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Patel KP, Baumbach A. Delineation of Acute Coronary Syndromes: The Acute Total Occlusion versus ST segment paradigm. Eur Heart J Qual Care Clin Outcomes 2024:qcae030. [PMID: 38637318 DOI: 10.1093/ehjqcco/qcae030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Affiliation(s)
- Kush P Patel
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Andreas Baumbach
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
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Patel KP, Lansky AJ, Kelbæk H, Xu B, van Royen N, Johnson TW, Anderson R, Wijns W, Baumbach A. Long-Term Percutaneous Coronary Intervention Outcomes in Chronic Versus Acute Coronary Syndromes (TARGET All Comers Trial). Am J Cardiol 2024; 217:94-101. [PMID: 38350507 DOI: 10.1016/j.amjcard.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/20/2023] [Accepted: 12/08/2023] [Indexed: 02/15/2024]
Abstract
In the Targeted therapy with a localised abluminal coated, low-dose sirolimus-eluting, biodegreadable polymer coronary stent (TARGET; NCT02520180) All Comers trial the biodegradable polymer (BP) sirolimus-eluting FIREHAWK stent was noninferior to the durable polymer (DP) everolimus-eluting XIENCE stent with respect to target lesion failure (TLF) at 1 and 5 years; however, the long-term safety and efficacy in the setting of acute coronary syndromes (ACS) are not known. We sought to assess the long-term outcomes in ACS versus chronic coronary syndromes (CCS) with BP sirolimus-eluting stent (SES) versus DP everolimus-eluting stent (EES). The TARGET AC study was a multicenter, open-label, noninferiority trial of all comer patients randomly allocated 1:1 to BP SES or DP EES (stratified by ST-elevation myocardial infarction and study site). In this predefined substudy, the outcomes were compared based on clinical presentation (ACS vs CCS) and treatment allocation. A total of 1,653 patients were enrolled (728 with ACS and 922 with CCS), with 94% completing the 5-year follow-up. The baseline characteristics were well-matched between the 2 stent types; however, co-morbidities were more prevalent in the CCS than in the ACS population. TLF (15.5% vs 17.7%, p = 0.24), patient-oriented outcomes (32.0% vs 34.4%, p = 0.31), and stent thrombosis (4.1% vs 3.3%, p = 0.40) were similar between patients with ACS and patients with CCS. In the ACS cohort, the outcomes at 5 years for BP SES versus DP EES were similar for TLF (16.0% vs 14.9%, p = 0.70), ischemia-driven target lesion revascularization (5.6% vs 8.3%, p = 0.17), and definite/probable stent thrombosis (2.7% vs 4.6%, p = 0.18). The same was true for the CCS cohort, with 5-year outcomes for BP SES versus DP EES for TLF (18.0% vs 17.4%, p = 0.82), ischemia-driven target lesion revascularization (6.4% vs 5.0%, p = 0.37), and definite/probable stent thrombosis (3.0% vs 1.8%, p = 0.26). In conclusion, in the TARGET AC trial, 1 in 3 patients had a major adverse event at 5 years, irrespective of CCS or ACS presentation. Long-term, the BP sirolimus-eluting FIREHAWK stent was as safe and effective as the DP everolimus-eluting XIENCE stent across the spectrum of clinical presentations.
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Affiliation(s)
- Kush P Patel
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Alexandra J Lansky
- Division of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Henning Kelbæk
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark
| | - Bo Xu
- Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China; Peking Union Medical College, Beijing, China
| | - Niels van Royen
- Department of Cardiology, Radbound University, Nijmegen, the Netherlands
| | - Thomas W Johnson
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom; University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Richard Anderson
- Department of Cardiology, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, University of Galway, Galway, Ireland
| | - Andreas Baumbach
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom.
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Patel KP, Baumbach A. Timing treatment for tricuspid regurgitation. Eur Heart J 2024; 45:598-600. [PMID: 37950518 DOI: 10.1093/eurheartj/ehad768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 11/12/2023] Open
Affiliation(s)
- Kush P Patel
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London EC1M 6BQ, UK
| | - Andreas Baumbach
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London EC1M 6BQ, UK
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Kumar NS, Khanji MY, Patel KP, Ricci F, Providencia R, Chahal A, Sohaib A, Awad WI. Surgical management of atrial fibrillation in patients undergoing cardiac surgery: a systematic review of clinical practice guidelines and recommendations. Eur Heart J Qual Care Clin Outcomes 2024; 10:14-24. [PMID: 37873664 DOI: 10.1093/ehjqcco/qcad060] [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: 07/03/2023] [Revised: 09/20/2023] [Accepted: 10/20/2023] [Indexed: 10/25/2023]
Abstract
AIMS Surgical ablation of atrial fibrillation (AF) has been demonstrated to be a safe procedure conducted concomitantly alongside cardiac surgery. However, there are conflicting guideline recommendations surrounding indications for surgical ablation. We conducted a systematic review of current recommendations on concomitant surgical AF ablation. METHODS AND RESULTS We identified publications from MEDLINE and EMBASE between January 2011 and December 2022 and additionally searched Guideline libraries and websites of relevant organizations in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Of 895 studies screened, 4 were rigorously developed (AGREE-II > 50%) and included. All guidelines agreed on the definitions of paroxysmal, persistent, and longstanding AF based on duration and refraction to current treatment modalities. In the Australia-New Zealand (CSANZ) and European (EACTS) guidelines, opportunistic screening for patients >65 years is recommended. The EACTS recommends systematic screening for those aged >75 or at high stroke risk (Class IIa, Level B). However, this was not recommended by American Heart Association or Society of Thoracic Surgeons guidelines. All guidelines identified surgical AF ablation during concomitant cardiac surgery as safe and recommended for consideration by a Heart Team with notable variation in recommendation strength and the specific indication (three guidelines fail to specify any indication for surgery). Only the STS recommended left atrial appendage occlusion (LAAO) alongside surgical ablation (Class IIa, Level C). CONCLUSION Disagreements exist in recommendations for specific indications for concomitant AF ablation and LAAO, with the decision subject to Heart Team assessment. Further evidence is needed to develop recommendations for specific indications for concomitant AF procedures and guidelines need to be made congruent.
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Affiliation(s)
- Niraj S Kumar
- Barts Heart Centre, St. Bartholomew's Hospital, London, UK
- National Medical Research Association, London, UK
| | - Mohammed Y Khanji
- Barts Heart Centre, St. Bartholomew's Hospital, London, UK
- Newham University Hospital, Barts Health NHS Trust, London, UK
- NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Kush P Patel
- Barts Heart Centre, St. Bartholomew's Hospital, London, UK
- Institute of Cardiovascular Sciences, University College London, UK
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, G.d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Rui Providencia
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Anwar Chahal
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Wael I Awad
- Barts Heart Centre, St. Bartholomew's Hospital, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
- University of South Wales, Cardiff, UK
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Patel KP, McKenna M, Thornton GD, Vandermolen S, Abdulelah ZA, Awad W, Baumbach A, Mathur A, Treibel TA, Lloyd G, Mullen MJ, Bhattacharyya S. Predictors of outcome in patients with moderate mixed aortic valve disease. Heart 2023:heartjnl-2023-323321. [PMID: 38148159 DOI: 10.1136/heartjnl-2023-323321] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/13/2023] [Indexed: 12/28/2023] Open
Abstract
OBJECTIVES Grading the severity of moderate mixed aortic stenosis and regurgitation (MAVD) is challenging and the disease poorly understood. Identifying markers of haemodynamic severity will improve risk stratification and potentially guide timely treatment. This study aims to identify prognostic haemodynamic markers in patients with moderate MAVD. METHODS Moderate MAVD was defined as coexisting moderate aortic stenosis (aortic valve area (AVA) 1.0-1.5 cm2) and moderate aortic regurgitation (vena contracta (VC) 0.3-0.6 cm). Consecutive patients diagnosed between 2015 and 2019 were included from a multicentre registry. The primary composite outcome of death or heart failure hospitalisation was evaluated among these patients. Demographics, comorbidities, echocardiography and treatment data were assessed for their prognostic significance. RESULTS 207 patients with moderate MAVD were included, aged 78 (66-84) years, 56% male sex, AVA 1.2 (1.1-1.4) cm2 and VC 0.4 (0.4-0.5) cm. Over a follow-up of 3.5 (2.5-4.7) years, the composite outcome was met in 89 patients (43%). Univariable associations with the primary outcome included older age, previous myocardial infarction, previous cerebrovascular event, atrial fibrillation, New York Heart Association >2, worse renal function, tricuspid regurgitation ≥2 and mitral regurgitation ≥2. Markers of biventricular systolic function, cardiac remodelling and transaortic valve haemodynamics demonstrated an inverse association with the primary composite outcome. In multivariable analysis, peak aortic jet velocity (Vmax) was independently and inversely associated with the composite outcome (HR: 0.63, 95% CI 0.43 to 0.93; p=0.021) in an adjusted model along with age (HR: 1.05, 95% CI 1.03 to 1.08; p<0.001), creatinine (HR: 1.002, 95% CI 1.001 to 1.003; p=0.005), previous cerebrovascular event (85% vs 42%; HR: 3.04, 95% CI 1.54 to 5.99; p=0.001) and left ventricular ejection fraction (LVEF) (HR: 0.97, 95% CI 0.95 to 0.99; p=0.007). Patients with Vmax ≤2.8 m/s and LVEF ≤50% (n=27) had the worst outcome compared with the rest of the population (72% vs 41%; HR: 3.87, 95% CI 2.20 to 6.80; p<0.001). CONCLUSIONS Patients with truly moderate MAVD have a high incidence of death and heart failure hospitalisation (43% at 3.5 (2.5-4.7) years). Within this group, a high-risk group characterised by disproportionately low aortic Vmax (≤2.8 m/s) and adverse remodelling (LVEF ≤50%) have the worst outcomes.
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Affiliation(s)
- Kush P Patel
- Institute of Cardiovascular Science, University College London, London, UK
- Barts Heart Centre, West Smithfield, London, UK
| | | | - George D Thornton
- Institute of Cardiovascular Science, University College London, London, UK
- Barts Heart Centre, West Smithfield, London, UK
| | - Sebastian Vandermolen
- Institute of Cardiovascular Science, University College London, London, UK
- The William Harvey Research Institute, Queen Mary University, London, UK
| | | | - Wael Awad
- Barts Heart Centre, West Smithfield, London, UK
| | - Andreas Baumbach
- Barts Heart Centre, West Smithfield, London, UK
- The William Harvey Research Institute, Queen Mary University, London, UK
| | - Anthony Mathur
- Barts Heart Centre, West Smithfield, London, UK
- The William Harvey Research Institute, Queen Mary University, London, UK
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, London, UK
- Barts Heart Centre, West Smithfield, London, UK
| | - Guy Lloyd
- Barts Heart Centre, West Smithfield, London, UK
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Toscano E, Ahmed MS, Patel KP, Treibel T, Kennon S, Baumbach A. Percutaneous Treatment of Severe Aortic Regurgitation After Surgical Mitral Valve Repair. JACC Case Rep 2023; 28:102131. [PMID: 38204547 PMCID: PMC10774882 DOI: 10.1016/j.jaccas.2023.102131] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 10/23/2023] [Accepted: 10/27/2023] [Indexed: 01/12/2024]
Abstract
A 54-year-old woman who had recently undergone surgical mitral and tricuspid valve repair was diagnosed with severe aortic regurgitation. She was scheduled for percutaneous treatment and underwent successful transcatheter aortic valve implantation with a 27-mm Trilogy valve (JenaValve Technology). The case documents feasibility of percutaneous treatment in the presence of a mitral ring.
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Affiliation(s)
- Evelina Toscano
- Interventional Cardiology Unit, Policlinico di Monza, Monza, Italy
| | - Mahmoud Saad Ahmed
- Barts Heart Centre, London, United Kingdom
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Kush P. Patel
- Barts Heart Centre, London, United Kingdom
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Thomas Treibel
- Barts Heart Centre, London, United Kingdom
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Simon Kennon
- Barts Heart Centre, London, United Kingdom
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Andreas Baumbach
- Barts Heart Centre, London, United Kingdom
- Center for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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Patel KP, Lin A, Kumar N, Esposito G, Grodecki K, Lloyd G, Mathur A, Baumbach A, Mullen MJ, Williams MC, Newby DE, Treibel TA, Dweck MR, Dey D. Influence of cusp morphology and sex on quantitative valve composition in severe aortic stenosis. Eur Heart J Cardiovasc Imaging 2023; 24:1653-1660. [PMID: 37339331 DOI: 10.1093/ehjci/jead142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/09/2023] [Accepted: 06/02/2023] [Indexed: 06/22/2023] Open
Abstract
AIMS Aortic stenosis is characterized by fibrosis and calcification of the valve, with a higher proportion of fibrosis observed in women. Stenotic bicuspid aortic valves progress more rapidly than tricuspid valves, which may also influence the relative composition of the valve. We aimed to investigate the influence of cusp morphology on quantitative aortic valve composition quantified from contrast-enhanced computed tomography angiography in severe aortic stenosis. METHODS AND RESULTS Patients undergoing transcatheter aortic valve implantation with bicuspid and tricuspid valves were propensity matched 1:1 by age, sex, and comorbidities. Computed tomography angiograms were analysed using semi-automated software to quantify the fibrotic and calcific scores (volume/valve annular area) and the fibro-calcific ratio (fibrotic score/calcific score). The study population (n = 140) was elderly (76 ± 10 years, 62% male) and had a peak aortic jet velocity of 4.1 ± 0.7 m/s. Compared with those with tricuspid valves (n = 70), patients with bicuspid valves (n = 70) had higher fibrotic scores [204 (interquartile range 118-267) vs. 144 (99-208) mm3/cm2, P = 0.006] with similar calcific scores (P = 0.614). Women had greater fibrotic scores than men in bicuspid [224 (181-307) vs. 169 (109-247) mm3/cm2, P = 0.042] but not tricuspid valves (P = 0.232). Men had greater calcific scores than women in both bicuspid [203 (124-355) vs. 130 (70-182) mm3/cm2, P = 0.008] and tricuspid [177 (136-249) vs. 100 (62-150) mm3/cm2, P = 0.004] valves. Among both valve types, women had a greater fibro-calcific ratio compared with men [tricuspid 1.86 (0.94-2.56) vs. 0.86 (0.54-1.24), P = 0.001 and bicuspid 1.78 (1.21-2.90) vs. 0.74 (0.44-1.53), P = 0.001]. CONCLUSIONS In severe aortic stenosis, bicuspid valves have proportionately more fibrosis than tricuspid valves, especially in women.
