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Hashim SW, Collazo S, Greco A, Mather JF, McKay RG. Half-dose direct oral anticoagulation versus warfarin for atrial fibrillation following cardiac surgery. J Cardiovasc Surg (Torino) 2024; 65:169-176. [PMID: 38470020 DOI: 10.23736/s0021-9509.24.12815-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
BACKGROUND Optimal anticoagulation strategies have not been defined for patients with atrial fibrillation following cardiac surgery. METHODS From a total cohort of 228 patients with pre-existing or new onset atrial fibrillation following coronary artery bypass grafting and/or valve surgery, we compared in-hospital and 30-day outcomes in 119 patients treated with low-dose aspirin and a half-dose direct oral anticoagulant (DOAC) versus 109 treated with low-dose aspirin and warfarin. RESULTS DOAC patients were older (73.1±7.0 vs. 68.7±11.4 years, P<0.001) and had a lower incidence of preoperative atrial fibrillation (37 [31.1%] vs. 69 [63.3%], P<0.001). Otherwise, the two cohorts were well matched for baseline demographics, cardiovascular risk factors, comorbidities, prior cardiac history and STS Risk Score. In comparison to Warfarin patients, DOAC patients had a shorter length of post-surgical stay (6 [5-8] vs. 7 [5-10] days, P=0.037). The two cohorts, however, had a similar incidence of stroke, transient ischemic attack, reoperation for bleeding and postoperative blood bank product usage. Follow-up 30-day outcomes did not differ between the two groups with respect to mortality (0 [0.0%] vs. 0 [0.0%], P=1.000) and hospital readmission (16 [13.4%] vs. 14 [12.8%], P=0.893), although two DOAC patients required drainage of sanguineous pericardial effusions. CONCLUSIONS In comparison to warfarin, half-dose DOAC anticoagulation in patients with atrial fibrillation following cardiac surgery is associated with a shorter postoperative length of stay, without a significant increase in stroke/transient ischemic attack, reoperation for bleeding or postoperative blood product transfusion. Follow-up echocardiography in anticoagulated patients is recommended to rule out significant sanguineous pericardial effusions in the early postoperative period following hospital discharge.
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Affiliation(s)
- Sabet W Hashim
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Susan Collazo
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | | | - Jeff F Mather
- Clinical Research Center, Hartford Hospital, Hartford, CT, USA
| | - Raymond G McKay
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA -
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Mosleh W, Mather JF, Delago AJ, Eastman L, Crain N, Swann EL, Masih R, DeVries JT, McKay RG, Young MN. The Benefit of Percutaneous Coronary Intervention Before Transcatheter Aortic Valve Replacement: A Multicenter Retrospective Outcome-Based Study. Am J Cardiol 2023; 206:175-184. [PMID: 37708748 DOI: 10.1016/j.amjcard.2023.08.064] [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: 06/25/2023] [Revised: 08/03/2023] [Accepted: 08/11/2023] [Indexed: 09/16/2023]
Abstract
There is inadequate evidence regarding the role of percutaneous coronary intervention (PCI) in patients who underwent transcatheter aortic valve replacement (TAVR). The current American Heart Association/American College of Cardiology guidelines are limited to class 2A recommendations for pre-TAVR revascularization in the setting of hemodynamically significant left main (LM), proximal left anterior descending (pLAD), or extensive bifurcation disease regardless of angina status. We performed a multicenter, retrospective, observational study assessing the benefit of PCI in patients with coronary artery disease who underwent transfemoral TAVR for severe symptomatic aortic stenosis. Patients were divided into 2 cohorts: (1) patients who did not undergo pre-TAVR PCI within the preceding 12 months (no-PCI group) and (2) patients who received pre-TAVR PCI within the preceding 12 months (PCI group). The primary outcome was defined as the composite end point of in-hospital and 30-day adverse events, including all-cause mortality, cardiac arrest, and myocardial infarction. Subgroup analyses were performed on patients with LM and/or pLAD disease and other high-risk features, including angina and heart failure. Comparisons were made between 1,809 consecutive patients (1,364 in the no-PCI group and 445 in the PCI group). There were no differences between the 2 cohorts regarding the primary composite outcome (2.0% vs 2.8%, p = 0.918) or individual secondary outcomes. Although LM/pLAD disease, New York Heart Association classes III to IV, and Society of Thoracic Surgeons risk score ≥8 were all independent predictors of the primary outcome, none of the subgroups demonstrated a benefit favoring PCI. In conclusion, there is no observed benefit from PCI within 12 months pre-TAVR in patients with severe aortic stenosis and concomitant coronary artery disease, including patients with LM/pLAD disease.
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Affiliation(s)
- Wassim Mosleh
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Augustin J Delago
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Lauren Eastman
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Nathan Crain
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Emily L Swann
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Rohit Masih
- Cardiology, Hartford Healthcare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - James T DeVries
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Raymond G McKay
- Cardiology, Hartford Healthcare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael N Young
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
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Patail H, Kompella R, Hoover NE, Reis W, Masih R, Mather JF, Sutton TS, McKay RG. In-Hospital and One-Year Outcomes of Transcatheter Aortic Valve Replacement in Patients Requiring Supplemental Home Oxygen Use. Cardiol Res 2023; 14:228-236. [PMID: 37304920 PMCID: PMC10257506 DOI: 10.14740/cr1497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/28/2023] [Indexed: 06/13/2023] Open
Abstract
Background There have been limited reports with inconsistent results on the impact of long-term use of oxygen therapry (LTOT) in patients treated with transcatheter aortic valve replacement (TAVR). Methods We compared in-hospital and intermediate TAVR outcomes in 150 patients requiring LTOT (home O2 cohort) with 2,313 non-home O2 patients. Results Home O2 patients were younger, and had more comorbidities including chronic obstructive pulmonary disease (COPD), diabetes, carotid artery disease, lower forced expiratory volume (FEV1) (50.3±21.1% vs. 75.0±24.7%, P < 0.001), and lower diffusion capacity (DLCO, 48.6±19.2% vs. 74.6±22.4%, P < 0.001). These differences represented higher baseline Society of Thoracic Surgeons (STS) risk score (15.5±10.2% vs. 9.3±7.0%, P < 0.001) and lower pre-procedure Kansas City Cardiomyopathy Questionnaire (KCCQ-12) scores (32.5 ± 22.2 vs. 49.1 ± 25.4, P < 0.001). The home O2 cohort required higher use of alternative TAVR vascular access (24.0% vs. 12.8%, P = 0.002) and general anesthesia (51.3% vs. 36.0%, P < 0.001). Compared to non-home O2 patients, home O2 patients showed increased in-hospital mortality (5.3% vs. 1.6%, P = 0.001), procedural cardiac arrest (4.7% vs. 1.0%, P < 0.001), and postoperative atrial fibrillation (4.0% vs. 1.5%, P = 0.013). At 1-year follow-up, the home O2 cohort had a higher all-cause mortality (17.3% vs. 7.5%, P < 0.001) and lower KCCQ-12 scores (69.5 ± 23.8 vs. 82.1 ± 19.4, P < 0.001). Kaplan-Meir analysis revealed a lower survival rate in the home O2 cohort with an overall mean (95% confidence interval (CI)) survival time of 6.2 (5.9 - 6.5) years (P < 0.001). Conclusion Home O2 patients represent a high-risk TAVR cohort with increased in-hospital morbidity and mortality, less improvement in 1-year KCCQ-12, and increased mortality at intermediate follow-up.
