, Hospital Ibbenbueren, 49477 Ibbenbueren, Germany;
| | - Alexander Vogt
- Department of Medicine III, University Clinic Halle (Saale), 06097 Halle (Saale), Germany; (A.V.); (S.N.)
| | - Raj Ramanan
- University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA 15213, USA; (R.R.); (C.T.)
| | - David Boldt
- UCLA Healthcare System, Los Angeles, CA 90095, USA; (D.B.); (V.G.)
| | | | - Andrea Montisci
- Istituto Clinico Sant’Ambrogio, University of Milan, 20149 Milan, Italy;
| | - Tobias Spangenberg
- Department of Cardiology, Angiology and Intensive Care, Marien Hospital Hamburg, 22087 Hamburg, Germany;
| | | | | | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium; (F.S.T.); (L.P.)
| | - Sebastian Muenz
- SLK-Hospital Heilbronn, 74078 Heilbronn, Germany; (D.S.); (S.M.)
| | - Monica Buerle
- RKH Hospital Ludwigsburg, 71640 Ludwigsburg, Germany; (M.U.); (M.B.)
| | - Naveen G. Nagaraj
- Heart Center, University Hospital Zurich, 8006 Zurich, Switzerland; (M.H.); (N.G.N.)
| | - Sebastian Nuding
- Department of Medicine III, University Clinic Halle (Saale), 06097 Halle (Saale), Germany; (A.V.); (S.N.)
| | - Catalin Toma
- University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA 15213, USA; (R.R.); (C.T.)
| | - Vadim Gudzenko
- UCLA Healthcare System, Los Angeles, CA 90095, USA; (D.B.); (V.G.)
| | | | - Federico Pappalardo
- Department of Anesthesia and Intensive Care, IRCCS ISMETT, UPMC Italy, 90127 Palermo, Italy;
| | - Georg Trummer
- Department of Cardiovascular Surgery, Heart Center, University of Freiburg, 79106 Freiburg, Germany; (G.T.); (C.B.)
| | - Christoph Benk
- Department of Cardiovascular Surgery, Heart Center, University of Freiburg, 79106 Freiburg, Germany; (G.T.); (C.B.)
| | - Guido Michels
- Department of Acute and Emergency Care, St. Antonius Hospital Eschweiler, 52249 Eschweiler, Germany;
| | - Daniel Duerschmied
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany; (D.D.); (C.v.z.M.); (C.B.); (T.W.); (D.L.S.)
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, 79106 Freiburg, Germany;
| | - Constantin von zur Muehlen
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany; (D.D.); (C.v.z.M.); (C.B.); (T.W.); (D.L.S.)
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, 79106 Freiburg, Germany;
| | - Christoph Bode
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany; (D.D.); (C.v.z.M.); (C.B.); (T.W.); (D.L.S.)
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, 79106 Freiburg, Germany;
| | - Klaus Kaier
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, 79106 Freiburg, Germany;
- Institute of Medical Biometry and Statistics, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY 10032, USA;
| | - Tobias Wengenmayer
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany; (D.D.); (C.v.z.M.); (C.B.); (T.W.); (D.L.S.)
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, 79106 Freiburg, Germany;
| | - Dawid L. Staudacher
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany; (D.D.); (C.v.z.M.); (C.B.); (T.W.); (D.L.S.)
- Department of Cardiology and Angiology I, Heart Center, University of Freiburg, 79106 Freiburg, Germany;
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