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Affiliation(s)
- Kush P Patel
- Department of Cardiology, Barts Health NHS Trust, London, UK
| | - Andrew Lin
- Department of Cardiology, Barts Health NHS Trust, London, UK
- Departments of Biomedical Sciences and Medicine, Cedars-Sinai Medical Center, Biomedical Imaging Research Institute, 116N Robertson Blvd, Suite 400, Los Angeles, CA 90048, USA
| | - Niraj Kumar
- Department of Cardiology, Barts Health NHS Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Giulia Esposito
- Department of Cardiology, Barts Health NHS Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Kajetan Grodecki
- Departments of Biomedical Sciences and Medicine, Cedars-Sinai Medical Center, Biomedical Imaging Research Institute, 116N Robertson Blvd, Suite 400, Los Angeles, CA 90048, USA
- First Department of Cardiology, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland
| | - Guy Lloyd
- Department of Cardiology, Barts Health NHS Trust, London, UK
| | - Anthony Mathur
- Department of Cardiology, Barts Health NHS Trust, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Andreas Baumbach
- Department of Cardiology, Barts Health NHS Trust, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
- Yale University School of Medicine, New Haven, CT, USA
| | | | - Michelle C Williams
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, UK
| | - David E Newby
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, UK
| | - Thomas A Treibel
- Department of Cardiology, Barts Health NHS Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Marc R Dweck
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, UK
| | - Damini Dey
- Departments of Biomedical Sciences and Medicine, Cedars-Sinai Medical Center, Biomedical Imaging Research Institute, 116N Robertson Blvd, Suite 400, Los Angeles, CA 90048, USA
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Patel KP, Mukhopadhyay S, Bedford K, Richards R, Queenan H, Jerrum M, Banton J, Ozkor M, Mathur A, Kennon S, Baumbach A, Mullen MJ. Rapid Assessment and Treatment In Decompensated Aortic Stenosis (ASTRID-AS study)- A pilot study. Eur Heart J Qual Care Clin Outcomes 2023; 9:724-730. [PMID: 36378116 PMCID: PMC10627808 DOI: 10.1093/ehjqcco/qcac074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/01/2022] [Accepted: 11/12/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute decompensated aortic stenosis (ADAS) is common and associated with higher mortality, acute kidney injury (AKI) and longer hospital length of stay (LoS) compared with electively treated stable AS. The aim of this study was to assess the impact of a dedicated pathway that reduces time to transcatheter aortic valve implantation (TAVI) in ADAS, hypothesizing that LoS can be reduced without compromising patient safety. METHODS AND RESULTS Using a prospective, open label, cluster design, patients from 5 referring centres were allocated to the ASessment and TReatment In Decompensated Aortic Stenosis (ASTRID-AS) pathway where the diagnosis, referral, investigations and treatment of ADAS were prioritised and expedited. 15 hospitals remained on the conventional pathway that followed the same process, albeit according to a waiting list. The primary efficacy endpoint was hospital LoS and the secondary safety endpoint, a composite of death or AKI at 30 days post-TAVI. 58 conventional patients and 25 ASTRID-AS patients were included in this study. Time to TAVI in the conventional vs. ASTRID-AS cohort was 22 (15-30) vs. 10 (6-12) days; P < 0.001, respectively. Length of hospital stay was 24 (18-33) vs. 13 (8-18) days; P < 0.001, respectively. 13.4 bed days were saved per patient using the ASTRID-AS pathway. Secondary safety endpoint occurred in 12 (20.7%) vs. 1 (4.0%) patients; P = 0.093, respectively. Procedural complications were similar between the two cohorts. CONCLUSION A dedicated pathway for ADAS that shortens time to TAVI demonstrated reduced hospital LoS without compromising patient safety and a trend towards improving clinical outcomes.
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Affiliation(s)
- Kush P Patel
- Institute of Cardiovascular science, University College London, London, EC1E 6BT, UK
- Barts Heart Centre, West Smithfield, London, EC1A 7BE, UK
| | | | - Kerry Bedford
- Barts Heart Centre, West Smithfield, London, EC1A 7BE, UK
| | - Rhian Richards
- Barts Heart Centre, West Smithfield, London, EC1A 7BE, UK
| | - Helen Queenan
- Barts Heart Centre, West Smithfield, London, EC1A 7BE, UK
| | - Melanie Jerrum
- Barts Heart Centre, West Smithfield, London, EC1A 7BE, UK
| | - Judy Banton
- Barts Heart Centre, West Smithfield, London, EC1A 7BE, UK
| | - Mick Ozkor
- Barts Heart Centre, West Smithfield, London, EC1A 7BE, UK
| | - Anthony Mathur
- Barts Heart Centre, West Smithfield, London, EC1A 7BE, UK
- The William Harvey Research Institute, London, E1 4NS, UK
| | - Simon Kennon
- Barts Heart Centre, West Smithfield, London, EC1A 7BE, UK
| | - Andreas Baumbach
- Barts Heart Centre, West Smithfield, London, EC1A 7BE, UK
- The William Harvey Research Institute, London, E1 4NS, UK
- Yale University School of Medicine, New Haven, CT 06510. USA
| | - Michael J Mullen
- Institute of Cardiovascular science, University College London, London, EC1E 6BT, UK
- Barts Heart Centre, West Smithfield, London, EC1A 7BE, UK
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Baumbach A, Patel KP, Kennon S, Ozkor M, Mathur A, Huerta FDL, Tamm AR. A heart valve dedicated for aortic regurgitation: Review of technology and early clinical experience with the transfemoral Trilogy system. Catheter Cardiovasc Interv 2023; 102:766-771. [PMID: 37560819 DOI: 10.1002/ccd.30795] [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: 05/13/2023] [Revised: 07/04/2023] [Accepted: 07/28/2023] [Indexed: 08/11/2023]
Abstract
Aortic regurgitation (AR) is associated with morbidity and premature mortality. Surgical aortic valve replacement is not an option for many patients due to an adverse surgical risk profile, whilst transcatheter aortic valve implantation with most available prostheses has demonstrated suboptimal implantation success and outcomes. The JenaValve Trilogy™ system provides an attractive solution for such patients as it utilizes clips that directly attach onto the native valve leaflets to anchor. Initially designed for transapical delivery, the current transfemoral delivery system is under investigation in the United States and approved for aortic stenosis and regurgitation in Europe. We present an expert review on the technical aspects of the Trilogy system, provide a guide for implantation, discuss the available evidence for the technology and provide illustrative case examples.
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Affiliation(s)
- Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Kush P Patel
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Simon Kennon
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Mick Ozkor
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Anthony Mathur
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | | | - Alexander R Tamm
- Department of Cardiology, Cardiology I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
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Patel KP, Sawatari H, Chahal A, Vuyisile NT, Somers V, Mullen MJ, Ricci F, Khanji MY. Health Care Resource, Economic, and Readmission Implications After Acute Decompensated Aortic Stenosis-A Nationwide Study. Am J Cardiol 2023; 204:200-206. [PMID: 37544145 DOI: 10.1016/j.amjcard.2023.07.081] [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: 04/11/2023] [Revised: 06/22/2023] [Accepted: 07/13/2023] [Indexed: 08/08/2023]
Abstract
Acute decompensated aortic stenosis (ADAS) is common. The cumulative burden of ADAS from a clinical, health care resource, and financial perspective is unknown. This study sought to assess the national impact of ADAS compared with electively treated, stable patients with aortic stenosis (non-ADAS). Using the National Readmissions Database between 2016 and 2019, patients with ADAS and non-ADAS were identified using International Classification of Diseases, Tenth Revision codes. Patients with ADAS were propensity-matched to non-ADAS patients (1:2) using age, gender, and Charlson co-morbidity index. We compared in-hospital mortality, length of stay (LOS), health care-associated costs, and 90-day readmission data between the 2 cohorts. A total of 51,498 propensity-matched patients were included in this study: median age 75 years, 64% men. The in-hospital mortality for ADAS was higher than non-ADAS (2.8% vs 1.5%, p <0.0001). The LOS during the index admission was longer for ADAS (9 [5 to 13] vs 4 [2 to 6] days, p <0.0001). The health care-associated costs per patient was greater for ADAS ($55,450.0 [41,860.4 to 74,500.7] vs $43,405.7 [34,218.5 to 56,034.8], p <0.0001). Readmission to hospital within 90 days was more frequent in ADAS (21.1 vs 16.8%, p <0.001). The in-hospital mortality during readmission was higher with ADAS (3.9% vs 2.8%, p = 0.004). The readmission LOS was longer with ADAS (4 [2 to 7] vs 3 [2 to 6] days, p <0.0001). In conclusion, ADAS imposes a significant burden clinically and financially and on health care resources compared with non-ADAS during the index admission and 90-day follow-up. There is an urgent need to predict ADAS and optimize the timing of aortic valve replacement to reduce the incidence and the burden associated with ADAS.
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Affiliation(s)
- Kush P Patel
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Hiroyuki Sawatari
- Department of Perioperative and Critical Care Management, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Anwar Chahal
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nkomo T Vuyisile
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Virend Somers
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael J Mullen
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, G.d'Annunzio University of Chieti-Pescara, Chieti, Italy; Clinical Research Center, Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Malmö, Sweden; Fondazione Villaserena per la Ricerca, Città Sant'Angelo, Italy
| | - Mohammed Y Khanji
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, London, United Kingdom.
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11
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Patel KP, Vandermolen S, Alharbi B, Hoare D, Mukhopadhyay S, Smith A, Bhattacharyya S, Muthurangu V, Mullen MJ. Identifying Characteristics of Short-Term Response to Transcatheter Edge-to-Edge Mitral Valve Repair. Am J Cardiol 2023; 204:183-184. [PMID: 37544142 DOI: 10.1016/j.amjcard.2023.07.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 07/11/2023] [Indexed: 08/08/2023]
Affiliation(s)
- Kush P Patel
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom.
| | - Sebastian Vandermolen
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Badr Alharbi
- Institute of Cardiovascular Science, Institute of Population Health Sciences, University College London, London, United Kingdom; Emergency medical service, King Khalid University, Abha, Saudi Arabia
| | - David Hoare
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Science, Institute of Population Health Sciences, University College London, London, United Kingdom
| | | | - Andrew Smith
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Sanjeev Bhattacharyya
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Vivek Muthurangu
- Centre for Translational Cardiovascular Imaging, Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Michael J Mullen
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
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12
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Poletti E, De Backer O, Scotti A, Costa G, Bruno F, Fiorina C, Buzzatti N, Latini A, Rudolph TK, van den Dorpel MMP, Brinkmann C, Patel KP, Panoulas V, Schofer J, Giordano A, Barbanti M, Regazzoli D, Taramasso M, Saia F, Baumbach A, Maisano F, Van Mieghem NM, Søndergaard L, Latib A, Amat Santos IJ, Bedogni F, Testa L. Transcatheter Aortic Valve Replacement for Pure Native Aortic Valve Regurgitation: The PANTHEON International Project. JACC Cardiovasc Interv 2023; 16:1974-1985. [PMID: 37648345 DOI: 10.1016/j.jcin.2023.07.026] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/03/2023] [Accepted: 07/11/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) in patients with pure severe native aortic valve regurgitation (NAVR) has been associated with suboptimal results. The available evidence concerns mostly outdated transcatheter heart valves (THVs). OBJECTIVES The aim of this study was to investigate the performance of new-generation THVs in patients treated for pure severe NAVR. METHODS The PANTHEON (Performance of Currently Available Transcatheter Aortic Valve Platforms in Inoperable Patients With Pure Aortic Regurgitation of a Native Valve) study retrospectively included patients who underwent TAVR with currently available devices (both self-expanding [SE] and balloon expandable [BE]) for severe NAVR. Technical and device success rates as well as a composite of all-cause mortality and heart failure rehospitalization at 1 year were evaluated. The rate and clinical consequences of acute transcatheter valve embolization or migration (TVEM) were also considered. RESULTS A total of 201 patients were included. Overall technical and device success rates were 83.6% and 76.1%, respectively, and did not differ between SE and BE devices. These figures were due mostly to TVEM occurrence (14.6% vs 16.1%; P = 0.47) and residual moderate or greater aortic regurgitation (9.2% vs 10.1%; P = 0.87). Patients who experienced TVEM compared with those without TVEM had a significantly higher incidence of the composite endpoint at 1 year (25.7% vs 15.8%; P = 0.05). CONCLUSIONS Despite improved THV platforms and techniques, TAVR for pure severe NAVR remains a challenging procedure, with significant risk for TVEM. SE and BE platforms demonstrated comparable performance in this setting. (Performance of Currently Available Transcatheter Aortic Valve Platforms in Inoperable Patients With Pure Aortic Regurgitation of a Native Valve [PANTHEON]; NCT05319171).
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Affiliation(s)
- Enrico Poletti
- Clinical and Interventional Cardiology Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Ole De Backer
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Andrea Scotti
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Giuliano Costa
- Division of Cardiology, CAST, Azienda Ospedaliero - Universitaria Policlinico G. Rodolico - San Marco, University of Catania, Catania, Italy
| | - Francesco Bruno
- Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom
| | | | | | - Alessia Latini
- Cardio Center, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Tanja K Rudolph
- Department for General and Interventional Cardiology/Angiology, Heart and Diabetes Center North Rhine-Westphalia Bochum, University Hospital of the Ruhr University, Bad Oeynhausen, Germany
| | - Mark M P van den Dorpel
- Department of Interventional Cardiology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | | | - Kush P Patel
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London United Kingdom
| | - Vasileios Panoulas
- Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom
| | - Joachim Schofer
- MVZ Department of Structural Heart Disease at St. Georg, Hamburg, Germany
| | - Arturo Giordano
- Cardiovascular Interventional Operative Unit, Presidio Ospedaliero Pineta Grande, Castel Volturno, Caserta, Italy; Operative Unit of Hemodynamics, Casa di Salute Santa Lucia, Naples, Italy
| | | | - Damiano Regazzoli
- Cardio Center, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Maurizio Taramasso
- HerzZentrum Hirslanden Zurich Clinic of Cardiac Surgery, Zurich, Switzerland
| | - Francesco Saia
- Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS University Hospital of Bologna, Bologna, Italy
| | - Andreas Baumbach
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London United Kingdom
| | | | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Lars Søndergaard
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Azeem Latib
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Ignacio J Amat Santos
- Instituto de Ciencias del Corazón, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Francesco Bedogni
- Clinical and Interventional Cardiology Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Luca Testa
- Clinical and Interventional Cardiology Department, IRCCS Policlinico San Donato, Milan, Italy.
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13
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Patel KP, Vandermolen S, Cooper J, Pugliese F, Ozkor M, Kennon S, Mathur A, Khanji MY, Mullen MJ, Baumbach A, Awad WI. Comparing Outcomes Between Surgical and Transcatheter Aortic Valve Replacement in Classical Low-Flow Low-Gradient Aortic Stenosis. Am J Cardiol 2023; 192:206-211. [PMID: 36842338 DOI: 10.1016/j.amjcard.2023.01.020] [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: 10/30/2022] [Revised: 12/29/2022] [Accepted: 01/13/2023] [Indexed: 02/27/2023]
Abstract
Patients with classic low-flow low-gradient (cLFLG) aortic stenosis (AS) have a poor prognosis but still benefit from aortic valve replacement. There is a paucity of evidence to guide the choice between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). This study compared procedural and midterm outcomes in patients with cLFLG AS between TAVR and SAVR. Patients with cLFLG AS, defined as an aortic valve area ≤1 cm2, mean gradient <40 mm Hg, and left ventricular ejection fraction <50%, were selected from a single center between 2015 and 2020. Inverse probability weighting and regression were used to adjust for differences in baseline characteristics, the nonrandom assignment of treatment modalities, and procedural differences. The primary end point was all-cause mortality. A total of 322 patients (220 TAVR and 102 SAVR) were included. At a follow-up of 4.4 ± 1.5 years, the adjusted hazard ratio (HR) for mortality after inverse probability weighting with SAVR was 0.66, 95% confidence interval (CI) 0.31 to 1.35; p = 0.24. Worse renal function at baseline (per 10 ml/min/m2 increase HR 0.92, 95% CI 0.84 to 1.00, p = 0.04) and multiple valve interventions (HR 5.39, 95% CI 2.62 to 11.12, p <0.001) independently predicted mortality. There was no difference in stroke and permanent pacemaker implantation, but the rates of renal replacement therapy were higher among the SAVR cohort: 13.7% versus 0%; p <0.001. In conclusion, among patients with cLFLG AS, there was no difference in midterm mortality between TAVR and SAVR, supporting the use of either treatment. However, in patients with poor renal function or at risk of renal failure, TAVR may be the preferred option.