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Affiliation(s)
- Haris Patail
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Ritika Kompella
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | | | - Wyona Reis
- Department of Cardiology, Hartford Hospital, Hartford, CT, USA
| | - Rohit Masih
- Department of Internal Medicine, Hartford Hospital, Hartford, CT, USA
| | - Jeff F. Mather
- Department of Research Administration, Hartford Hospital, Hartford, CT, USA
| | - Trevor S. Sutton
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT, USA
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Sutton TS, Bailey DL, Rizvi A, Al-Araji R, Kasliwala Q, Nero T, Scalzo M, Panza G, Mather JF, Orlando R, Hashim S, McKay RG. Racial and Ethnic Disparities in the Treatment and Outcomes for Witnessed Out-of-Hospital Cardiac Arrest in Connecticut. Resuscitation 2023:109850. [PMID: 37230326 DOI: 10.1016/j.resuscitation.2023.109850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/14/2023] [Accepted: 05/15/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Racial and ethnic disparities in the treatment and outcomes for witnessed out-of-hospital cardiac arrest (OHCA) in the United States have been previously described. We sought to characterize disparities in pre-hospital care, overall survival, and survival with favorable neurological outcomes following witnessed OHCA in the state of Connecticut. METHODS We performed a cross-sectional study to compare pre-hospital treatment and outcomes for White versus Black and Hispanic (Minority) OHCA patients submitted from Connecticut to the Cardiac Arrest Registry to Enhance Survival (CARES) between 2013 and 2021. Primary outcomes included bystander CPR use, bystander automated external defibrillator (AED) use with attempted defibrillation, overall survival, and survival with favorable cerebral function. RESULTS 2,809 patients with witnessed OHCA were analyzed (924 Black or Hispanic; 1885 White). Minorities had lower rates of bystander CPR (31.4% vs 39.1%, P=0.002) and bystander AED placement with attempted defibrillation (10.5% vs 14.4%, P=0.004), with lower rates of survival to hospital discharge (10.3% vs 14.8%, P=0.001) and survival with favorable cerebral function (65.3% vs 80.2%, P=0.003). Minorities were less likely to receive bystander CPR in communities with median annual household income >$80, 000 (OR, 0.56; 95% CI, 0.33 - 0.95; P=0.030) and in integrated neighborhoods (OR, 0.70; 95% CI, 0.52 - 0.95; P=0.020). CONCLUSIONS Black and Hispanic Connecticut patients with witnessed OHCA have lower rates of bystander CPR, attempted AED defibrillation, overall survival, and survival with favorable neurological outcomes compared to White patients. Minorities were less likely to receive bystander CPR in affluent and integrated communities.
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Affiliation(s)
| | | | - Asad Rizvi
- Department of Cardiology, Hartford Hospital
| | | | | | - Thomas Nero
- Department of Cardiology, St Vincent's Medical Center
| | | | - Gregory Panza
- Department of Research Administration, Hartford Hospital
| | - Jeff F Mather
- Department of Research Administration, Hartford Hospital
| | | | - Sabet Hashim
- Department of Cardiac Surgery, Hartford Hospital
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Mosleh W, Memon S, Hoover NE, Mather JF, Hagberg RC, Azemi T, Sadiq IR, Haider J, McMahon SR, Hashim S, McKay RG. Intermediate Follow-Up of Balloon-Expandable Versus Self-Expanding Transcatheter Aortic Valve Implantation in Patients With Small Aortic Annuli. Am J Cardiol 2023; 192:31-38. [PMID: 36731250 DOI: 10.1016/j.amjcard.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/16/2022] [Accepted: 01/03/2023] [Indexed: 02/04/2023]
Abstract
The clinical impact of prosthesis-patient mismatch (PPM) in patients with small aortic annuli who underwent transcatheter aortic valve (AV) implantation with either balloon-expandable (BE) or self-expanding (SE) valves remains controversial. We assessed in-hospital and intermediate clinical outcomes in 573 patients with transfemoral transcatheter AV implantation with a small AV annulus, defined as an AV annulus area ≤430 mm2. A total of 337 patients treated with a 23-mm BE valve (SAPIEN 3, Ultra) were compared with 236 patients treated with a 26-mm SE valve (Evolut series). Valve-in-valve cases were excluded, and late echo follow-up (mean 674 ± 438 days) was assessed in a subset of 292 patients (51.0%). Well-matched BE and SE cohorts did not differ with respect to major in-hospital outcomes, other than a borderline increase in vascular complications and composite bleeding in patients with SE. Patients with BE had a higher incidence of severe PPM on discharge echocardiography (16.9% vs 6.8%, p <0.002). The mean AV gradient at 30 days was higher for patients with BE (12.2 ± 4.2 vs 6.2 ± 7.9 mm Hg, p <0.001) and at late follow-up (14.0 ± 8.2 vs 7.2 ± 3.5 mm Hg, p <0.001). The follow-up left ventricular ejection fraction and incidence of >mild aortic insufficiency were similar. All-cause mortality for the 2 cohorts was similar, with an overall mean (95% confidence interval) survival time of 61.2 months (57.8 to 64.5; p = 0.98). There were no significant survival differences between combined patients with BE and SE with no, moderate, or severe PPM, with an overall mean (95% confidence interval) survival time of 32.5 (30.5 to 34.5) months combining valve types (p = 0.23). In conclusion, despite an increased incidence of PPM with higher mean AV gradients that persist on late echocardiography in the BE cohort, patients with BE and SE with small aortic annuli have similar clinical outcomes at intermediate follow-up. Moderate and severe PPM had no impact on survival at a mean follow-up of 32.5 months.