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Affiliation(s)
- Kush P Patel
- Barts Heart Center, West Smithfield, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Sebastian Vandermolen
- Barts Heart Center, West Smithfield, London, United Kingdom; National Institute for Heart Research Barts Biomedical Research Center and Center for Advanced Cardiovascular Imaging, William Harvey Research Institute, Queen Mary University of London, United Kingdom
| | - Jackie Cooper
- Barts Heart Center, West Smithfield, London, United Kingdom; National Institute for Heart Research Barts Biomedical Research Center and Center for Advanced Cardiovascular Imaging, William Harvey Research Institute, Queen Mary University of London, United Kingdom
| | - Francesca Pugliese
- Barts Heart Center, West Smithfield, London, United Kingdom; National Institute for Heart Research Barts Biomedical Research Center and Center for Advanced Cardiovascular Imaging, William Harvey Research Institute, Queen Mary University of London, United Kingdom
| | - Mick Ozkor
- Barts Heart Center, West Smithfield, London, United Kingdom
| | - Simon Kennon
- Barts Heart Center, West Smithfield, London, United Kingdom
| | - Anthony Mathur
- Barts Heart Center, West Smithfield, London, United Kingdom; Center for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, United Kingdom
| | - Mohammed Y Khanji
- Barts Heart Center, West Smithfield, London, United Kingdom; National Institute for Heart Research Barts Biomedical Research Center and Center for Advanced Cardiovascular Imaging, William Harvey Research Institute, Queen Mary University of London, United Kingdom
| | - Michael J Mullen
- Barts Heart Center, West Smithfield, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Andreas Baumbach
- Barts Heart Center, West Smithfield, London, United Kingdom; Center for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, United Kingdom
| | - Wael I Awad
- Barts Heart Center, West Smithfield, London, United Kingdom; Center for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, United Kingdom.
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14
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Patel KP, Baumbach A. Future of transcatheter aortic valve implantation: where do we go from here? Heart 2023; 109:564-571. [PMID: 36631145 DOI: 10.1136/heartjnl-2022-321575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Kush P Patel
- Structural Heart Intervention Department, Barts Heart Centre, London, UK.,Barts Heart Centre, Barts Health NHS Trust, London, UK
| | - Andreas Baumbach
- Barts Heart Centre, Barts Health NHS Trust, London, UK .,Cardiology, Queen Mary University of London, London, UK
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15
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Gama F, Rosmini S, Bandula S, Patel KP, Massa P, Tobon-Gomez C, Ecke K, Stroud T, Condron M, Thornton GD, Bennett JB, Wechelakar A, Gillmore JD, Whelan C, Lachmann H, Taylor SA, Pugliese F, Fontana M, Moon JC, Hawkins PN, Treibel TA. Extracellular Volume Fraction by Computed Tomography Predicts Long-Term Prognosis Among Patients With Cardiac Amyloidosis. JACC Cardiovasc Imaging 2022; 15:2082-2094. [PMID: 36274040 DOI: 10.1016/j.jcmg.2022.08.006] [Citation(s) in RCA: 2] [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: 05/24/2022] [Revised: 07/29/2022] [Accepted: 08/04/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Light chain (AL) and transthyretin (ATTR) amyloid fibrils are deposited in the extracellular space of the myocardium, resulting in heart failure and premature mortality. Extracellular expansion can be quantified by computed tomography, offering a rapid, cheaper, and more practical alternative to cardiac magnetic resonance, especially among patients with cardiac devices or on renal dialysis. OBJECTIVES This study sought to investigate the association of extracellular volume fraction by computed tomography (ECVCT), myocardial remodeling, and mortality in patients with systemic amyloidosis. METHODS Patients with confirmed systemic amyloidosis and varying degrees of cardiac involvement underwent electrocardiography-gated cardiac computed tomography. Whole heart and septal ECVCT was analyzed. All patients also underwent clinical assessment, electrocardiography, echocardiography, serum amyloid protein component, and/or technetium-99m (99mTc) 3,3-diphosphono-1,2-propanodicarboxylic acid scintigraphy. ECVCT was compared across different extents of cardiac infiltration (ATTR Perugini grade/AL Mayo stage) and evaluated for its association with myocardial remodeling and all-cause mortality. RESULTS A total of 72 patients were studied (AL: n = 35, ATTR: n = 37; median age: 67 [IQR: 59-76] years, 70.8% male). Mean septal ECVCT was 42.7% ± 13.1% and 55.8% ± 10.9% in AL and ATTR amyloidosis, respectively, and correlated with indexed left ventricular mass (r = 0.426; P < 0.001), left ventricular ejection fraction (r = 0.460; P < 0.001), N-terminal pro-B-type natriuretic peptide (r = 0.563; P < 0.001), and high-sensitivity troponin T (r = 0.546; P < 0.001). ECVCT increased with cardiac amyloid involvement in both AL and ATTR amyloid. Over a mean follow-up of 5.3 ± 2.4 years, 40 deaths occurred (AL: n = 14 [35.0%]; ATTR: n = 26 [65.0%]). Septal ECVCT was independently associated with all-cause mortality in ATTR (not AL) amyloid after adjustment for age and septal wall thickness (HR: 1.046; 95% CI: 1.003-1.090; P = 0.037). CONCLUSIONS Cardiac amyloid burden quantified by ECVCT is associated with adverse cardiac remodeling as well as all-cause mortality among ATTR amyloid patients. ECVCT may address the need for better identification and risk stratification of amyloid patients, using a widely accessible imaging modality.
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Affiliation(s)
- Francisco Gama
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Hospital Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Stefania Rosmini
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Steve Bandula
- Centre for Medical Image Computing, Department of Medical Physics, University College London, London, United Kingdom
| | - Kush P Patel
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Paolo Massa
- University Sant'Orsola Hospital, Bologna, Italy; National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | | | - Karolin Ecke
- Canon Medical Systems Europe, Zoetermeer, the Netherlands
| | - Tyler Stroud
- Canon Medical Systems Europe, Zoetermeer, the Netherlands
| | - Mark Condron
- Canon Medical Systems Europe, Zoetermeer, the Netherlands
| | - George D Thornton
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Jonathan B Bennett
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Ashutosh Wechelakar
- Queen Mary University of London, London, United Kingdom; National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Julian D Gillmore
- Queen Mary University of London, London, United Kingdom; National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Carol Whelan
- Centre for Medical Image Computing, Department of Medical Physics, University College London, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom; Queen Mary University of London, London, United Kingdom; National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Helen Lachmann
- Queen Mary University of London, London, United Kingdom; National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, United Kingdom
| | - Francesca Pugliese
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Queen Mary University of London, London, United Kingdom
| | - Marianna Fontana
- Centre for Medical Image Computing, Department of Medical Physics, University College London, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom; Queen Mary University of London, London, United Kingdom; National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - James C Moon
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Philip N Hawkins
- Queen Mary University of London, London, United Kingdom; National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Thomas A Treibel
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom.
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16
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Gama F, Rosmini S, Bandula S, Patel KP, Thornton GD, Bennett JB, Wechelakar A, Gillmore JD, Whelan C, Lachmann H, Taylor S, Fontana M, Moon J, Hawkins PN, Treibel T. Extracellular volume fraction by computed tomography predicts long-term prognosis among patients with cardiac amyloidosis. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.184] [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: 11/13/2022] Open
Abstract
Abstract
Objective
This study sought to investigate the association of extracellular volume fraction by computed tomography (ECVCT), myocardial remodeling and mortality in patients with systemic amyloidosis.
Background
Light chain (AL) and transthyretin (ATTR) amyloid fibrils are deposited in the extracellular space of the myocardium, resulting in heart failure and premature mortality. Extracellular expansion can be quantified by CT, offering a rapid and cost-effective alternative to cardiovascular magnetic resonance (CMR), especially among patients with cardiac devices or on renal dialysis.
Methods
Patients with confirmed systemic amyloidosis and varying degrees of cardiac involvement underwent ECG-gated cardiac CT. ECVCT was analysed in the inter-ventricular septum. All patients also underwent clinical assessment, ECG, echocardiography, serum amyloid protein component (SAP) and/or technetium-99m (99mTc) 3,3-diphosphono-1,2-propanodicarboxylic acid scintigraphy. ECVCT was compared across different extents of cardiac infiltration (ATTR Perugini Grade / AL Mayo Class) and evaluated for its association with myocardial remodelling and all-cause mortality.
Results
72 patients were studied (AL n=35, ATTR n=37; age 67 (59–76) years, 71% males). Mean septal ECVCT was 42.7±13.1% and 55.8±10.9% in AL and ATTR, respectively, and correlated with indexed left ventricular (LV) mass (r=0.426, p<0.001), LV ejection fraction [LVEF, (r=0.460, p<0.001)], NT-proBNP (r=0.563, p<0.001) and hsTnT (r=0.546, p=0.02). ECVCT increased with cardiac amyloid involvement in both AL and ATTR (Figure 1). Over a mean follow-up of 5.3±2.4 years, 40 deaths occurred (AL 14 [35%]; ATTR 26 [65%]). ECVCT was independently associated with all-cause mortality in ATTR (not AL) after adjustment for age and IV septal wall thickness (HR: 1.046, 95% CI: 1.003–1.090, p=0.037).
Conclusion
Cardiac amyloid burden quantified by ECVCT is associated with adverse cardiac remodelling as well as all-cause mortality among ATTR amyloid patients. ECVCT may address the need for better identification and risk stratification of amyloid patients, using a widely-accessible imaging modality (Figure 2).
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- F Gama
- Barts Heart Centre, St Bartholomew's Hospital, Cardiac imaging , London , United Kingdom
| | - S Rosmini
- Barts Heart Centre , London , United Kingdom
| | - S Bandula
- University College of London , London , United Kingdom
| | - K P Patel
- Barts Heart Centre, St Bartholomew's Hospital, Cardiac imaging , London , United Kingdom
| | - G D Thornton
- Barts Heart Centre, St Bartholomew's Hospital, Cardiac imaging , London , United Kingdom
| | - J B Bennett
- Barts Heart Centre, St Bartholomew's Hospital, Cardiac imaging , London , United Kingdom
| | - A Wechelakar
- Queen Mary University of London , London , United Kingdom
| | - J D Gillmore
- Queen Mary University of London , London , United Kingdom
| | - C Whelan
- University College of London , London , United Kingdom
| | - H Lachmann
- Queen Mary University of London , London , United Kingdom
| | - S Taylor
- University College of London , London , United Kingdom
| | - M Fontana
- University College of London , London , United Kingdom
| | - J Moon
- Barts Heart Centre, St Bartholomew's Hospital, Cardiac imaging , London , United Kingdom
| | - P N Hawkins
- Queen Mary University of London , London , United Kingdom
| | - T Treibel
- Barts Heart Centre, St Bartholomew's Hospital, Cardiac imaging , London , United Kingdom
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Esposito G, Kumar N, Pugliese F, Sayers M, Chow AW, Kennon S, Ozkor M, Mathur A, Baumbach A, Lloyd G, Mullen A, Cook A, Mullen M, Patel KP. Predictors of post-TAVI conduction abnormalities in patients with bicuspid aortic valves. Open Heart 2022; 9:openhrt-2022-001995. [PMID: 35790318 PMCID: PMC9258482 DOI: 10.1136/openhrt-2022-001995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 06/06/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES This study evaluates predictors of conduction abnormalities (CA) following transcatheter aortic valve implantation (TAVI) in patients with bicuspid aortic valves (BAV). BACKGROUND TAVI is associated with CA that commonly necessitate a permanent pacemaker. Predictors of CA are well established among patients with tricuspid aortic valves but not in those with BAV. METHODS This is a single-centre, retrospective, observational study of patients with BAV treated with TAVI. Pre-TAVI ECG and CT scans and procedural characteristics were evaluated in 58 patients with BAV. CA were defined as a composite of high-degree atrioventricular block, new left bundle branch block with a QRS >150 ms or PR >240 ms and right bundle branch block with new PR prolongation or change in axis. Predictors of CA were identified using regression analysis and optimum cut-off values determined using area under the receiver operating characteristic curve analysis. RESULTS CA occurred in 35% of patients. Bioprosthesis implantation depth, the difference between membranous septum (MS) length and implantation depth (δMSID) and device landing zone (DLZ) calcification adjacent to the MS were identified as univariate predictors of CA. The optimum cut-off for δMSID was 1.25 mm. Using this cut-off, low δMSID and DLZ calcification adjacent to MS predicted CA, adjusted OR 8.79, 95% CI 1.88 to 41.00; p=0.01. Eccentricity of the aortic valve annulus, type of BAV and valve calcium quantity and distribution did not predict CA. CONCLUSIONS In BAV patients undergoing TAVI, short δMSID and DLZ calcification adjacent to MS are associated with an increased risk of CA.
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Affiliation(s)
- Giulia Esposito
- King's College London Faculty of Life Sciences and Medicine, London, UK.,Cardiology, Barts Health NHS Trust, London, UK
| | - Niraj Kumar
- Cardiology, Barts Health NHS Trust, London, UK.,University College London Institute of Cardiovascular Science, London, UK
| | - Francesca Pugliese
- Cardiology, Barts Health NHS Trust, London, UK.,Centre for Advanced Cardiovascular Imaging, Queen Mary University William Harvey Research Institute, London, UK
| | - Max Sayers
- Cardiology, Barts Health NHS Trust, London, UK
| | | | | | - Mick Ozkor
- Cardiology, Barts Health NHS Trust, London, UK
| | - Anthony Mathur
- Barts Health NHS Trust, London, UK.,Centre for Cardiovascular Medicine and Devices, Queen Mary University William Harvey Research Institute, London, UK
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, Queen Mary University William Harvey Research Institute, London, UK.,Barts Heart Centre, Barts Health NHS Trust, London, UK
| | - Guy Lloyd
- Cardiology, Barts Health NHS Trust, London, UK
| | - Aigerim Mullen
- University College London Institute of Cardiovascular Science, London, UK
| | - Andrew Cook
- University College London Institute of Cardiovascular Science, London, UK
| | | | - Kush P Patel
- Cardiology, Barts Health NHS Trust, London, UK .,University College London Institute of Cardiovascular Science, London, UK
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18
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Patel KP, Badiani S, Ganeshalingam A, Vijayakumar M, Thornton G, Mathur A, Kennon S, Bhattacharyya S, Baumbach A, Moon JC, Treibel TA, Mullen MJ, Lloyd G. Preprocedural Prognostic Factors in Acute Decompensated Aortic Stenosis. Am J Cardiol 2022; 174:96-100. [PMID: 35527043 DOI: 10.1016/j.amjcard.2022.03.037] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/26/2022] [Accepted: 03/02/2022] [Indexed: 12/18/2022]
Abstract
Acute decompensated aortic stenosis (ADAS) is common and associated with poor outcomes. Myocardial remodeling and function, including a novel echo staging classification (0 to 4, representing increasing degrees of cardiac damage/dysfunction), impact outcomes in stable aortic stenosis. However, this has not been assessed in patients with ADAS. This study aims to evaluate the impact of the myocardium, echo staging classification, and clinical parameters on mortality in ADAS. ADAS was defined as an acute deterioration in symptoms (New York Heart Association 4, Canadian Cardiovascular Society 3/4, or syncope) that warranted admission to the hospital and urgent aortic valve replacement. Using a retrospective observational study design, 292 consecutive patients with ADAS who underwent transcatheter aortic valve implantation (TAVI) were identified and included in this study. Echocardiographic and clinical characteristics were evaluated using regression analysis. The outcome was all-cause mortality after TAVI. At 1 year after TAVI, advanced echo staging (>2) independently predicted mortality (hazards ratio: 1.85, 95% confidence interval: 1.01 to 3.39; p = 0.045). At a follow-up of 2.4 ± 1.4 years, myocardial, valvular, and clinical parameters did not predict mortality, except for frailty (hazards ratio: 2.31, 95% confidence interval: 1.38 to 3.85; p = 0.001). In patients with ADAS, short-term mortality after TAVI is influenced by more advanced cardiac damage/dysfunction based on the echo staging classification, whereas mid-term mortality is driven by frailty rather than echo staging classification.
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Affiliation(s)
- Kush P Patel
- Barts Heart Centre, St Bartholomew's Hospital, London; Institute of Cardiovascular Science, University College London, London
| | | | | | - Mohit Vijayakumar
- Institute of Cardiovascular Science, University College London, London
| | - George Thornton
- Barts Heart Centre, St Bartholomew's Hospital, London; Institute of Cardiovascular Science, University College London, London
| | - Anthony Mathur
- Barts Heart Centre, St Bartholomew's Hospital, London; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London; Yale University School of Medicine, New Haven, Connecticut
| | - Simon Kennon
- Barts Heart Centre, St Bartholomew's Hospital, London
| | | | - Andreas Baumbach
- Barts Heart Centre, St Bartholomew's Hospital, London; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London; Yale University School of Medicine, New Haven, Connecticut
| | - James C Moon
- Barts Heart Centre, St Bartholomew's Hospital, London; Institute of Cardiovascular Science, University College London, London
| | - Thomas A Treibel
- Barts Heart Centre, St Bartholomew's Hospital, London; Institute of Cardiovascular Science, University College London, London
| | - Michael J Mullen
- Barts Heart Centre, St Bartholomew's Hospital, London; Institute of Cardiovascular Science, University College London, London
| | - Guy Lloyd
- Barts Heart Centre, St Bartholomew's Hospital, London; Institute of Cardiovascular Science, University College London, London; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London.
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19
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Patel KP, Vandermolen S, Herrey AS, Cheasty E, Menezes L, Moon JC, Pugliese F, Treibel TA. Cardiac Computed Tomography: Application in Valvular Heart Disease. Front Cardiovasc Med 2022; 9:849540. [PMID: 35402562 PMCID: PMC8987722 DOI: 10.3389/fcvm.2022.849540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 02/22/2022] [Indexed: 11/13/2022] Open
Abstract
The incidence and prevalence of valvular heart disease (VHD) is increasing and has been described as the next cardiac epidemic. Advances in imaging and therapeutics have revolutionized how we assess and treat patients with VHD. Although echocardiography continues to be the first-line imaging modality to assess the severity and the effects of VHD, advances in cardiac computed tomography (CT) now provide novel insights into VHD. Transcatheter valvular interventions rely heavily on CT guidance for procedural planning, predicting and detecting complications, and monitoring prosthesis. This review focuses on the current role and future prospects of CT in the assessment of aortic and mitral valves for transcatheter interventions, prosthetic valve complications such as thrombosis and endocarditis, and assessment of the myocardium.
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Affiliation(s)
- Kush P. Patel
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom
- Faculty of Population Health Sciences, Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Sebastian Vandermolen
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Anna S. Herrey
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom
- Faculty of Population Health Sciences, Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Emma Cheasty
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom
| | - Leon Menezes
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom
- Institute of Nuclear Medicine, University College London, London, United Kingdom
- NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - James C. Moon
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom
- Faculty of Population Health Sciences, Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Francesca Pugliese
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Thomas A. Treibel
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom
- Faculty of Population Health Sciences, Institute of Cardiovascular Sciences, University College London, London, United Kingdom
- Institute of Nuclear Medicine, University College London, London, United Kingdom
- *Correspondence: Thomas A. Treibel,
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20
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Patel KP, Treibel TA, Scully PR, Fertleman M, Searle S, Davis D, Moon JC, Mullen MJ. Futility in Transcatheter Aortic Valve Implantation: A Search for Clarity. Interv Cardiol 2022; 17:e01. [PMID: 35111240 PMCID: PMC8790725 DOI: 10.15420/icr.2021.15] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/05/2021] [Indexed: 12/12/2022] Open
Abstract
Although transcatheter aortic valve implantation (TAVI) has revolutionised the landscape of treatment for aortic stenosis, there exists a cohort of patients where TAVI is deemed futile. Among the pivotal high-risk trials, one-third to half of patients either died or received no symptomatic benefit from the procedure at 1 year. Futility of TAVI results in the unnecessary exposure of risk for patients and inefficient resource utilisation for healthcare services. Several cardiac and extra-cardiac conditions and frailty increase the risk of mortality despite TAVI. Among the survivors, these comorbidities can inhibit improvements in symptoms and quality of life. However, certain conditions are reversible with TAVI (e.g. functional mitral regurgitation), attenuating the risk and improving outcomes. Quantification of disease severity, identification of reversible factors and a systematic evaluation of frailty can substantially improve risk stratification and outcomes. This review examines the contribution of pre-existing comorbidities towards futility in TAVI and suggests a systematic approach to guide patient evaluation.
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Affiliation(s)
- Kush P Patel
- Institute of Cardiovascular Sciences, University College London London, UK.,Barts Heart Centre, St Bartholomew's Hospital London, UK
| | - Thomas A Treibel
- Institute of Cardiovascular Sciences, University College London London, UK.,Barts Heart Centre, St Bartholomew's Hospital London, UK
| | - Paul R Scully
- Institute of Cardiovascular Sciences, University College London London, UK.,Barts Heart Centre, St Bartholomew's Hospital London, UK
| | - Michael Fertleman
- Cutrale Perioperative and Ageing Group, Department of Bioengineering, Imperial College London London, UK
| | - Samuel Searle
- MRC Unit for Lifelong Health and Ageing, University College London London, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, University College London London, UK
| | - James C Moon
- Institute of Cardiovascular Sciences, University College London London, UK.,Barts Heart Centre, St Bartholomew's Hospital London, UK
| | - Michael J Mullen
- Institute of Cardiovascular Sciences, University College London London, UK.,Barts Heart Centre, St Bartholomew's Hospital London, UK
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21
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Patel KP, Lim WY, Pavithran A, Assadi R, Wan D, Kennon S, Ozkor M, Earley M, Sporton S, Dhinoja M, Hayward C, Muthumala A, Hunter R, Lowe M, Lambiase P, Segal O, Mathur A, Schilling R, Baumbach A, Mullen MJ, Chow AW. Early pacemaker implantation for transcatheter aortic valve implantation is safe and effective. Pacing Clin Electrophysiol 2022; 45:103-110. [PMID: 34727374 DOI: 10.1111/pace.14397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/09/2021] [Accepted: 10/24/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Permanent pacemaker (PPM) implantation is a common complication of transcatheter aortic valve implantation (TAVI). The optimum timing of PPM implantation is still unclear as conduction abnormalities evolve and a balance needs to be struck between conservative delays in the hope of conduction recovery and overutilization of pacing. This study aimed to assess the safety and efficacy of early PPM implantation, without an observation period, among TAVI patients. METHODS This is a retrospective, observational study of 1398 TAVI patients. Clinical and pacing data were collected at baseline, 30 days and at a median of 15 (4-21) months post-TAVI. Study endpoints included PPM-related complications, pacing utilization and hospital length of stay. RESULTS One hundred five patients (8.2%) required a PPM, of which 13 were implanted pre and 92 post-TAVI. Seventy-six percent required pacing for either second- or third-degree heart block. Time to implantation for post-TAVI PPM was 1 (0-3) day. Six patients experienced a pacing-related complication- lead displacement (n = 3), hematoma (n = 2), and device infection (n = 1). Pacing utilization defined as pacing >10% of the time or a pacing requirement at the time of the pacing check was demonstrated in 83% of patients. Multivariate analysis revealed complete heart block (CHB) was the only independent predictor of pacing utilization. Hospital length of stay for the post-TAVI PPM group was longer than the group without PPM (4 [2-8] vs. 3 [2-4] days; p < .001). CONCLUSIONS Early PPM implantation in TAVI patients is safe and majority of patients require pacing in the short and mid-term.
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Affiliation(s)
- Kush P Patel
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
- Institute of Cardiovascular Science, University College London, UK
| | - Wei Yao Lim
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Asha Pavithran
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Rangeena Assadi
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Daniel Wan
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Simon Kennon
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Mick Ozkor
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Mark Earley
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Simon Sporton
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Mehul Dhinoja
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Carl Hayward
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Amal Muthumala
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Ross Hunter
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK
| | - Martin Lowe
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Pier Lambiase
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK
| | - Oliver Segal
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Anthony Mathur
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK
| | - Richard Schilling
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK
| | - Andreas Baumbach
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK
- Yale University School of Medicine, New Haven, USA
| | - Michael J Mullen
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Anthony Wc Chow
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK
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22
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Patel KP, Scully PR, Nitsche C, Kammerlander AA, Joy G, Thornton G, Hughes R, Williams S, Tillin T, Captur G, Chacko L, Kelion A, Sabharwal N, Newton JD, Kennon S, Ozkor M, Mullen M, Hawkins PN, Gillmore JD, Menezes L, Pugliese F, Hughes AD, Fontana M, Lloyd G, Treibel TA, Mascherbauer J, Moon JC. Impact of afterload and infiltration on coexisting aortic stenosis and transthyretin amyloidosis. Heart 2022; 108:67-72. [PMID: 34497140 DOI: 10.1136/heartjnl-2021-319922] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 08/23/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The coexistence of wild-type transthyretin cardiac amyloidosis (ATTR) is common in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). However, the impact of ATTR and AS on the resultant AS-ATTR is unclear and poses diagnostic and management challenges. We therefore used a multicohort approach to evaluate myocardial structure, function, stress and damage by assessing age-related, afterload-related and amyloid-related remodelling on the resultant AS-ATTR phenotype. METHODS We compared four samples (n=583): 359 patients with AS, 107 with ATTR (97% Perugini grade 2), 36 with AS-ATTR (92% Perugini grade 2) and 81 age-matched and ethnicity-matched controls. 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy was used to diagnose amyloidosis (Perugini grade 1 was excluded). The primary end-point was NT-pro Brain Natriuretic Peptide (BNP) and secondary end-points related to myocardial structure, function and damage. RESULTS Compared with older age controls, the three disease cohorts had greater cardiac remodelling, worse function and elevated NT-proBNP/high-sensitivity Troponin-T (hsTnT). NT-proBNP was higher in AS-ATTR (2844 (1745, 4635) ng/dL) compared with AS (1294 (1077, 1554)ng/dL; p=0.002) and not significantly different to ATTR (3272 (2552, 4197) ng/dL; p=0.63). Diastology, hsTnT and prevalence of carpal tunnel syndrome were statistically similar between AS-ATTR and ATTR and higher than AS. The left ventricular mass indexed in AS-ATTR was lower than ATTR (139 (112, 167) vs 180 (167, 194) g; p=0.013) and non-significantly different to AS (120 (109, 130) g; p=0.179). CONCLUSIONS The AS-ATTR phenotype likely reflects an early stage of amyloid infiltration, but the combined insult resembles ATTR. Even after treatment of AS, ATTR-specific therapy is therefore likely to be beneficial.
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Affiliation(s)
- Kush P Patel
- Institute of Cardiovascular Science, University College London, London, UK
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Paul Richard Scully
- Institute of Cardiovascular Science, University College London, London, UK
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Christian Nitsche
- Department of Internal Medicine, Medical University of Vienna, Wien, Austria
| | | | - George Joy
- Cardiac Imaging Department, Barts Heart Centre, London, UK
| | - George Thornton
- Institute of Cardiovascular Science, University College London, London, UK
- Cardiac Imaging Department, Barts Heart Centre, London, UK
| | - Rebecca Hughes
- Institute of Cardiovascular Science, University College London, London, UK
- Cardiac Imaging Department, Barts Heart Centre, London, UK
| | | | | | - Gabriella Captur
- Institute of Cardiovascular Science, University College London, London, UK
- MRC Unit for Lifelong Health and Ageing, London, UK
| | | | - Andrew Kelion
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nikant Sabharwal
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - James D Newton
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Simon Kennon
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Mick Ozkor
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Michael Mullen
- Department of Cardiology, Barts Heart Centre, London, UK
| | | | | | - Leon Menezes
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Francesca Pugliese
- Department of Cardiology, Barts Heart Centre, London, UK
- Advanced Cardiovascular Imaging, William Harvey Research Institute, The London Chest Hospital, London, UK
| | | | | | - Guy Lloyd
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, London, UK
- Department of Cardiology, Barts Heart Centre, London, UK
| | | | - James C Moon
- Institute of Cardiovascular Science, University College London, London, UK
- Department of Cardiology, Barts Heart Centre, London, UK
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23
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Scully PR, Patel KP, Klotz E, Augusto JB, Thornton GD, Saberwal B, Haberland U, Kennon S, Ozkor M, Mullen M, Lloyd G, Kelion A, Menezes LJ, Hawkins PN, Moon JC, Pugliese F, Treibel TA. Myocardial Fibrosis Quantified by Cardiac CT Predicts Outcome in Severe Aortic Stenosis After Transcatheter Intervention. JACC Cardiovasc Imaging 2021; 15:542-544. [PMID: 34922871 PMCID: PMC8901438 DOI: 10.1016/j.jcmg.2021.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 10/19/2021] [Accepted: 10/26/2021] [Indexed: 11/05/2022]
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24
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Vandermolen S, Patel KP, Saberwal B, Cooper J, Pugliese F, Khanji M, Mullen MJ, Ozkor M, Kennon S, Baumbach A, Awad W. Outcomes of trans-catheter versus surgical aortic valve replacement for patients with classic low-flow low-gradient aortic stenosis. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1644] [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: 11/13/2022] Open
Abstract
Abstract
Background
Classical low-flow low-gradient aortic stenosis (cLFLG-AS) is frequently encountered within clinical practice [1], and is often associated with high mortality [2]. Whilst aortic valve replacement can improve outcomes, there is a lack of real-world data guiding the decision between trans-catheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) in this specific patient cohort.
Purpose
To compare outcomes between TAVI and SAVR in patients with cLFLG-AS.
Methods
cLFLG-AS was defined by an aortic valve area <1cm2, mean gradient <40mmHg or peak velocity <4m/s and left ventricular ejection fraction <50%. All patients who met cLFLG-AS criteria who underwent TAVI or SAVR at our tertiary referral centre between 2015 and 2020 were included. Inverse probability weighting was used to adjust for differences in baseline characteristics and the non-random assignment of treatment modalities. The primary end-point was all-cause mortality. Secondary end-points were procedure-related permanent pacemaker implantation, renal replacement therapy (RRT) and stroke.