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Affiliation(s)
- Wassim Mosleh
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | | | - Jeff F Mather
- Department of Research Administration, Hartford Hospital, Hartford, Connecticut
| | - Robert C Hagberg
- Cardiac Surgery, Hartford Healthcare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | | | | | | | | | - Sabet Hashim
- Cardiac Surgery, Hartford Healthcare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
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Memon S, Kompella R, Konstantinidis I, Pino ME, Hoover N, Gizelis S, Mather JF, Hagberg R, Hashim S, Zeman J, McKay RG. ASSOCIATION BETWEEN BALLOON-EXPANDABLE VALVE SIZE AND NEED FOR PERMANENT PACEMAKER POST TAVR. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01475-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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7
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Shaik A, Hoover N, Memon S, Mather JF, McKay RG, Duvall WL, McMahon SR. ONE-YEAR OUTCOMES OF TRANSCATHETER AORTIC VALVE REPLACEMENT IN PATIENTS WITH LOW BODY MASS INDEX. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01476-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Ali A, Schirmer T, Kiernan FJ, Piccirillo B, Ingrassia J, Azemi T, Sadiq I, Fram DB, Rizvi A, Joshi S, Mather J, McKay RG. Recovery From the Impact of COVID-19 on Treatment Times and Clinical Outcomes of Patients With ST-Segment Elevation Myocardial Infarction: An Interim Analysis. Tex Heart Inst J 2023; 50:491449. [PMID: 36913275 PMCID: PMC10178640 DOI: 10.14503/thij-22-7919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND Previous studies have documented a negative impact of the COVID-19 pandemic on emergent percutaneous treatment of patients with ST-segment elevation myocardial infarction (STEMI), but few have examined recovery of healthcare systems in restoring prepandemic STEMI care. METHODS Retrospective analysis was performed of data from 789 patients with STEMI from a large tertiary medical center treated with percutaneous coronary intervention between January 1, 2019, and December 31, 2021. RESULTS For patients with STEMI presenting to the emergency department, median time from door to balloon was 37 minutes in 2019, 53 minutes in 2020, and 48 minutes in 2021 (P < .001), whereas median time from first medical contact to device changed from 70 to 82 to 75 minutes, respectively (P = .002). Treatment time changes in 2020 and 2021 correlated with median emergency department evaluation time (30 to 41 to 22 minutes, respectively; P = .001) but not median catheterization laboratory revascularization time. For transfer patients, median time from first medical contact to device changed from 110 to 133 to 118 minutes, respectively (P = .005). In 2020 and 2021, patients with STEMI had greater late presentation (P = .028) and late mechanical complications (P = .021), with nonsignificant increases in yearly in-hospital mortality (3.6% to 5.2% to 6.4%; P = .352). CONCLUSION COVID-19 was associated with worsening STEMI treatment times and outcomes in 2020. Despite improving treatment times in 2021, in-hospital mortality had not decreased in the setting of a persistent increase in late patient presentation and associated STEMI complications.
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Affiliation(s)
- Abdelrahman Ali
- Division of Hospital Medicine, Hartford Hospital, Hartford, Connecticut
| | - Thomas Schirmer
- Division of Cardiology, Hartford Hospital, Hartford, Connecticut
| | | | - Bryan Piccirillo
- Division of Cardiology, Hartford Hospital, Hartford, Connecticut
| | - Joseph Ingrassia
- Division of Cardiology, Hartford Hospital, Hartford, Connecticut
| | - Talhat Azemi
- Division of Cardiology, Hartford Hospital, Hartford, Connecticut
| | - Immad Sadiq
- Division of Cardiology, Hartford Hospital, Hartford, Connecticut
| | - Daniel B Fram
- Division of Cardiology, Hartford Hospital, Hartford, Connecticut
| | - Asad Rizvi
- Division of Cardiology, Hartford Hospital, Hartford, Connecticut
| | - Saurabh Joshi
- Division of Cardiology, Hartford Hospital, Hartford, Connecticut
| | - Jeffrey Mather
- Division of Research Administration, Hartford Hospital, Hartford, Connecticut
| | - Raymond G McKay
- Division of Cardiology, Hartford Hospital, Hartford, Connecticut
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Masih R, Haider J, Hoover N, Memon S, Hagberg R, Hashim S, McKay RG. INCIDENCE, DETERMINANTS AND PROGNOSTIC IMPACT OF ACUTE KIDNEY INJURY VERSUS RECOVERY FOLLOWING TAVR. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01359-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Takata ET, Eschert J, Mather J, McLaughlin T, Hammond J, Hashim SW, McKay RG, Sutton TS. Enhanced Recovery After Surgery Is Associated With Reduced Hospital Length of Stay after Urgent or Emergency Isolated Coronary Artery Bypass Surgery at an Urban, Tertiary Care Teaching Hospital: An Interrupted Time Series Analysis With Propensity Score Matching. J Cardiothorac Vasc Anesth 2023; 37:31-41. [PMID: 36379833 DOI: 10.1053/j.jvca.2022.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate whether enhanced recovery after surgery (ERAS) was associated with reduced length of stay (LOS) after urgent or emergency coronary artery bypass graft surgery (CABG). DESIGN A retrospective analysis of an institutional database for urgent or emergency isolated CABG before versus after ERAS. Propensity matching identified comparable subpopulations pre- versus post-ERAS. Interrupted time series analysis was used to evaluate LOS. SETTING At a tertiary care teaching hospital. PARTICIPANTS A total of 1,012 patients undergoing urgent or emergent CABG-346 from 2016 to 2017 (pre-ERAS), and 666 from 2018 to 2020 (post-ERAS). Emergent CABG was performed within 24 hours, and urgent CABG was performed during the same hospitalization to reduce clinical risk. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Propensity-matched post-ERAS (n = 565) versus pre-ERAS patients (n = 330) demonstrated reduced LOS (9 [8-13] v (10 [8-14] days p = 0.015), increased likelihood of extubation within 6 hours (46.0% v 35.8%, p = 0.003), shorter ventilation time (6.3 [5.1-10.2] v (7.2 [5.4-12.2] hours, p = 0.003), reduced morphine milligram equivalent use on postoperative days 1 and 2 (69.6 ± 62.2 v 99.0 ± 61.6, p < 0.001), and increased intraoperative ketamine use (58.8% v 35.2%, p < 0.001). There were no differences regarding reintubation, intensive care unit readmission, or 30-day morbidity. Adjusted segmental regression (n = 1,012) for LOS demonstrated reduced mean LOS of approximately 2 days after ERAS (β2 coefficient -1.943 [-3.766 to -0.121], p = 0.037), with stable trends for mean LOS and no change in slope throughout the pre-ERAS and post-ERAS time periods. CONCLUSIONS Enhanced recovery after surgery was associated with reduced LOS after urgent or emergency CABG without adverse effects on prolonged ventilation, reintubation, intensive care unit readmission, or 30-day outcomes.
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Affiliation(s)
- Edmund T Takata
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT
| | - John Eschert
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT
| | - Jeff Mather
- Research Administration, Hartford Hospital, Hartford, CT
| | | | - Jonathan Hammond
- Department of Cardiac Surgery and Heart and Vascular Institute, Hartford Hospital, Hartford, CT
| | - Sabet W Hashim
- Department of Cardiac Surgery and Heart and Vascular Institute, Hartford Hospital, Hartford, CT
| | - Raymond G McKay
- Heart and Vascular Research Institute, Hartford Hospital, Hartford, CT
| | - Trevor S Sutton
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT.