Results
322 patients were included (220 TAVI and 102 SAVR). Baseline characteristics were: male sex 70%, mean gradient 30mmHg (23–35), aortic valve area 0.8cm2 (0.6–0.9). Patients undergoing TAVI were older than the SAVR group (81.3±8.5 vs 70.6±11.1 years, p<0.0001) with higher Logistic Euroscore (19.3 (11.8–32.3) vs 7.1 (3.7–14.1), p<0.0001) (figure 1).
At median follow-up of 2.7 years (1.5–4.1), 99 patients had died; 70 (31.8%) had TAVI and 29 (28.4%) had SAVR. Both unweighted and weighted Kaplan-Meier curve analysis was performed; there was similar survival between SAVR and TAVI (log rank test 0=0.27 and p=0.4 respectively) (figure 2).
Adjusted hazard ratio (HR) for mortality with SAVR was 0.78 unweighted (95% CI 0.5–1.21; p=0.27) and 0.66 weighted (95% CI 0.26–1.64; p=0.37).
In terms of contributory procedural factors, concomitant multiple valve intervention in the SAVR group independently affected mortality (HR 5.47, 95% CI 2.52–11.51, p<0.001).
There was no difference in permanent pacemaker insertion or stroke across the two groups, but rates of RRT were higher in SAVR cohort (13.7% vs 0%, p<0.001).
Conclusions
Despite the TAVI cohort being both older and at higher risk, there was no observed difference in mortality between TAVI and SAVR in the mid-term. Deciding upon intervention choice can therefore be based upon criteria other than the specific presence of a classic low-flow low-gradient state.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Clinical training research fellowship from the British Heart Foundation Baseline characteristics by treatmentKaplan-Meier curves for TAVI vs SAVR
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Affiliation(s)
| | - K P Patel
- Barts Heart Centre, London, United Kingdom
| | - B Saberwal
- Barts Heart Centre, London, United Kingdom
| | - J Cooper
- Queen Mary University of London, London, United Kingdom
| | - F Pugliese
- Barts Heart Centre, London, United Kingdom
| | - M Khanji
- Barts Heart Centre, London, United Kingdom
| | - M J Mullen
- Barts Heart Centre, London, United Kingdom
| | - M Ozkor
- Barts Heart Centre, London, United Kingdom
| | - S Kennon
- Barts Heart Centre, London, United Kingdom
| | - A Baumbach
- Barts Heart Centre, London, United Kingdom
| | - W Awad
- Barts Heart Centre, London, United Kingdom
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Patel KP, Michail M, Treibel TA, Rathod K, Jones DA, Ozkor M, Kennon S, Forrest JK, Mathur A, Mullen MJ, Lansky A, Baumbach A. Coronary Revascularization in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis. JACC Cardiovasc Interv 2021; 14:2083-2096. [PMID: 34620388 DOI: 10.1016/j.jcin.2021.07.058] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 02/25/2021] [Revised: 06/25/2021] [Accepted: 07/27/2021] [Indexed: 01/09/2023]
Abstract
Aortic stenosis (AS) and coronary artery disease (CAD) frequently coexist, with up to two thirds of patients with AS having significant CAD. Given the challenges when both disease states are present, these patients require a tailored approach diagnostically and therapeutically. In this review the authors address the impact of AS and aortic valve replacement (AVR) on coronary hemodynamic status and discuss the assessment of CAD and the role of revascularization in patients with concomitant AS and CAD. Remodeling in AS increases the susceptibility of myocardial ischemia, which can be compounded by concomitant CAD. AVR can improve coronary hemodynamic status and reduce ischemia. Assessment of the significance of coexisting CAD can be done using noninvasive and invasive metrics. Revascularization in patients undergoing AVR can benefit certain patients in whom CAD is either prognostically or symptomatically important. Identifying this cohort of patients is challenging and as yet incomplete. Patients with dual pathology present a diagnostic and therapeutic challenge; both AS and CAD affect coronary hemodynamic status, they provoke similar symptoms, and their respective treatments can have an impact on both diseases. Decisions regarding coronary revascularization should be based on understanding this complex relationship, using appropriate coronary assessment and consensus within a multidisciplinary team.
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Affiliation(s)
- Kush P Patel
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Michael Michail
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Krishnaraj Rathod
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Daniel A Jones
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Mick Ozkor
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Simon Kennon
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - John K Forrest
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Anthony Mathur
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Michael J Mullen
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Alexandra Lansky
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andreas Baumbach
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Yale University School of Medicine, New Haven, Connecticut, USA.
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26
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Bhuva AN, Moralee R, Brunker T, Lascelles K, Cash L, Patel KP, Lowe M, Sekhri N, Alpendurada F, Pennell DJ, Schilling R, Lambiase PD, Chow A, Moon JC, Litt H, Baksi AJ, Manisty CH. Evidence to support magnetic resonance conditional labelling of all pacemaker and defibrillator leads in patients with cardiac implantable electronic devices. Eur Heart J 2021; 43:2469-2478. [PMID: 34435642 PMCID: PMC9259370 DOI: 10.1093/eurheartj/ehab350] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 03/09/2021] [Revised: 04/20/2021] [Accepted: 05/28/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS Many cardiac pacemakers and defibrillators are not approved by regulators for magnetic resonance imaging (MRI). Even following generator exchange to an approved magnetic resonance (MR)-conditional model, many systems remain classified 'non-MR conditional' due to the leads. This classification makes patient access to MRI challenging, but there is no evidence of increased clinical risk. We compared the effect of MRI on non-MR conditional and MR-conditional pacemaker and defibrillator leads. METHODS AND RESULTS Patients undergoing clinical 1.5T MRI with pacemakers and defibrillators in three centres over 5 years were included. Magnetic resonance imaging protocols were similar for MR-conditional and non-MR conditional systems. Devices were interrogated pre- and immediately post-scan, and at follow-up, and adverse clinical events recorded. Lead parameter changes peri-scan were stratified by MR-conditional labelling. A total of 1148 MRI examinations were performed in 970 patients (54% non-MR conditional systems, 39% defibrillators, 15% pacing-dependent) with 2268 leads. There were no lead-related adverse clinical events, and no clinically significant immediate or late lead parameter changes following MRI in either MR-conditional or non-MR conditional leads. Small reductions in atrial and right ventricular sensed amplitudes and impedances were similar between groups, with no difference in the proportion of leads with parameter changes greater than pre-defined thresholds (7.1%, 95% confidence interval: 6.1-8.3). CONCLUSIONS There was no increased risk of MRI in patients with non-MR conditional pacemaker or defibrillator leads when following recommended protocols. Standardizing MR conditions for all leads would significantly improve access to MRI by enabling patients to be scanned in non-specialist centres, with no discernible incremental risk.
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Affiliation(s)
- Anish N Bhuva
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, EC1A 7BE, UK.,Institute for Cardiovascular Science, University College London, London, WC1E 6HX, UK.,Health Data Research UK, University College London, London, UK
| | - Russell Moralee
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, EC1A 7BE, UK
| | - Tamara Brunker
- Department of Radiology, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Karen Lascelles
- Cardiovascular Magnetic Resonance Unit, Royal Brompton & Harefield NHS Foundation Trust and National Heart and Lung Institute, Imperial College, London, SW3 6NP, UK
| | - Lizette Cash
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, EC1A 7BE, UK
| | - Kush P Patel
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, EC1A 7BE, UK
| | - Martin Lowe
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, EC1A 7BE, UK
| | - Neha Sekhri
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, EC1A 7BE, UK
| | - Francisco Alpendurada
- Cardiovascular Magnetic Resonance Unit, Royal Brompton & Harefield NHS Foundation Trust and National Heart and Lung Institute, Imperial College, London, SW3 6NP, UK
| | - Dudley J Pennell
- Cardiovascular Magnetic Resonance Unit, Royal Brompton & Harefield NHS Foundation Trust and National Heart and Lung Institute, Imperial College, London, SW3 6NP, UK
| | - Richard Schilling
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, EC1A 7BE, UK
| | - Pier D Lambiase
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, EC1A 7BE, UK.,Institute for Cardiovascular Science, University College London, London, WC1E 6HX, UK
| | - Anthony Chow
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, EC1A 7BE, UK
| | - James C Moon
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, EC1A 7BE, UK.,Institute for Cardiovascular Science, University College London, London, WC1E 6HX, UK
| | - Harold Litt
- Department of Radiology, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - A John Baksi
- Cardiovascular Magnetic Resonance Unit, Royal Brompton & Harefield NHS Foundation Trust and National Heart and Lung Institute, Imperial College, London, SW3 6NP, UK
| | - Charlotte H Manisty
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, EC1A 7BE, UK.,Institute for Cardiovascular Science, University College London, London, WC1E 6HX, UK
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Anjana RR, Parikh PV, Mahla JK, Kelawala DN, Patel KP, Ashwath SN. Comparative evaluation of isoflurane and sevoflurane in avian patients. Vet World 2021; 14:1067-1073. [PMID: 34220105 PMCID: PMC8243694 DOI: 10.14202/vetworld.2021.1067-1073] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/12/2021] [Indexed: 11/18/2022] Open
Abstract
Background and Aim: Literature comparing the use of isoflurane and sevoflurane inhalation anesthetic agents in birds is scarce. This study aimed to evaluate the comparison of isoflurane and sevoflurane during induction, maintenance, and recovery of anesthesia in avian patients. Materials and Methods: In this study, 24 injured avian patients (n=24) were selected randomly and divided into four groups during kite flying festival. In the present study, isoflurane and sevoflurane were used as induction and maintenance anesthetic agents, with and without butorphanol tartrate premedication agent in all the birds. Different physiological parameters were evaluated, namely, cloacal temperature (°F), heart rate (beats/min), respiratory rate (breaths/min), and SpO2 (%) were recorded at 0, 10, 20 min, and at recovery time. The quality of anesthesia was assessed on the basis of induction time, quality of induction, production of analgesia, muscle relaxation, body reflexes, recovery time, quality of recovery, sitting, standing, and complete recovery time (CRT). Results: The mean±standard error value of induction time was 230.00±32.55, 280.00±25.29, 180.00±21.90, and 260.00±36.87 s, respectively, in Groups I, II, III, and IV. The feather plucking, pharyngeal, and toe pinching reflexes were noticed, when the birds were passing through the light plane of anesthesia during induction. Comparison of cloacal temperature at the time of recovery between Group-I versus Group-III revealed a significant difference (p<0.05). Comparison of mean respiratory rates at the time of recovery between Group-II versus Group-IV revealed a significant difference (p<0.05). Excellent quality of recovery was observed in all the groups of anesthetic protocols. Sitting, standing, and CRT were observed shortest in avian patients maintained with sevoflurane as compared to isoflurane. Conclusion: The quality of induction of anesthesia was rapid in avian patients when induced with sevoflurane as compared to isoflurane. Rapid onset of induction and recovery of anesthesia were found with sevoflurane followed by isoflurane. Induction and maintenance of anesthesia in avian patients with sevoflurane resulted in the lowest time required for sitting, standing, and CRT.
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Affiliation(s)
- R R Anjana
- Department of Veterinary Surgery and Radiology, Anand Agricultural University, Anand, Gujarat, India
| | - P V Parikh
- Department of Veterinary Surgery and Radiology, Anand Agricultural University, Anand, Gujarat, India
| | - J K Mahla
- Department of Veterinary Surgery and Radiology, Anand Agricultural University, Anand, Gujarat, India
| | - D N Kelawala
- Department of Veterinary Surgery and Radiology, Anand Agricultural University, Anand, Gujarat, India
| | - K P Patel
- Department of Veterinary Surgery and Radiology, Anand Agricultural University, Anand, Gujarat, India
| | - S N Ashwath
- Department of Veterinary Surgery and Radiology, Anand Agricultural University, Anand, Gujarat, India
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Scully P, Patel KP, Augusto JB, Klotz E, Lloyd G, Kelion A, Kennon S, Ozkor M, Mullen M, Cavalcante JL, Menezes LJ, Hawkins PN, Moon JC, Pugliese F, Treibel TA. Myocardial fibrosis quantification by cardiac CT predicts outcome in severe aortic stenosis. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeaa356.230] [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: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Foundation. Main funding source(s): British Heart Foundation
Background
Myocardial extracellular volume (ECV) increases with fibrosis, oedema or infiltration. ECV by CMR predicts all-cause and cardiovascular mortality in severe AS after valve intervention. Previous studies have shown that ECV can be reliably quantified by computed tomography (ECVCT), but these studies have not differentiated between ECV elevation due to fibrosis or cardiac amyloid deposition (13-16% of patients with severe AS).
Purpose
We hypothesised that ECVCT quantification, performed as part of a transcatheter aortic valve implantation (TAVI) work-up CT, predicts survival in patients with severe AS without cardiac amyloid (lone AS).
Methods
Patients aged ≥75, with severe AS, referred for TAVI at Barts Heart Centre (as part of ATTRact-AS (NCT03029026)) underwent CT as part of their clinical work-up. All patients had 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy and those with a positive result were excluded. CT was performed on a 128-slice dual-source 3rdgeneration scanner (Siemens Somatom FORCE) and ECVCT was acquired during the TAVI work-up CT using additional pre- and 3-minute post-contrast ‘axial shuttle mode’ acquisitions (no additional contrast). ECVCT was calculated from the Hounsfield units (HU) and a venous haematocrit (HCT): ECVCT = (1-HCT) x (ΔHUmyo/ΔHUblood).
Results
Following exclusion of 16 patients with cardiac uptake on DPD, 93 patients (41% male, aged 85 ± 5 years) were included in the study. All patients had severe AS (AV Vmax 4.12 ± 0.63m/s, mean AV gradient 42 ± 14mmHg, AVA 0.71 ± 0.23cm2). The mean HCT was 0.38 ± 0.04 and total dose-length product for additional research scans was 364 ± 41 mGy.cm. 76 patients (82%) underwent TAVI. ECVCT was 32 ± 3% in the entire cohort, which we then split into those with a ‘higher’ ECVCT (>34%, n = 23, representing the highest quartile) and those with a ‘lower’ ECVCT (≤34%, n = 70, representing the lower quartiles). Over a median follow-up of 25 months (IQR 17-34 months) there were 27 deaths (29%), of whom 11 did not undergo TAVI (41%). There were 10 deaths in the 23 patients (44%) with a higher ECVCT, compared to 17 in the 70 patients (24%) with a lower ECVCT (p = 0.03, figure 1). This mortality difference remained significant when those patients who did not undergo TAVI were excluded (p = 0.03).
Conclusions
Myocardial fibrosis quantified by ECVCT is associated with a significantly worse prognosis in lone AS, even after patients with AS-amyloid are excluded. ECVCT can be performed as a simple addition to the TAVI work-up CT and provides additional prognostic information.
Abstract Figure.
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Affiliation(s)
- P Scully
- University College London, London, United Kingdom of Great Britain & Northern Ireland
| | - KP Patel
- University College London, London, United Kingdom of Great Britain & Northern Ireland
| | - JB Augusto
- University College London, London, United Kingdom of Great Britain & Northern Ireland
| | - E Klotz
- Siemens Healthineers, Forccheim, Germany
| | - G Lloyd
- Barts Health NHS Trust, Barts Heart Centre, London, United Kingdom of Great Britain & Northern Ireland
| | - A Kelion
- John Radcliffe Hospital, Oxford, United Kingdom of Great Britain & Northern Ireland
| | - S Kennon
- Barts Health NHS Trust, Barts Heart Centre, London, United Kingdom of Great Britain & Northern Ireland
| | - M Ozkor
- Barts Health NHS Trust, Barts Heart Centre, London, United Kingdom of Great Britain & Northern Ireland
| | - M Mullen
- Barts Health NHS Trust, Barts Heart Centre, London, United Kingdom of Great Britain & Northern Ireland
| | - JL Cavalcante
- Minneapolis Heart Institute Foundation, Minneapolis, United States of America
| | - LJ Menezes
- Barts Health NHS Trust, Barts Heart Centre, London, United Kingdom of Great Britain & Northern Ireland
| | - PN Hawkins
- National Amyloidosis Centre, London, United Kingdom of Great Britain & Northern Ireland
| | - JC Moon
- University College London, London, United Kingdom of Great Britain & Northern Ireland
| | - F Pugliese
- Queen Mary University of London, London, United Kingdom of Great Britain & Northern Ireland
| | - TA Treibel
- University College London, London, United Kingdom of Great Britain & Northern Ireland
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29
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Subbiah V, Shen T, Terzyan SS, Liu X, Hu X, Patel KP, Hu M, Cabanillas M, Behrang A, Meric-Bernstam F, Vo PTT, Mooers BHM, Wu J. Structural basis of acquired resistance to selpercatinib and pralsetinib mediated by non-gatekeeper RET mutations. Ann Oncol 2021; 32:261-268. [PMID: 33161056 PMCID: PMC7883646 DOI: 10.1016/j.annonc.2020.10.599] [Citation(s) in RCA: 122] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Selpercatinib (LOXO-292) and pralsetinib (BLU-667) are highly potent RET-selective protein tyrosine kinase inhibitors (TKIs) for treating advanced RET-altered thyroid cancers and non-small-cell lung cancer (NSCLC). It is critical to analyze RET mutants resistant to these drugs and unravel the molecular basis to improve patient outcomes. PATIENTS AND METHODS Cell-free DNAs (cfDNAs) were analyzed in a RET-mutant medullary thyroid cancer (MTC) patient and a CCDC6-RET fusion NSCLC patient who had dramatic response to selpercatinib and later developed resistance. Selpercatinib-resistant RET mutants were identified and cross-profiled with pralsetinib in cell cultures. Crystal structures of RET-selpercatinib and RET-pralsetinib complexes were determined based on high-resolution diffraction data collected with synchrotron radiation. RESULTS RETG810C/S mutations at the solvent front and RETY806C/N mutation at the hinge region were found in cfDNAs of an MTC patient with RETM918T/V804M/L, who initially responded to selpercatinib and developed resistance. RETG810C mutant was detected in cfDNAs of a CCDC6-RET-fusion NSCLC patient who developed acquired resistance to selpercatinib. Five RET kinase domain mutations at three non-gatekeeper residues were identified from 39 selpercatinib-resistant cell lines. All five selpercatinib-resistant RET mutants were cross-resistant to pralsetinib. X-ray crystal structures of the RET-selpercatinib and RET-pralsetinib complexes reveal that, unlike other TKIs, these two RET TKIs anchor one end in the front cleft and wrap around the gate wall to access the back cleft. CONCLUSIONS RET mutations at the solvent front and the hinge are resistant to both drugs. Selpercatinib and pralsetinib use an unconventional mode to bind RET that avoids the interference from gatekeeper mutations but is vulnerable to non-gatekeeper mutations.
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Affiliation(s)
- V Subbiah
- Department of Investigational Cancer Therapeutics, Division of Cancer Medicine, the University of Texas MD Anderson Cancer Center, Houston, USA.
| | - T Shen
- Peggy and Charles Stephenson Cancer Center, Oklahoma City, USA; Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - S S Terzyan
- Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, USA; Laboratory of Biomolecular Structure and Function, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - X Liu
- Peggy and Charles Stephenson Cancer Center, Oklahoma City, USA; Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - X Hu
- Peggy and Charles Stephenson Cancer Center, Oklahoma City, USA; Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - K P Patel
- Molecular Diagnostics Laboratory, Division of Diagnostic Imaging, the University of Texas MD Anderson Cancer Center, Houston, USA
| | - M Hu
- Endocrine and Neoplasia, Division of Diagnostic Imaging, the University of Texas MD Anderson Cancer Center, Houston, USA
| | - M Cabanillas
- Endocrine and Neoplasia, Division of Diagnostic Imaging, the University of Texas MD Anderson Cancer Center, Houston, USA
| | - A Behrang
- Musculoskeletal Imaging, Division of Diagnostic Imaging, the University of Texas MD Anderson Cancer Center, Houston, USA
| | - F Meric-Bernstam
- Department of Investigational Cancer Therapeutics, Division of Cancer Medicine, the University of Texas MD Anderson Cancer Center, Houston, USA
| | - P T T Vo
- Peggy and Charles Stephenson Cancer Center, Oklahoma City, USA
| | - B H M Mooers
- Peggy and Charles Stephenson Cancer Center, Oklahoma City, USA; Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, USA; Laboratory of Biomolecular Structure and Function, University of Oklahoma Health Sciences Center, Oklahoma City, USA.
| | - J Wu
- Peggy and Charles Stephenson Cancer Center, Oklahoma City, USA; Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, USA.
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Nitsche C, Scully PR, Patel KP, Kammerlander AA, Koschutnik M, Dona C, Wollenweber T, Ahmed N, Thornton GD, Kelion AD, Sabharwal N, Newton JD, Ozkor M, Kennon S, Mullen M, Lloyd G, Fontana M, Hawkins PN, Pugliese F, Menezes LJ, Moon JC, Mascherbauer J, Treibel TA. Prevalence and Outcomes of Concomitant Aortic Stenosis and Cardiac Amyloidosis. J Am Coll Cardiol 2021; 77:128-139. [PMID: 33181246 PMCID: PMC7805267 DOI: 10.1016/j.jacc.2020.11.006] [Citation(s) in RCA: 162] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/26/2020] [Accepted: 11/04/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Older patients with severe aortic stenosis (AS) are increasingly identified as having cardiac amyloidosis (CA). It is unknown whether concomitant AS-CA has worse outcomes or results in futility of transcatheter aortic valve replacement (TAVR). OBJECTIVES This study identified clinical characteristics and outcomes of AS-CA compared with lone AS. METHODS Patients who were referred for TAVR at 3 international sites underwent blinded research core laboratory 99mtechnetium-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) bone scintigraphy (Perugini grade 0: negative; grades 1 to 3: increasingly positive) before intervention. Transthyretin-CA (ATTR) was diagnosed by DPD and absence of a clonal immunoglobulin, and light-chain CA (AL) was diagnosed via tissue biopsy. National registries captured all-cause mortality. RESULTS A total of 407 patients (age 83.4 ± 6.5 years; 49.8% men) were recruited. DPD was positive in 48 patients (11.8%; grade 1: 3.9% [n = 16]; grade 2/3: 7.9% [n = 32]). AL was diagnosed in 1 patient with grade 1. Patients with grade 2/3 had worse functional capacity, biomarkers (N-terminal pro-brain natriuretic peptide and/or high-sensitivity troponin T), and biventricular remodeling. A clinical score (RAISE) that used left ventricular remodeling (hypertrophy/diastolic dysfunction), age, injury (high-sensitivity troponin T), systemic involvement, and electrical abnormalities (right bundle branch block/low voltages) was developed to predict the presence of AS-CA (area under the curve: 0.86; 95% confidence interval: 0.78 to 0.94; p < 0.001). Decisions by the heart team (DPD-blinded) resulted in TAVR (333 [81.6%]), surgical AVR (10 [2.5%]), or medical management (65 [15.9%]). After a median of 1.7 years, 23% of patients died. One-year mortality was worse in all patients with AS-CA (grade: 1 to 3) than those with lone AS (24.5% vs. 13.9%; p = 0.05). TAVR improved survival versus medical management; AS-CA survival post-TAVR did not differ from lone AS (p = 0.36). CONCLUSIONS Concomitant pathology of AS-CA is common in older patients with AS and can be predicted clinically. AS-CA has worse clinical presentation and a trend toward worse prognosis, unless treated. Therefore, TAVR should not be withheld in AS-CA.
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Affiliation(s)
- Christian Nitsche
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Paul R Scully
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Cardiology Department, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Kush P Patel
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Andreas A Kammerlander
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Matthias Koschutnik
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Carolina Dona
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Tim Wollenweber
- Department of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Nida Ahmed
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - George D Thornton
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | | | | | | | - Muhiddin Ozkor
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Simon Kennon
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Michael Mullen
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Guy Lloyd
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Queen Mary University London, London, United Kingdom
| | | | | | - Francesca Pugliese
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Queen Mary University London, London, United Kingdom
| | - Leon J Menezes
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; UCL/ULCH NIHR Biomedical Research Centre, London, United Kingdom
| | - James C Moon
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Julia Mascherbauer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom.
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Treibel TA, Patel KP, Cavalcante JL. Extracellular Volume Imaging in Aortic Stenosis During Routine Pre-TAVR Cardiac Computed Tomography. JACC Cardiovasc Imaging 2020; 13:2602-2604. [DOI: 10.1016/j.jcmg.2020.08.023] [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] [Received: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 01/09/2023]
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Scully PR, Patel KP, Saberwal B, Klotz E, Augusto JB, Thornton GD, Hughes RK, Manisty C, Lloyd G, Newton JD, Sabharwal N, Kelion A, Kennon S, Ozkor M, Mullen M, Hartman N, Cavalcante JL, Menezes LJ, Hawkins PN, Treibel TA, Moon JC, Pugliese F. Identifying Cardiac Amyloid in Aortic Stenosis: ECV Quantification by CT in TAVR Patients. JACC Cardiovasc Imaging 2020; 13:2177-2189. [PMID: 32771574 PMCID: PMC7536272 DOI: 10.1016/j.jcmg.2020.05.029] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [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: 03/24/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 01/06/2023]
Abstract
Objectives The purpose of this study was to validate computed tomography measured ECV (ECVCT) as part of routine evaluation for the detection of cardiac amyloid in patients with aortic stenosis (AS)-amyloid. Background AS-amyloid affects 1 in 7 elderly patients referred for transcatheter aortic valve replacement (TAVR). Bone scintigraphy with exclusion of a plasma cell dyscrasia can diagnose transthyretin-related cardiac amyloid noninvasively, for which novel treatments are emerging. Amyloid interstitial expansion increases the myocardial extracellular volume (ECV). Methods Patients with severe AS underwent bone scintigraphy (Perugini grade 0, negative; Perugini grades 1 to 3, increasingly positive) and routine TAVR evaluation CT imaging with ECVCT using 3- and 5-min post-contrast acquisitions. Twenty non-AS control patients also had ECVCT performed using the 5-min post-contrast acquisition. Results A total of 109 patients (43% male; mean age 86 ± 5 years) with severe AS and 20 control subjects were recruited. Sixteen (15%) had AS-amyloid on bone scintigraphy (grade 1, n = 5; grade 2, n = 11). ECVCT was 32 ± 3%, 34 ± 4%, and 43 ± 6% in Perugini grades 0, 1, and 2, respectively (p < 0.001 for trend) with control subjects lower than lone AS (28 ± 2%; p < 0.001). ECVCT accuracy for AS-amyloid detection versus lone AS was 0.87 (0.95 for 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid Perugini grade 2 only), outperforming conventional electrocardiogram and echocardiography parameters. One composite parameter, the voltage/mass ratio, had utility (similar AUC of 0.87 for any cardiac amyloid detection), although in one-third of patients, this could not be calculated due to bundle branch block or ventricular paced rhythm. Conclusions ECVCT during routine CT TAVR evaluation can reliably detect AS-amyloid, and the measured ECVCT tracks the degree of infiltration. Another measure of interstitial expansion, the voltage/mass ratio, also performed well.
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Affiliation(s)
- Paul R Scully
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Kush P Patel
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Bunny Saberwal
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | | | - João B Augusto
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - George D Thornton
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Rebecca K Hughes
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Charlotte Manisty
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Guy Lloyd
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Sciences, University College London, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - James D Newton
- John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Nikant Sabharwal
- John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Andrew Kelion
- John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Simon Kennon
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Muhiddin Ozkor
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Michael Mullen
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Neil Hartman
- Nuclear Medicine, Swansea Bay UHB, Port Talbot, United Kingdom
| | | | - Leon J Menezes
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Nuclear Medicine, University College London, London, United Kingdom; NIHR University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Thomas A Treibel
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - James C Moon
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Francesca Pugliese
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; NIHR Barts Biomedical Research Centre, London, United Kingdom.
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Scully PR, Patel KP, Treibel TA, Thornton GD, Hughes RK, Chadalavada S, Katsoulis M, Hartman N, Fontana M, Pugliese F, Sabharwal N, Newton JD, Kelion A, Ozkor M, Kennon S, Mullen M, Lloyd G, Menezes LJ, Hawkins PN, Moon JC. Prevalence and outcome of dual aortic stenosis and cardiac amyloid pathology in patients referred for transcatheter aortic valve implantation. Eur Heart J 2020; 41:2759-2767. [PMID: 32267922 PMCID: PMC7395329 DOI: 10.1093/eurheartj/ehaa170] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 12/07/2019] [Accepted: 03/05/2020] [Indexed: 12/20/2022] Open
Abstract
AIMS Cardiac amyloidosis is common in elderly patients with aortic stenosis (AS) referred for transcatheter aortic valve implantation (TAVI). We hypothesized that patients with dual aortic stenosis and cardiac amyloid pathology (AS-amyloid) would have different baseline characteristics, periprocedural and mortality outcomes. METHODS AND RESULTS Patients aged ≥75 with severe AS referred for TAVI at two sites underwent blinded bone scintigraphy prior to intervention (Perugini Grade 0 negative, 1-3 increasingly positive). Baseline assessment included echocardiography, electrocardiogram (ECG), blood tests, 6-min walk test, and health questionnaire, with periprocedural complications and mortality follow-up. Two hundred patients were recruited (aged 85 ± 5 years, 50% male). AS-amyloid was found in 26 (13%): 8 Grade 1, 18 Grade 2. AS-amyloid patients were older (88 ± 5 vs. 85 ± 5 years, P = 0.001), with reduced quality of life (EQ-5D-5L 50 vs. 65, P = 0.04). Left ventricular wall thickness was higher (14 mm vs. 13 mm, P = 0.02), ECG voltages lower (Sokolow-Lyon 1.9 ± 0.7 vs. 2.5 ± 0.9 mV, P = 0.03) with lower voltage/mass ratio (0.017 vs. 0.025 mV/g/m2, P = 0.03). High-sensitivity troponin T and N-terminal pro-brain natriuretic peptide were higher (41 vs. 21 ng/L, P < 0.001; 3702 vs. 1254 ng/L, P = 0.001). Gender, comorbidities, 6-min walk distance, AS severity, prevalence of disproportionate hypertrophy, and post-TAVI complication rates (38% vs. 35%, P = 0.82) were the same. At a median follow-up of 19 (10-27) months, there was no mortality difference (P = 0.71). Transcatheter aortic valve implantation significantly improved outcome in the overall population (P < 0.001) and in those with AS-amyloid (P = 0.03). CONCLUSIONS AS-amyloid is common and differs from lone AS. Transcatheter aortic valve implantation significantly improved outcome in AS-amyloid, while periprocedural complications and mortality were similar to lone AS, suggesting that TAVI should not be denied to patients with AS-amyloid.