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Ingrassia JJ, Mosleh W, Conner CM, Mather JF, Loya DS, Yaffee DW, Sutton TS, Takata ET, McMahon SR, Hashim SW, McKay RG. Impact of Ticagrelor Versus Clopidogrel on Bleeding Outcomes of Isolated Coronary Artery Bypass Grafting. Cardiovasc Revasc Med 2023; 46:44-51. [PMID: 35961855 DOI: 10.1016/j.carrev.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 08/02/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Increased bleeding risks have been documented in patients exposed to P2Y12 inhibitors within 5 days of coronary artery bypass surgery (CABG). This study aimed to determine the relative CABG bleeding risks of clopidogrel versus ticagrelor exposure and the proper time course of ticagrelor discontinuation prior to surgery. METHODS Clinical outcomes were assessed in 2075 isolated CABG patients, including 375 who had received P2Y12 inhibitors within 5 days of surgery (155 clopidogrel, 213 ticagrelor, 7 prasugrel). BARC-4 CABG bleeding complications and perioperative blood product usage were assessed in propensity-matched P2Y12-inhibited and non-P2Y12-inhibited cohorts. RESULTS P2Y12-inhibited patients (n = 375) in comparison to matched non-P2Y12-inhibited patients (n = 1138) had higher rates of re-operation for bleeding (3.8 % vs 1.3 %, p = 0.003), postoperative red blood cell transfusion ≥5 units (5.7 % vs 2.7 %, p = 0.007), and intraoperative and postoperative blood product utilization (42.3 % vs 27.1 %, p < 0.001; 41.8 % vs 32.2 %, p < 0.001, respectively). Univariate predictors of BARC-4 bleeding included clopidogrel (OR: 2.145, 95 % CI: 1.131-4.067, p = 0.019) and ticagrelor discontinued within 3 days of surgery (OR: 2.153, 95 % CI: 1.003-4.169, p = 0.049). Multivariate logistic regression demonstrated that only clopidogrel exposure was an independent BARC-4 bleeding predictor (OR: 1.850, 95 % CI: 1.007-3.398, p = 0.048). Unadjusted ticagrelor patients with drug discontinuation 4-5 days prior to CABG only demonstrated higher rates of perioperative platelet transfusion, without additional signs of excessive bleeding. CONCLUSIONS Clopidogrel exposure within 5 days of CABG is an independent predictor of BARC-4 bleeding, whereas major ticagrelor bleeding effects are confined to drug exposure within 3 days of surgery.
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Affiliation(s)
- Joseph J Ingrassia
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | | | - Chad M Conner
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | | | - Deborah S Loya
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - David W Yaffee
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Trevor S Sutton
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT, USA
| | - Edmund T Takata
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT, USA
| | - Sean R McMahon
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Sabet W Hashim
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Raymond G McKay
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA.
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12
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Hashim SW, McMahon SR, Vaitkeviciute IK, Collazo S, Hashim IM, Loya DS, Takata ET, Mather JF, McKay RG. Propensity-matched comparison of right mini-thoracotomy versus median sternotomy for isolated mitral valve repair. J Cardiovasc Surg (Torino) 2022; 63:724-733. [PMID: 36106398 DOI: 10.23736/s0021-9509.22.12397-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND A right mini-thoracotomy (RT) versus median sternotomy (MS) approach for isolated mitral valve (MV) repair has been associated with less postoperative morbidity, shorter hospital stay, and faster functional recovery, but with consistently longer cross-clamp time and higher operative costs. METHODS We assessed the impact of a modified operative technique on outcomes in 158 RT versus 129 MS patients treated with myxomatous MV repair from 2016 through 2021. Propensity matching based upon the Society of Thoracic Surgeons Risk Score was used to compare 108 patients in each cohort. RESULTS Propensity-matched RT patients had reductions in total ventilation time (P=0.025), postoperative atrial fibrillation (P=0.019), and hospital length of stay (P<0.001). RT and MS patients had similar cross-clamp times (66.4±13.7 vs 64.8±16.0 minutes, P=0.414), with less overall leaflet resection (32.4% vs 57.4%, P<0.001) and fewer Gore-Tex NeoChords implanted per patient (1.7±0.7 vs 2.1±1.0, P=0.028) in the RT group. The two cohorts did not differ with respect to 30-day major surgical complications. No patient died and there was no difference between the two groups with respect to freedom from re-operation (98.2% vs 98.2%, P=0.800) at a mean follow-up of 21.4±18.5 months. Direct total hospital costs were lower for the RT group (P=0.018), with reductions in postoperative charges offsetting increased operating room costs. CONCLUSIONS In this single-center study, the RT compared to the MS approach for myxomatous MV repair resulted in less postoperative morbidity and shorter hospital length of stay, with similar cross-clamp time, reduced total hospital costs, and comparable intermediate outcomes.
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Affiliation(s)
- Sabet W Hashim
- Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Sean R McMahon
- Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Irena K Vaitkeviciute
- Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Susan Collazo
- Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | | | - Deborah S Loya
- Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Edmund T Takata
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT, USA -
| | - Jeff F Mather
- Research Administration, Hartford Hospital, Hartford, CT, USA
| | - Raymond G McKay
- Hartford Health Care Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
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Hoover NE, Ouranos HB, Memon S, Azemi T, Piccirillo BJ, Sadiq IR, Rizvi AA, Haider JM, Hagberg RC, Mather JF, Underhill DJ, McKay RG, Cheema M. Transcarotid Versus Transfemoral Transcatheter Aortic Valve Replacement (from a Propensity-Matched Comparison). Am J Cardiol 2022; 185:71-79. [DOI: 10.1016/j.amjcard.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/09/2022] [Accepted: 09/05/2022] [Indexed: 11/01/2022]
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Hoover NE, Curtis L, Haider J, McMahon SR, Arora B, Duvall WL, McKay RG, Hagberg R. IMPACT OF MODERATE AND SEVERE TRICUSPID REGURGITATION ON QUALITY-OF-LIFE OUTCOMES IN PATIENTS UNDERGOING TRANSATHETER AORTIC VALVE REPLACEMENT. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01622-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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15
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McKay RG, McMahon SR, Hoover NE, Curtis L, Duvall WL, Arora B, Mather J, Amin H, Kompella R. IMPACT OF PREOPERATIVE ATRIAL FIBRILLATION ON ONE YEAR MORTALITY AND QUALITY OF LIFE FOLLOWING TRANSCATHETER AORTIC VALVE REPLACEMENT. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01744-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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16
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Sutton TS, McKay RG, Mather J, Takata E, Eschert J, Cox M, Douglas A, McLaughlin T, Loya D, Mennett R, Cech MG, Hinchey J, Walker A, Hammond J, Hashim S. Enhanced Recovery After Surgery is Associated with Improved Outcomes and Reduced Racial and Ethnic Disparities Following Isolated Coronary Artery Bypass Surgery: A Retrospective Analysis with Propensity Score Matching. J Cardiothorac Vasc Anesth 2022; 36:2418-2431. [DOI: 10.1053/j.jvca.2022.02.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/07/2022] [Accepted: 02/21/2022] [Indexed: 11/11/2022]
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17
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Joshi S, Mosleh W, Amer MR, Tawayha M, Mather JF, Kiernan FJ, McKay RG, Piccirillo B. Outcomes of Transcatheter Aortic Valve Replacement in Patients Treated With Systemic Steroids. J Invasive Cardiol 2022; 34:E49-E54. [PMID: 34982726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Chronic steroid therapy is associated with higher vascular complication rates in patients undergoing transcatheter aortic valve replacement (TAVR). The effect of corticosteroids on aortic annular complications has not been directly assessed in this population. METHODS A retrospective analysis of 1095 patients undergoing transfemoral TAVR was performed. Patients treated with chronic steroids at the time of the procedure (n = 99) were compared with those who received no steroids (n = 992). The primary outcome included a composite of aortic annular complications, defined as a combination of aortic annular rupture, aortic dissection/perforation, and left ventricular perforation. RESULTS The primary outcome was significantly higher in the steroid group (4.0% vs 0.5%; P<.01). This finding was primarily driven by higher rates of acute annular rupture in the steroid group (2.0% vs 0.2%; P=.04). Steroid use was associated with higher rates of intraoperative cardiac arrest (5.1% vs 1.5%; P=.03), device capture/retrieval (4.0% vs 0.8%; P=.01), and emergent conversion to open heart surgery (4.0% vs 0.6%; P<.01). There were no differences with respect to in-hospital mortality, stroke, myocardial infarction, need for permanent pacemaker, bleeding complications, minor vascular complications, hospital length of stay, hospital 30-day readmission, or 30-day echocardiographic findings. Additionally, within the steroid group, there were no significant differences between balloon-expandable vs self-expanding TAVR prostheses with respect to composite aortic annular complications. CONCLUSION Chronic steroid therapy increases the risk of aortic annular complications in patients undergoing TAVR, with detrimental consequences including intraoperative cardiac arrest and conversion to open heart surgery. Steroid use should be considered in patient selection and determination of procedural technique for TAVR.