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Affiliation(s)
- Paul R Scully
- Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, UK
- Institute of Cardiovascular Science, University College London, Gower Street, London WC1E 6BT, UK
| | - Kush P Patel
- Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, UK
- Institute of Cardiovascular Science, University College London, Gower Street, London WC1E 6BT, UK
| | - Thomas A Treibel
- Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, UK
- Institute of Cardiovascular Science, University College London, Gower Street, London WC1E 6BT, UK
| | - George D Thornton
- Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, UK
| | - Rebecca K Hughes
- Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, UK
- Institute of Cardiovascular Science, University College London, Gower Street, London WC1E 6BT, UK
| | | | - Michail Katsoulis
- Institute of Health Informatics, University College London, 222 Euston Road, London NW1 2DA, UK
| | - Neil Hartman
- Nuclear Medicine, Abertawe Bro Morgannwg University Health Board, 4 Seaway Parade, Port Talbot SA12 7BR, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Rowland Hill Street, London NW3 2PF, UK
| | - Francesca Pugliese
- Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, UK
- William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Nikant Sabharwal
- John Radcliffe Hospital, Oxford University Hospitals, Headley Way, Headington, Oxford OX3 9DU, UK
| | - James D Newton
- John Radcliffe Hospital, Oxford University Hospitals, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Andrew Kelion
- John Radcliffe Hospital, Oxford University Hospitals, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Muhiddin Ozkor
- Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, UK
| | - Simon Kennon
- Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, UK
| | - Michael Mullen
- Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, UK
| | - Guy Lloyd
- Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, UK
- Institute of Cardiovascular Science, University College London, Gower Street, London WC1E 6BT, UK
- William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Leon J Menezes
- Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, UK
- Institute of Nuclear Medicine, University College London, 235 Euston Road, London NW1 2BU, UK
- NIHR University College London Hospitals Biomedical Research Centre, 149 Tottenham Court Road, London W1T 7DN, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, Rowland Hill Street, London NW3 2PF, UK
| | - James C Moon
- Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, UK
- Institute of Cardiovascular Science, University College London, Gower Street, London WC1E 6BT, UK
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Scully PR, Morris E, Patel KP, Treibel TA, Burniston M, Klotz E, Newton JD, Sabharwal N, Kelion A, Manisty C, Kennon S, Ozkor M, Mullen M, Hartman N, Elliott PM, Pugliese F, Hawkins PN, Moon JC, Menezes LJ. DPD Quantification in Cardiac Amyloidosis: A Novel Imaging Biomarker. JACC Cardiovasc Imaging 2020; 13:1353-1363. [PMID: 32498921 PMCID: PMC7264710 DOI: 10.1016/j.jcmg.2020.03.020] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/13/2020] [Accepted: 03/18/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To assess whether single-photon emission computed tomography (SPECT/CT) quantification of bone scintigraphy would improve diagnostic accuracy and offer a means of quantifying amyloid burden. BACKGROUND Transthyretin-related cardiac amyloidosis is common and can be diagnosed noninvasively using bone scintigraphy; interpretation, however, relies on planar images. SPECT/CT imaging offers 3-dimensional visualization. METHODS This was a single-center, retrospective analysis of 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scans reported using the Perugini grading system (0 = negative; 1 to 3 = increasingly positive). Conventional planar quantification techniques (heart/contralateral lung, and heart/whole-body retention ratios) were performed. Heart, adjacent vertebra, paraspinal muscle and liver peak standardized uptake values (SUVpeak) were recorded from SPECT/CT acquisitions. An SUV retention index was also calculated: (cardiac SUVpeak/vertebral SUVpeak) × paraspinal muscle SUVpeak. In a subgroup of patients, SPECT/CT quantification was compared with myocardial extracellular volume quantification by CT imaging (ECVCT). RESULTS A total of 100 DPD scans were analyzed (patient age 84 ± 9 years; 52% male): 40 were Perugini grade 0, 12 were grade 1, 41 were grade 2, and 7 were grade 3. Cardiac SUVpeak increased from grade 0 to grade 2; however, it plateaued between grades 2 and 3 (p < 0.001). Paraspinal muscle SUVpeak increased with grade (p < 0.001), whereas vertebral SUVpeak decreased (p < 0.001). The composite parameter of SUV retention index overcame the plateauing of the cardiac SUVpeak and increased across all grades (p < 0.001). Cardiac SUVpeak correlated well (r2 = 0.73; p < 0.001) with ECVCT. Both the cardiac SUVpeak and SUV retention index had excellent diagnostic accuracy (area under the curve [AUC]: 0.999). The heart to contralateral lung ratio performed the best of the planar quantification techniques (AUC: 0.987). CONCLUSIONS SPECT/CT quantification in DPD scintigraphy is possible and outperforms planar quantification techniques. Differentiation of Perugini grade 2 or 3 is confounded by soft tissue uptake, which can be overcome by a composite SUV retention index. This index can help in the diagnosis of cardiac amyloidosis and may offer a means of monitoring response to therapy.
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Affiliation(s)
- Paul R Scully
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Elizabeth Morris
- Clinical Physics, St. Bartholomew's Hospital, London, United Kingdom
| | - Kush P Patel
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Thomas A Treibel
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Maria Burniston
- Clinical Physics, St. Bartholomew's Hospital, London, United Kingdom
| | | | - James D Newton
- John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Nikant Sabharwal
- John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Andrew Kelion
- John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Charlotte Manisty
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Simon Kennon
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Muhiddin Ozkor
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Michael Mullen
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Neil Hartman
- Nuclear Medicine, Abertawe Bro Morgannwg University HB, Swansea, United Kingdom
| | - Perry M Elliott
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Francesca Pugliese
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; NIHR Barts Biomedical Research Centre, London, United Kingdom
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - James C Moon
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Sciences, University College London, London, United Kingdom
| | - Leon J Menezes
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Nuclear Medicine, University College London, London, United Kingdom; NIHR University College London Hospitals Biomedical Research Centre, London, United Kingdom.
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Patel KP, Patel PA, Vunnam SR, Jain R, Vunnam RR. Patients with COVID-19: are current isolation guidelines effective enough? Public Health 2020; 183:38-39. [PMID: 32417566 PMCID: PMC7211713 DOI: 10.1016/j.puhe.2020.04.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 04/25/2020] [Indexed: 02/07/2023]
Affiliation(s)
- K P Patel
- Department of Internal Medicine, University of Nebraska Medical Center College of Medicine, Omaha, NE, USA.
| | - P A Patel
- Nova Southeastern University Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - S R Vunnam
- Department of Internal Medicine, University of Nebraska Medical Center College of Medicine, Omaha, NE, USA
| | - R Jain
- Division of Hospital Medicine, Penn State Health Milton S. Hershey Medical Center, College of Medicine, Hershey, PA, USA
| | - R R Vunnam
- Division of Hospital Medicine, Penn State Health Milton S. Hershey Medical Center, College of Medicine, Hershey, PA, USA
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Patel KP, Giraud AS, Samuel CS, Royce SG. Combining an epithelial repair factor and anti-fibrotic with a corticosteroid offers optimal treatment for allergic airways disease. Br J Pharmacol 2016; 173:2016-29. [PMID: 27060978 DOI: 10.1111/bph.13494] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/21/2016] [Accepted: 03/23/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE We evaluated the extent to which individual versus combination treatments that specifically target airway epithelial damage [trefoil factor-2 (TFF2)], airway fibrosis [serelaxin (RLX)] or airway inflammation [dexamethasone (DEX)] reversed the pathogenesis of chronic allergic airways disease (AAD). EXPERIMENTAL APPROACH Following induction of ovalbumin (OVA)-induced chronic AAD in 6–8 week female Balb/c mice, animals were i.p. administered naphthalene (NA) on day 64 to induce epithelial damage, then received daily intranasal administration of RLX (0.8 mg·mL(−1)), TFF2 (0.5 mg·mL(−1)), DEX (0.5 mg·mL(−1)), RLX + TFF2 or RLX + TFF2 + DEX from days 67–74. On day 75, lung function was assessed by invasive plethysmography, before lung tissue was isolated for analyses of various measures. The control group was treated with saline + corn oil (vehicle for NA). KEY RESULTS OVA + NA-injured mice demonstrated significantly increased airway inflammation, airway remodelling (AWR) (epithelial damage/thickness; subepithelial myofibroblast differentiation, extracellular matrix accumulation and fibronectin deposition; total lung collagen concentration), and significantly reduced airway dynamic compliance (cDyn). RLX + TFF2 markedly reversed several measures of OVA + NA-induced AWR and normalized the reduction in cDyn. The combined effects of RLX + TFF2 + DEX significantly reversed peribronchial inflammation score, airway epithelial damage, subepithelial extracellular matrix accumulation/fibronectin deposition and total lung collagen concentration (by 50–90%) and also normalized the reduction of cDyn. CONCLUSIONS AND IMPLICATIONS Combining an epithelial repair factor and anti-fibrotic provides an effective means of treating the AWR and dysfunction associated with AAD/asthma and may act as an effective adjunct therapy to anti-inflammatory corticosteroids
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Affiliation(s)
- K P Patel
- Fibrosis Laboratory, Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Pharmacology, Monash University, Vic., Australia
| | - A S Giraud
- Murdoch Children's Research Institute, University of Melbourne, Vic., Australia.,Department of Paediatrics, University of Melbourne, Vic., Australia
| | - C S Samuel
- Fibrosis Laboratory, Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Pharmacology, Monash University, Vic., Australia
| | - S G Royce
- Fibrosis Laboratory, Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Pharmacology, Monash University, Vic., Australia.,Respiratory Pharmacology Laboratory, Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Pharmacology, Monash University, Vic., Australia
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DiNardo CD, Jabbour E, Ravandi F, Takahashi K, Daver N, Routbort M, Patel KP, Brandt M, Pierce S, Kantarjian H, Garcia-Manero G. IDH1 and IDH2 mutations in myelodysplastic syndromes and role in disease progression. Leukemia 2015; 30:980-4. [PMID: 26228814 PMCID: PMC4733599 DOI: 10.1038/leu.2015.211] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- C D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - E Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - F Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - N Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - M Routbort
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K P Patel
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - M Brandt
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - H Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Royce SG, Lim CXF, Patel KP, Wang B, Samuel CS, Tang MLK. Intranasally administered serelaxin abrogates airway remodelling and attenuates airway hyperresponsiveness in allergic airways disease. Clin Exp Allergy 2015; 44:1399-408. [PMID: 25113628 DOI: 10.1111/cea.12391] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 03/03/2014] [Accepted: 05/08/2014] [Indexed: 01/24/2023]
Abstract
BACKGROUND The peptide hormone relaxin plays a key role in the systemic hemodynamic and renovascular adaptive changes that occur during pregnancy, which is linked to its antiremodelling effects. Serelaxin (a recombinant form of human gene-2 relaxin) has been shown to inhibit lung fibrosis in various disease models and reverse airway remodelling and airway hyperresponsiveness (AHR) in allergic airways disease (AAD). OBJECTIVE Although continuous systemic delivery of exogenous serelaxin alleviates allergic fibrosis and AHR, more direct routes for administration into the lung have not been investigated. Thus, intranasal administration of serelaxin was evaluated for its ability to reverse airway remodelling and AHR associated with AAD. METHODS Female Balb/c mice were subjected to a 9-week model of chronic AAD. Subgroups of animals (n = 12/group) were then treated intranasally with serelaxin (0.8 mg/mL) or vehicle once daily for 14 days (from weeks 9-11). Saline-sensitized/challenged mice treated with intranasal saline served as additional controls. Differential bronchoalveolar lavage (BAL) cell counts, ovalbumin (OVA)-specific IgE levels, tissue inflammation, parameters of airway remodelling and AHR were then assessed. RESULTS Chronic AAD was associated with significant increases in differential BAL cell counts, OVA-specific IgE levels, inflammation, epithelial thickening, goblet cell metaplasia, TGF-β1 expression, epithelial Smad2 phosphorylation (pSmad2), subepithelial collagen thickness, total lung collagen concentration and AHR (all P < 0.05 vs. respective measurements from saline-treated mice). Daily intranasal delivery of serelaxin significantly diminished AAD-induced epithelial thickening, epithelial pSmad2, subepithelial and total lung collagen content (fibrosis) and AHR (all P < 0.05 vs. vehicle-treated AAD mice). CONCLUSIONS AND CLINICAL RELEVANCE Intranasal delivery of serelaxin can effectively reduce airway remodelling and AHR, when administered once daily. Respirable preparations of serelaxin may have therapeutic potential for the prevention and/or reversal of established airway remodelling and AHR in asthma.
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Affiliation(s)
- S G Royce
- Allergy and Immune Disorders, Murdoch Children's Research Institute, Melbourne, Vic., Australia; Department of Pharmacology, Monash University, Melbourne, Vic., Australia
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Abstract
A number of neurohumoral processes are activated in heart failure, including an increase in the plasma concentration of norepinephrine. Few studies have been performed to examine the role of the central nervous system in the activation of sympathetic outflow during heart failure (HF). In this paper I review these limited studies, with particular emphasis on examining the role of the paraventricular nucleus (PVN) in the exaggerated sympathetic outflow commonly observed in heart failure. The conclusion is that heart failure is associated with changes in specific areas in the brain and that alterations in the activation of neurons in the PVN are likely related to abnormalities in vasopressin production, blood volume regulation, and sympathoexcitation observed in the heart failure state. Furthermore, neuronal nitric oxide within the PVN that is involved in mediating sympathetic outflow via a GABA mechanism from the PVN may be deficient in inhibiting overall sympathetic outflow leading to the exaggerated sympathetic outflow commonly observed in heart failure.
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Affiliation(s)
- K P Patel
- Department of Physiology and Biophysics, University of Nebraska Medical Center, Omaha, Nebraska, 68198-4575, USA
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Abstract
Activation of the CiaRH two-component signaling system prevents the development of competence for genetic transformation in Streptococcus pneumoniae through a previously unknown mechanism. Earlier studies have shown that CiaRH controls the expression of htrA, which we show encodes a surface-expressed serine protease. We found that mutagenesis of the putative catalytic serine of HtrA, while not impacting the competence of a ciaRH+ strain, restored a normal competence profile to a strain having a mutation that constitutively activates the CiaH histidine kinase. This result implies that activity of HtrA is necessary for the CiaRH system to inhibit competence. Consistent with this finding, recombinant HtrA (rHtrA) decreased the competence of pneumococcal cultures. The rHtrA-mediated decline in transformation efficiency could not be corrected with excess competence-stimulating peptide (CSP), suggesting that HtrA does not act through degradation of this signaling molecule. The inhibitory effects of rHtrA and activated CiaH, however, were largely overcome in a strain having constitutive activation of the competence pathway through a mutation in the cytoplasmic domain of the ComD histidine kinase. Although these results suggested that HtrA might act through degradation of the extracellular portion of the ComD receptor, Western immunoblots for ComD did not reveal changes in protein levels attributable to HtrA. We therefore postulate that HtrA may act on an unknown protein target that potentiates the activation of the ComDE system by CSP. These findings suggest a novel regulatory role for pneumococcal HtrA in modulating the activity of a two-component signaling system that controls the development of genetic competence.