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Affiliation(s)
- Saurabh Joshi
- Division of Interventional Cardiology, Hartford Hospital Cardiac Laboratory, High Building, 80 Seymour Street, Hartford, CT 06115 USA.
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Abstract
OBJECTIVE The impact of asthma as a possible risk factor for adverse clinical outcomes in patients diagnosed with COVID-19 remains controversial. The purpose of this study was to examine the impact of asthma on adverse clinical outcomes in a COVID-19 hospitalized cohort. METHODS Retrospective, propensity-matched observational study of consecutive COVID-19-positive patients between February 24, 2020, and November 3, 2020 at a single health care system. RESULTS In the initial population of 1925 patients, 4.4% presented with asthma. Propensity score matching reduced the total sample to n = 1045: 88 (8.4%) with asthma and n = 957 without asthma. A total of 164 (15.7%) patients died during the hospitalization, including 7 (8.0%) in the asthma group and 157 (16.4%), p = .037, in the non-asthmatic cohort. There was no difference between these groups in need for mechanical ventilation, length of stay on a ventilator, or hospital length of stay.Logistic regression analysis demonstrated that asthma was an independent predictor of lower mortality, while older age, BMI > 30 kg/m2, heart failure, chronic kidney disease, and admission National Early Warning Score (NEWS) were significantly associated with an increased risk of in-hospital death. There were no significant differences between asthmatic and non-asthmatic cohorts with respect to need for mechanical ventilation, length of mechanical ventilation, serum markers of severe COVID-19 disease, or overall length of hospital stay. CONCLUSION We conclude that asthma in hospitalized COVID-19 patients is associated with a lower risk of mortality and no increase in disease severity in hospitalized COVID-19 patients.
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Affiliation(s)
- Jeffrey F Mather
- Division of Research Administration, Hartford Hospital, Hartford, CT, USA
| | - Wassim Mosleh
- Division of Cardiology, University of Connecticut, Farmington, CT, USA
| | - Raymond G McKay
- Division of Cardiology, Hartford Hospital, Hartford, CT, USA
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Ali A, Mather JF, McMahon S, Curtis LE, Hoover N, Ayer C, Amer MR, Dibble T, Roper L, Orlando R, McKay RG. Racial and ethnic disparities in the use of transcatheter aortic valve replacement in the State of Connecticut. Cardiovasc Revasc Med 2021; 37:7-12. [PMID: 34246611 DOI: 10.1016/j.carrev.2021.06.120] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/22/2021] [Accepted: 06/22/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Although prior national reports have identified trends in the underutilization of transcatheter aortic valve replacement (TAVR) in Afro-American and Latino populations, racial and ethnic healthcare disparities in TAVR use in the State of Connecticut have not been previously reported. METHODS We conducted a retrospective analysis of 1461 patients undergoing TAVR at our institute between from 2012 to 2020. Baseline demographics, procedural characteristics, clinical outcomes, median incomes and insurance coverage were compared between 1417 Caucasian and 44 minority patients, including 23 patients designated as Afro-American and 10 designated as Latino. Demographics of TAVR utilization at our institution were further compared to 6 additional Connecticut TAVR centers using Connecticut Hospital Association (CHA) ChimeData detailing hospital discharges for DRG 266 and 267. RESULTS In comparison to Caucasian patients, minority cohorts were younger (75.7 ± 9.0 vs 81.5 ± 5.1 years, p < 0.001) and had more co-morbidities including diabetes (64% vs 34%, p < 001), coronary artery disease (95% vs 78%, p = 0.039), end stage renal disease requiring dialysis (9% vs 3%, p = 0.009) and atrial fibrillation (77% vs 62%, p = 0.041). The two groups did not differ with respect to other risk factors or co-morbidities, baseline echocardiographic or CTA findings, STS risk score, or procedural technique. Minority patients had a longer length of hospital stay (9.5 ± 9.0 vs 6.4 ± 6.9 days, p = 0.003), but did not differ with respect to procedural complications. Socioeconomic differences between the two groups included lower median incomes and higher rates of Medicaid or no insurance coverage for minority versus Caucasian patients. CHA ChimeData revealed a similar underutilization of TAVR in minority subgroups in the remaining 6 Connecticut TAVR centers. CONCLUSIONS Despite statewide demographics describing 10.7% and 15.7% of the total population as Afro-American and Latino, respectively, only 3.0% of the total TAVR procedures performed at a large Connecticut health care facility were performed in minority subgroups. Despite having a higher burden of co-morbidities, minority patients had similar outcomes compared to Caucasian patients. Similar racial and ethnic disparities in TAVR utilization were confirmed statewide using CHA ChimeData.
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Affiliation(s)
- Abdelrahman Ali
- Divisions of Medicine, Cardiology, Surgery and Research Administration, Hartford Hospital, Hartford, CT, United States of America.
| | - Jeffrey F Mather
- Divisions of Medicine, Cardiology, Surgery and Research Administration, Hartford Hospital, Hartford, CT, United States of America
| | - Sean McMahon
- Divisions of Medicine, Cardiology, Surgery and Research Administration, Hartford Hospital, Hartford, CT, United States of America
| | - Lauren E Curtis
- Divisions of Medicine, Cardiology, Surgery and Research Administration, Hartford Hospital, Hartford, CT, United States of America
| | - Nicole Hoover
- Divisions of Medicine, Cardiology, Surgery and Research Administration, Hartford Hospital, Hartford, CT, United States of America
| | - Courtney Ayer
- Divisions of Medicine, Cardiology, Surgery and Research Administration, Hartford Hospital, Hartford, CT, United States of America
| | - Mostafa R Amer
- Divisions of Medicine, Cardiology, Surgery and Research Administration, Hartford Hospital, Hartford, CT, United States of America
| | - Tina Dibble
- Divisions of Medicine, Cardiology, Surgery and Research Administration, Hartford Hospital, Hartford, CT, United States of America
| | - Lizabeth Roper
- Divisions of Medicine, Cardiology, Surgery and Research Administration, Hartford Hospital, Hartford, CT, United States of America
| | - Rocco Orlando
- Divisions of Medicine, Cardiology, Surgery and Research Administration, Hartford Hospital, Hartford, CT, United States of America
| | - Raymond G McKay
- Divisions of Medicine, Cardiology, Surgery and Research Administration, Hartford Hospital, Hartford, CT, United States of America
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Mosleh W, Amer MR, Ding Y, Megaly M, Mather JF, McMahon S, Pershad A, McKay RG, Arora B. Benefit of Transcatheter Aortic Valve Replacement in Patients With Paradoxical Low-Flow Low-Gradient Versus High-Gradient Aortic Stenosis and Preserved Left Ventricular Function. Circ Cardiovasc Interv 2021; 14:e010042. [PMID: 33685217 DOI: 10.1161/circinterventions.120.010042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Wassim Mosleh
- Division of Cardiology, University of Connecticut, Farmington (W.M., Y.D.)
| | - Mostafa R Amer
- Division of Cardiology, Lankenau Heart Institute/Main Line Health, Wynnewood, PA (M.R.A.)
| | - Yuewen Ding
- Division of Cardiology, University of Connecticut, Farmington (W.M., Y.D.)
| | - Michael Megaly
- Division of Interventional Cardiology, Banner University Medical Center/University of Arizona, Phoenix (M.M., A.P.)
| | - Jeffrey F Mather
- Division of Research Administration, Hartford Hospital, CT (J.F.M.)
| | - Sean McMahon
- Division of Cardiology, Hartford Hospital, CT (S.M., R.G.M., B.A.)
| | - Ashish Pershad
- Division of Interventional Cardiology, Banner University Medical Center/University of Arizona, Phoenix (M.M., A.P.)
| | - Raymond G McKay
- Division of Cardiology, Hartford Hospital, CT (S.M., R.G.M., B.A.)
| | - Bhaskar Arora
- Division of Cardiology, Hartford Hospital, CT (S.M., R.G.M., B.A.)
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21
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Allen KB, Chhatriwalla AK, Saxon J, Hermiller J, Heimansohn D, Moainie S, McKay RG, Cheema M, Jones B, Hodson RW, Korngold E, Kirker E. Reply: Transcarotid trumps transapical/direct aortic access for transcatheter aortic valve replacement—It's a no brainer! J Thorac Cardiovasc Surg 2021; 164:e84-e86. [DOI: 10.1016/j.jtcvs.2021.01.032] [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: 01/06/2021] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 11/28/2022]
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22
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Amer MR, Mosleh W, Megaly M, Shah T, Ooi YS, McKay RG. Outcomes of transcarotid versus trans-subclavian transcatheter aortic valve replacement: A systematic review and meta-analysis. Cardiovascular Revascularization Medicine 2021; 33:20-25. [DOI: 10.1016/j.carrev.2021.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/03/2021] [Accepted: 01/05/2021] [Indexed: 11/17/2022]
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Abstract
INTRODUCTION To compare outcomes in patients hospitalized with coronavirus (COVID-19) receiving famotidine therapy with those not receiving famotidine. METHODS Retrospective, propensity-matched observational study of consecutive COVID-19-positive patients between February 24, 2020, and May 13, 2020. RESULTS Of 878 patients in the analysis, 83 (9.5%) received famotidine. In comparison to patients not treated with famotidine, patients treated with famotidine were younger (63.5 ± 15.0 vs 67.5 ± 15.8 years, P = 0.021), but did not differ with respect to baseline demographics or preexisting comorbidities. Use of famotidine was associated with a decreased risk of in-hospital mortality (odds ratio 0.37, 95% confidence interval 0.16-0.86, P = 0.021) and combined death or intubation (odds ratio 0.47, 95% confidence interval 0.23-0.96, P = 0.040). Propensity score matching to adjust for age difference between groups did not alter the effect on either outcome. In addition, patients receiving famotidine displayed lower levels of serum markers for severe disease including lower median peak C-reactive protein levels (9.4 vs 12.7 mg/dL, P = 0.002), lower median procalcitonin levels (0.16 vs 0.30 ng/mL, P = 0.004), and a nonsignificant trend to lower median mean ferritin levels (797.5 vs 964.0 ng/mL, P = 0.076). Logistic regression analysis demonstrated that famotidine was an independent predictor of both lower mortality and combined death/intubation, whereas older age, body mass index >30 kg/m, chronic kidney disease, National Early Warning Score, and higher neutrophil-lymphocyte ratio were all predictors of both adverse outcomes. DISCUSSION Famotidine use in hospitalized patients with COVID-19 is associated with a lower risk of mortality, lower risk of combined outcome of mortality and intubation, and lower levels of serum markers for severe disease in hospitalized patients with COVID-19.(Equation is included in full-text article.).
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Affiliation(s)
- Jeffrey F. Mather
- Divisions of Research Administration and Interventional Cardiology, Hartford Hospital, Hartford, Connecticut, USA
| | - Richard L. Seip
- Divisions of Research Administration and Interventional Cardiology, Hartford Hospital, Hartford, Connecticut, USA
| | - Raymond G. McKay
- Divisions of Research Administration and Interventional Cardiology, Hartford Hospital, Hartford, Connecticut, USA
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24
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Zaleski AL, Taylor BA, McKay RG, Thompson PD. Declines in Acute Cardiovascular Emergencies During the COVID-19 Pandemic. Am J Cardiol 2020; 129:124-125. [PMID: 32593434 PMCID: PMC7246052 DOI: 10.1016/j.amjcard.2020.05.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 01/17/2023]
Affiliation(s)
- Amanda L Zaleski
- Heart & Vascular Institute, Hartford Hospital, Hartford, Connecticut.