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Affiliation(s)
- M E Sebert
- Department of Microbiology, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Pliquett RU, Cornish KG, Patel KP, Schultz HD, Peuler JD, Zucker IH. Amelioration of depressed cardiopulmonary reflex control of sympathetic nerve activity by short-term exercise training in male rabbits with heart failure. J Appl Physiol (1985) 2003; 95:1883-8. [PMID: 12857767 DOI: 10.1152/japplphysiol.00486.2003] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The reflex regulation of sympathetic nerve activity has been demonstrated to be impaired in the chronic heart failure (CHF) state compared with the normal condition (Liu JL, Murakami H, and Zucker IH. Circ Res 82: 496-502, 1998). Exercise training (Ex) appears to be beneficial to patients with CHF and has been shown to reduce sympathetic outflow in this disease state (Hambrecht R, Hilbrich L, Erbs S, Gielen S, Fiehn E, Schoene N, and Schuler G. J Am Coll Cardiol 35: 706-713, 2000). We tested the hypothesis that Ex corrects the reduced cardiopulmonary (CP) reflex response to volume expansion in the CHF state. Normal, normal with Ex, CHF, and CHF with Ex (CHF-Ex) groups (n = 10-21) of male New Zealand White rabbits were studied. CHF was induced by chronic ventricular pacing. Rabbits were instrumented to record left ventricular end-diastolic pressure (LVEDP), left ventricular end-diastolic diameter (LVEDD), and renal sympathetic nerve activity (RSNA). Experiments were carried out with the animals in the conscious state. Volume expansion was performed with 6% dextran in normal saline at a rate of 5 ml/min to approximately 20% of estimated plasma volume without any significant effect on mean arterial pressure being exhibited. The relationships between RSNA and LVEDP and between RSNA and LVEDD were determined by linear regression; the slopes served as an index of CP reflex sensitivity. Normal rabbits exhibited a CP reflex sensitivity of -8.4 +/- 1.5%delta RSNA/mmHg. This value fell to 0.0 +/- 1.3%delta RSNA/mmHg in CHF rabbits (P < 0.001). Ex increased CP reflex sensitivity to -5.0 +/- 0.7%delta RSNA/mmHg in CHF-Ex rabbits (P < 0.05 compared with CHF). A similar trend was seen when related to the change in LVEDD. Furthermore, resting RSNA expressed as a percentage of maximum RSNA in response to cigarette smoke was also normalized by Ex in rabbits with CHF. Ex had no effect on these parameters in normal rabbits. These data confirm an impairment of CP reflex sensitivity and sympathoexcitation in CHF vs. normal animals. Ex substantially restored both CP reflex sensitivity and baseline RSNA in CHF animals. Thus Ex beneficially affects reflex regulation in CHF, thereby lowering resting sympathetic nerve activity.
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Affiliation(s)
- R U Pliquett
- Department of Physiology and Biophysics, University of Nebraska Medical Center, Omaha, Nebraska 68198-4575, USA
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Abstract
AIM Cardiovascular deconditioning occurs in individuals exposed to prolonged spaceflight or bedrest and is associated with the development of orthostatic intolerance. Although the precise mechanisms remain to be fully elucidated, astronauts returning from space or bedrest patients returning to normal upright posture present with decreases in plasma volume and alterations in autonomic function. The hindlimb unloaded (HU) rat has been a useful model to study the effects of cardiovascular deconditioning as it mimics many of the changes that occur after spaceflight and bedrest. RESULTS Experiments performed in HU rats suggest that cardiovascular deconditioning attenuates baroreflex mediated sympathoexcitation and enhances cardiopulmonary receptor mediated sympathoinhibition. These alterations appear to be due to changes in the central nervous system and may contribute to the pre disposition towards orthostatic intolerance associated with cardiovascular deconditioning. The paraventricular nucleus (PVN) of the hypothalamus is important in basal and reflex control of sympathetic outflow. Recent evidence suggests that nitric oxide (NO) is an important inhibitory neurotransmitter in the PVN and that alterations in nitroxidergic transmission in the PVN may be involved in elevated sympathetic tone in certain disease states. CONCLUSION Based on evidence from other laboratories and published and preliminary data from our own laboratories, this review proposes a role for the PVN in cardiovascular deconditioning. In particular, we discuss the hypothesis that increased NO in the PVN contributes to the altered cardiovascular reflexes observed following deconditioning and how these reflexes may be related to the orthostatic intolerance observed after prolonged spaceflight or bedrest.
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Affiliation(s)
- P J Mueller
- Department of Biomedical Sciences, Dalton Cardiovascular Research Center, University of Missouri-Columbia, 134 Research Park Drive, Columbia, MO 65211-3300, USA
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Abstract
AIM During heart failure (HF), excess sodium retention is triggered by increased plasma renin-angiotensin-aldosterone activity and increased basal sympathetic nerve discharge (SND). Enhanced basal SND in the renal nerves plays a role in sodium retention. Therefore, as a hypothetical model for the central sympathetic control pathways that are dysregulated as a consequence of HF, the central neural pathways regulating the sympathetic motor output to the kidney are reviewed in the context of their role during HF. CONCLUSION From these findings, a model of the neuroanatomical circuitry that may be affected during HF is constructed.
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Affiliation(s)
- M L Weiss
- Department of Anatomy and Physiology, Kansas State University, 1600 Denison Avenue, Manhattan, KS 66506-5602, USA
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Li YF, Patel KP. Paraventricular nucleus of the hypothalamus and elevated sympathetic activity in heart failure: the altered inhibitory mechanisms. Acta Physiol Scand 2003; 177:17-26. [PMID: 12492775 DOI: 10.1046/j.1365-201x.2003.01043.x] [Citation(s) in RCA: 123] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIM There is a characteristic neurohumoral activation in heart failure (HF). However, few studies have been performed to examine the role of the central nervous system in the activation of sympathetic outflow during HF. In this paper we review some of our studies, with particular emphasis on examining the role of the paraventricular nucleus (PVN) in the exaggerated sympathetic outflow commonly observed in HF. RESULTS Our studies have revealed that the inhibitory mechanisms regulating sympathetic outflow are mediated by nitric oxide (NO) and gamma-aminobutyric acid (GABA) within the PVN and are attenuated in HF. These alterations are associated with elevated sympathetic activity. Furthermore, these studies have indicated that the interactions among excitatory (angiotensin II and glutamate) and inhibitory (NO and GABA) neurotransmitters/mediators within the PVN significantly influence sympathetic outflow. CONCLUSION Reduced inhibitory actions of NO and/or GABA within the PVN may exaggerate an increase in the actions of excitatory neurotransmitters such as glutamate and angiotensin II within the PVN and this may contribute to the overall sympatho-excitation commonly observed in HF.
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Affiliation(s)
- Y-F Li
- Department of Physiology and Biophysics, University of Nebraska Medical Center, 984575 Nebraska Medical Center, Omaha, NE 68198-4575, USA
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Abstract
The paraventricular nucleus (PVN) of the hypothalamus is an important site of integration in the central nervous system for sympathetic outflow. Both glutamate and nitric oxide (NO) play an important role in the regulation of sympathetic nerve activity. The purpose of the present study was to examine the interaction of NO and glutamate within the PVN in the regulation of renal sympathetic nerve activity in rats. Renal sympathetic nerve discharge (RSND), arterial blood pressure (BP), and heart rate (HR) were measured in response to administration of N-methyl-D-aspartic acid (NMDA) and N(G)-monomethyl-L-arginine (L-NMMA) into the PVN. We found that microinjection of NMDA (25, 50, and 100 pmol) into the PVN increased RSND, BP, and HR in a dose-dependent manner, reaching 53 +/- 9%, 19 +/- 3 mmHg, and 32 +/- 12 beats/min, respectively, at the highest dose. These responses were significantly enhanced by prior microinjection of L-NMMA. On the other hand, inhibition of NO within the PVN by microinjection of L-NMMA also induced increases in RSND, BP, and HR in a dose-dependent manner, reaching 48 +/- 6.5%, 11 +/- 4 mmHg, and 55 +/- 16 beats/min, respectively, at the highest dose. This sympathoexcitatory response was eliminated by prior microinjection of DL-2-amino-5-phosphonovaleric acid, an antagonist of the NMDA receptor. Furthermore, with the use of the push-pull technique, perfusion of glutamate (0.5 micromol) or NMDA (0.1 nmol) into the PVN induced an increase in NO release. In conclusion, our data indicate that NMDA receptors within the PVN mediate an excitatory effect on renal sympathetic nerve activity, arterial BP, and HR. NO in the PVN, which is released by activation of the NMDA receptor, also inhibits NMDA-mediated increases in sympathetic nerve activity. This negative feedback of NO on the glutamate system within the PVN may play an important role in maintaining the overall balance and tone of sympathetic outflow in normal and pathophysiological conditions known to have increased sympathetic tone.
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Affiliation(s)
- Y F Li
- Department of Physiology and Biophysics, University of Nebraska Medical Center, Omaha, 68198-4547, USA
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Abstract
The neurons synthesizing nitric oxide (NO) that are part of the renal sympathetic pathways were located by double-staining for the neuronal isoform of nitric oxide synthase (nNOS) using immunocytochemistry to identify NO-synthesizing neurons and transneuronal tracing following infection of the left kidney with pseudorabies virus (PRV). Following kidney injection with PRV, the animals survived 4-day post-inoculation prior to sacrifice and tissue processing. PRV-infected neurons that double-stained for nNOS were found in the paraventricular hypothalamic nucleus (PVN), the raphe obscurus nucleus (ROb), the ventromedial medulla (VMM), the rostral ventrolateral medulla (rVLM) and the A5 cell group. In the thoracolumbar spinal cord, nNOS neurons co-localized with PRV-infected cells in the dorsal horn in laminae I, III-V ipsilateral to the injected kidney and in lamina X, the intermediolateral cell column, the lateral funiculus, the intercalated nucleus and the central autonomic area. We conclude that NO synthesizing cells may significantly affect renal autonomic pathways in the rat by interacting with the renal sensory and sympathomotor circuitry at multiple sites.
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Affiliation(s)
- M L Weiss
- Departments of Anatomy and Physiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS 66506-5602, USA.
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Abstract
We sought to investigate mechanisms that may account for impaired nitric oxide synthase (NOS)-dependent dilatation of cerebral arterioles during alcohol consumption. Our goals were to examine 1) the effect of exogenous application of a cofactor for NOS, i.e., tetrahydrobiopterin (BH4) on the reactivity of pial arterioles during alcohol consumption; and 2) endothelial NOS (eNOS) protein in nonalcohol-fed and alcohol-fed rats. Sprague-Dawley rats were fed liquid diets with or without alcohol for 2-3 mo. We measured in vivo diameter of pial arterioles in response to NOS-dependent agonists (ACh and ADP) and a NOS-independent agonist (nitroglycerin) before and during application of BH4. Blood vessels were then harvested for Western blot analysis of eNOS protein. In nonalcohol-fed rats, ACh and ADP produced vasodilatation, which was impaired in alcohol-fed rats. Vasodilatation to nitroglycerin was similar in both groups of rats. Application of BH4 did not alter vasodilatation in nonalcohol-fed rats but improved impaired vasodilatation in alcohol-fed rats. Also, eNOS protein in cerebral cortex microvessels, the basilar artery, and aorta was not different between nonalcohol-fed and alcohol-fed rats. Thus impaired NOS-dependent vasodilatation during alcohol consumption does not appear to be related to an alteration in eNOS protein but may be related to a deficiency and/or alteration in the utilization of BH4.
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Affiliation(s)
- H Sun
- Department of Physiology and Biophysics, University of Nebraska Medical Center, Omaha, Nebraska 68198-4575, USA
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Abstract
The gaseous molecule nitric oxide (NO) plays an important role in cardiovascular homeostasis. It plays this role by its action on both the central and peripheral autonomic nervous systems. In this review, the central role of NO in the regulation of sympathetic outflow and subsequent cardiovascular control is examined. After a brief introduction concerning the location of NO synthase (NOS) containing neurons in the central nervous system (CNS), studies that demonstrate the central effect of NO by systemic administration of NO modulators will be presented. The central effects of NO as assessed by intracerebroventricular, intracisternal, or direct injection within the specific central areas is also discussed. Our studies demonstrating specific medullary and hypothalamic sites involved in sympathetic outflow are summarized. The review will be concluded with a discussion of the role of central NO mechanisms in the altered sympathetic outflow in disease states such as hypertension and heart failure.
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Affiliation(s)
- K P Patel
- Department of Physiology and Biophysics, University of Nebraska Medical Center, 984575 Nebraska Medical Center, Omaha, NE 68198-4545, USA.
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Abstract
Autospectral and coherence analyses were used to determine the effect of paraventricular nucleus (PVN) GABA(A) receptor antagonism [microinfusion or microinjections of bicuculline methiodide (BMI) 100 pmoles] on sympathetic nerve discharge (SND) frequency components (bursting pattern and relationships between discharges in regionally selective nerves) in alpha-chloralose-anesthetized rats. SND was recorded from the renal, splenic, and lumbar nerves. The following observations were made. First, PVN BMI microinjections, but not PVN saline or cortical BMI microinjections, transformed the cardiac-related SND bursting pattern in baroreceptor-innervated rats to one characterized by the presence of low-frequency bursts not synchronized to the cardiac cycle or phrenic nerve discharge bursts. Second, SND pattern changes were similar in the renal, splenic, and lumbar nerves, and peak coherence values relating low-frequency bursts in sympathetic nerve pairs (renal-splenic, renal-lumbar, and splenic-lumbar) were significantly increased from preinjection control after PVN BMI microinjection. Third, PVN BMI microinjections significantly increased the coupling between low-frequency SND bursts in baroreceptor-denervated rats. Finally, PVN BMI-induced changes in the SND bursting pattern were not observed after PVN pretreatment with muscimol (GABA agonist, 1 nmole). We conclude that PVN GABA(A) receptor antagonism profoundly alters the frequency components in sympathetic nerves.
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Affiliation(s)
- M J Kenney
- Department of Anatomy and Physiology, Kansas State University, Manhattan, Kansas 66506, USA.
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Abstract
We have demonstrated a decreased neuronal nitric oxide (NO) synthase (nNOS) message in the hypothalamus of rats with heart failure (HF). Subsequently, we have demonstrated that NADPH diaphorase (a commonly used marker for nNOS activity) positive neurons are decreased in paraventricular nucleus (PVN) of rats with coronary artery ligation model of HF. The goal of the present study was to examine the influence of endogenous NO within the PVN on renal sympathetic nerve discharge (RSND) during HF. In alpha-chloralose- and urethane-anesthetized rats, an inhibitor of NO synthase, N(G)-monomethyl-L-arginine (L-NMMA) microinjected into the PVN (50, 100, and 200 pmol in 50-200 nl) produced a dose-dependent increase in RSND, blood pressure, and heart rate in control and HF rats. These responses were attenuated in rats with HF compared with control rats. On the other hand, the NO agonist, sodium nitroprusside, microinjected in PVN produced a dose-dependent decrease in RSND and blood pressure in control and HF rats. These responses were less in rats with HF compared with control rats. These data suggest that the endogenous NO-mediated effect within the PVN of HF rats is less potent in suppressing RSND compared with control rats. These data support the conclusion that the NO system within the PVN involved in controlling autonomic outflow is altered during HF and may contribute to the elevated levels of renal sympathoexcitation commonly observed in HF.
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Affiliation(s)
- K Zhang
- Department of Physiology and Biophysics, University of Nebraska Medical Center, Omaha, Nebraska 68198-4575, USA
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