| | - Beth A Taylor
- Heart & Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Raymond G McKay
- Heart & Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Paul D Thompson
- Heart & Vascular Institute, Hartford Hospital, Hartford, Connecticut
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Amer MR, Mosleh W, Memon S, Joshi S, Sullivan B, Sharkawi M, Mather JF, Kiernan FJ, McMahon S, Duvall WL, McKay RG. Comparison of Benefit of Transcatheter Aortic Valve Implantation in Patients With Low Gradient Versus High Gradient Aortic Stenosis and Left Ventricular Dysfunction. Am J Cardiol 2020; 125:1543-1549. [PMID: 32273053 DOI: 10.1016/j.amjcard.2020.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/06/2020] [Accepted: 02/10/2020] [Indexed: 11/30/2022]
Abstract
Patients with low gradient severe aortic stenosis (LG-AS) often exhibit significant limitations in functional status and quality of life. We aimed to evaluate the clinical effect of transcatheter aortic valve implantation (TAVI) on LG-AS patients compared to those with high transvalvular gradients and similar left ventricular dysfunction. Retrospective analysis of records for all patients with a left ventricular ejection fraction <50% who underwent TAVI at our institution was performed. Patients were grouped according to their transvalvular gradient. Data were collected from The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Clinical benefit endpoints included improvements in left ventricular ejection fraction and changes in the Kansas City Cardiomyopathy Questionnaire. Additional outcomes analyzed included 1-year all-cause mortality, stroke rates, rates of rehospitalization, need for a permanent pacemaker, and hospital length of stay. Two hundred three patients met our inclusion criteria. one hundred one LG-AS patients (mean transvalvular gradient <40 mm Hg) were compared to 102 patients with high transvalvular gradients (mean transvalvular gradient >40 mm Hg). LG-AS patients yielded similar improvements in left ventricular ejection fraction (43.5% ± 63.7 vs 37.7% ± 58.7; p = 0.525) and Kansas City Cardiomyopathy Questionnaire scores (423.51% ± 1257.02 vs 266.56% ± 822.81; p = 0.352). There were no differences between the groups with respect to 1-year mortality (16.8% vs 12.7%; p = 0.412), stroke rates, hospital length of stay, need for permanent pacemaker implantation or hospital readmissions. In conclusion, we found that TAVI is associated with comparable improvement in clinical and echocardiographic outcomes in LG-AS patients as compared to those with high gradient severe aortic stenosis.
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Affiliation(s)
- Mostafa R Amer
- Division of Cardiology, University of Connecticut, Farmington, Connecticut
| | - Wassim Mosleh
- Division of Cardiology, University of Connecticut, Farmington, Connecticut
| | - Sarfaraz Memon
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Saurabh Joshi
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Bethany Sullivan
- Division of Cardiology, University of Connecticut, Farmington, Connecticut
| | - Musa Sharkawi
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Jeffrey F Mather
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Francis J Kiernan
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Sean McMahon
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - W Lane Duvall
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Raymond G McKay
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut.
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Mosleh W, Amer MR, Joshi S, Mather JF, Gandhi S, Iyer V, Curtis L, Kiernan FJ, McMahon S, Duvall L, McKay RG. Comparative Outcomes of Balloon-Expandable S3 Versus Self-Expanding Evolut Bioprostheses for Transcatheter Aortic Valve Implantation. Am J Cardiol 2019; 124:1621-1629. [PMID: 31547995 DOI: 10.1016/j.amjcard.2019.08.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/08/2019] [Accepted: 08/12/2019] [Indexed: 12/20/2022]
Abstract
To date, comparisons between the balloon-expandable Edwards Sapien S3 (S3) versus the self-expanding Evolut R or PRO (Evolut) valves have been limited with respect to procedural outcomes. We aim to compare the safety, efficacy, and procedural efficiency of the S3 versus the Medtronic Evolut bioprostheses in patients who underwent transcatheter aortic valve implantation for severe aortic stenosis. Retrospective analysis was performed of all consecutive transcatheter aortic valve implantation procedures performed through the transfemoral approach with either S3 or Evolut at our hospital between September 2015 and January 2019. A total of 581 patients were included. There were no significant differences between S3 (n = 452) and Evolut (n = 129) concerning in-hospital or 30-day safety outcomes. S3 was associated with significantly shorter fluoroscopy times, lower fluoroscopy Air Kerma, and higher contrast use. S3 had lower postprocedure aortic valve area (1.71 ± 0.45 vs 1.84 ± 0.50 cm2, p = 0.004), larger peak gradient at 30 days (10.7 ± 3.8 vs 7.0 ± 3.2 mm Hg, p <0.001), and lower aortic regurgitation (AR) rates postprocedure (47% vs 33%, p = 0.024) and at 30 days (50% vs 33%, p = 0.008), driven by mild AR. Device type was an independent predictor of AR postprocedure and at 30 days. Patients with ≥mild AR were more likely to have had Evolut valves (odds ratio = 2.94, p <0.001), especially in larger valves (>26 mm). Severe prosthesis-patient mismatch was higher in S3 (14.8% vs 7.9%, p <0.001). In conclusion, S3 is associated with less radiation exposure, higher contrast use, and lower incidence of AR at 30 days. Alternately, S3 has a higher transaortic gradient at 30 days, and higher levels of severe prosthesis-patient mismatch.
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Mosleh W, Mather JF, Amer MR, Hiendlmayr B, Kiernan FJ, McKay RG. Propensity Matched Analysis Comparing Conscious Sedation Versus General Anesthesia in Transcatheter Aortic Valve Implantation. Am J Cardiol 2019; 124:70-77. [PMID: 31064667 DOI: 10.1016/j.amjcard.2019.03.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/17/2019] [Accepted: 03/19/2019] [Indexed: 12/29/2022]
Abstract
Conscious sedation (CS) has been increasingly utilized in transcatheter aortic valve implantation (TAVI). We aim to compare safety, efficacy, efficiency, and direct cost outcomes of patients who underwent TAVI with general anesthesia (GA) to those with CS. Records for all adult patients undergoing transfemoral TAVI at our institution between February 2012 and September 2018 were retrospectively screened. Patients were grouped by anesthesia treatment (GA or CS) and propensity matched. Safety (in-hospital and 30-day mortality, in-hospital and 30-day stroke, cardiac arrest, need for permanent pacemaker, and composite bleed/vascular adverse events), efficacy (follow-up echocardiographic findings), efficiency (procedure duration, fluoroscopy time, radiation dose, intensive care unit (ICU) stay, hospital length-of-stay, and discharge to home), and direct cost outcomes were compared. A total of 589 patients met our inclusion criteria. Propensity matching yielded 154 GA patients and 154 CS patients. There were no differences in the safety outcomes of in-hospital or 30-day mortality, in-hospital or 30-day stroke, cardiac arrest, and need for permanent pacemaker between GA and CS groups. There was a significant reduction in composite bleeding/vascular events in the CS group (8.4% vs 19.5%, p < 0.01). There were no differences in the follow-up echocardiograms with respect to aortic valve area, left ventricular ejection fraction, and incidence of moderate or severe aortic regurgitation. The CS group had shorter procedural fluoroscopy times and radiation dose, shorter length-of-stay and ICU stay, with similar procedural duration. CS patients were more likely to be discharged to home (59.7% vs 74.7%, p < 0.01). Total direct costs for CS were decreased in almost every departmental category, with a mean 10.4% reduction in overall direct costs (p < 0.001). In conclusion, TAVI with CS is associated with less bleeding and vascular events, lower procedural radiation exposure, reduced length of hospitalization and ICU stay, and lower direct costs in comparison with TAVI with GA. These outcomes occur without sacrificing procedural efficacy or safety.
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Affiliation(s)
- Wassim Mosleh
- Division of Cardiology, University of Connecticut, Farmington, Connecticut
| | - Jeffrey F Mather
- Department of Research Administration, Hartford Hospital, Hartford, Connecticut
| | - Mostafa R Amer
- Division of Primary Care Internal Medicine, University of Connecticut, Farmington, Connecticut
| | - Brett Hiendlmayr
- Division of Interventional Cardiology, Hartford Hospital, Hartford, Connecticut
| | - Francis J Kiernan
- Division of Interventional Cardiology, Hartford Hospital, Hartford, Connecticut
| | - Raymond G McKay
- Division of Interventional Cardiology, Hartford Hospital, Hartford, Connecticut.
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Abdelaziz A, Gowani SA, Hiendlmayr B, Jantz J, Kiernan F, McKay RG. Interatrial Septal Dissection Complicating a MitraClip Procedure. J Invasive Cardiol 2018; 30:E128. [PMID: 30373957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Left atrial dissection is an exceedingly rare complication of cardiac surgery, with an incidence of 0.16%-0.84%. We report the first case of interatrial dissection and hematoma in association with the MitraClip procedure. Hemodynamically stable patients can be managed conservatively, with echocardiographic imaging, often with resolution of the dissection over the course of weeks. Our patient remained hemodynamically stable and asymptomatic post operation; at 1-month follow-up, echocardiogram showed resolution of the interatrial septal dissection.
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Affiliation(s)
- Amged Abdelaziz
- Hartford Hospital, University of Connecticut, 85 Seymour Street, Hartford, CT 06106 USA.
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Kleiman N, Maini B, Reardon MJ, Katz S, Kauten J, McKay RG, Hagberg RC, Popma J. TCT-683 Early Stroke After Implantation of a Self-Expanding Transcatheter Aortic Valve Prosthesis: Experience From the CoreValve Clinical Trials. J Am Coll Cardiol 2015. [DOI: 10.1016/j.jacc.2015.08.702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rai M, Seip RL, Gupta A, McKay RG, Hirst J, Thompson PD, Ruaño G. CYP2C19 genotype-guided antiplatelet therapy in a patient with clopidogrel resistance. Conn Med 2012; 76:267-272. [PMID: 22685981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
We report a switch in antiplatelet medication based on platelet function and CYP2C19 genotype test results in a 74-year-old man with severe coronary arterial disease. Upon bare metal stent implantation at age 66, clopidogrel therapy (75 mg/ day) was initiated to supplement aspirin. Over the next eight years, the patient required multiple percutaneous coronary interventions for de novo coronary stenosis and in-stent restenosis. Platelet reactivity measured while on clopidogrel therapy was high, consistent with clopidogrel resistance. CYP2C19 genotype testing then revealed homozygosity for the *2 null allele. The *2/*2 designation indicates poor metabolizer status, indicating deficient capacity of the cytochrome p450 2C19 enzyme for activation of clopidogrel. A medication switch to prasugrel,which does not rely on activation by the 2C19 enzyme, reduced platelet reactivity by 86%. The patient has suffered no cardiovascular events in the 18 months since initiation of prasugrel therapy.
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Ching GG, Li D, Baker WL, Hohl PK, Mather JF, McKay RG, Lundbye JB. Major adverse cardiac events among postpercutaneous coronary intervention patients on clopidogrel and proton pump inhibitors. Conn Med 2012; 76:205-211. [PMID: 22611719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To determine if concomitant use of proton pump inhibitors (PPIs) and clopidogrel is associated with adverse events among postpercutaneous coronary intervention (PCI) patients. METHODS This is a single-center, retrospective case-control study of 3,287 consecutive patients on clopidogrel who underwent PCI. Univariate and multivariate analyses determined if concomitant PPI and clopidogrel use was associated with major adverse cardiac events (MACE). RESULTS There were significantly more deaths (3.0% vs 1.1%; P < 0.001), repeat revascularizations (3.8% vs 2.1%; P = 0.005) and MACE (7.1% vs 3.5%; P < 0.001) in the clopidogrel and PPI group. Cox regression revealed that PPI is an independent predictor of MACE (HR 1.70, 95% CI of 1.20-2.41; P = 0.003), mortality (HR 1.79; 95% CI 1.03-3.12, P = 0.038), and target-vessel revascularization (HR 1.75; 95% CI 1.12-2.72, P = 0.014). CONCLUSIONS Concomitant use of PPIs and clopidogrel among post PCI patients was associated with increased rates of all-cause mortality, target vessel revascularization, and combined MACE at nine months follow-up.
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Iqtidar AF, Li D, Mather J, McKay RG. Propensity matched analysis of bleeding and vascular complications associated with vascular closure devices vs standard manual compression following percutaneous coronary intervention. Conn Med 2011; 75:5-10. [PMID: 21329285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND In patients undergoing percutaneous coronary intervention (PCI), controversy exists regarding the effect of vascular closure device (VCD) use on bleeding and vascular complications with limited data available for comparison of the different devices. METHODS We developed propensity score matched groups, manual compression (MC) (n = 1,407) and VCD (n = 2,814), who underwent PCI in an eight-year period and compared their bleeding and vascular complications. Vascular closure device subtype analysis was also done. RESULTS Compared to MC, the VCD group had lower rates of hematoma > or = 10 cm (1.1% vs 2.1%, P < 0.01). Angioseal use was associated with the highest rate of surgical repair. Perclose had the lowest rates of bleeding and the lowest composite outcome of all vascular and bleeding complications at 5.6% vs 9.2% forAngiosealand 10.2% for Starclose (P < 0.001). CONCLUSION In patients undergoing PCI, VCD use is a safe method for achieving femoral artery hemostasis. Perclose use is associated with the least complications.
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Affiliation(s)
- Ali F Iqtidar
- Henry Low Heart Center, Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT 06107, USA.
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Magnuson RJ, Lundbye JB, Kiernan FJ, Alkeylani A, Schultz T, Stewart DS, Dougherty K, Li D, Mather J, Murphy D, McKay RG. IMPACT OF HYPERGLYCEMIA ON LONG-TERM CLINICAL OUTCOMES IN PATIENTS WITH NON-ST ELEVATION ACUTE CORONARY SYNDROMES TREATED WITH PERCUTANEOUS CORONARY INTERVENTION. J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)61182-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Shafi NA, McKay RG, Kiernan FJ, Silverman IE, Ahlquist M, Silverman DI. Determinants and clinical significance of persistent residual shunting in patients with percutaneous patent foramen ovale closure devices. Int J Cardiol 2009; 137:314-6. [PMID: 19616327 DOI: 10.1016/j.ijcard.2009.06.045] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Accepted: 06/26/2009] [Indexed: 11/16/2022]
Abstract
BACKGROUND Percutaneous patent foramen closure has emerged as a dynamic therapy for stroke prevention secondary to paradoxical embolism. Recent reports, however, have documented uncertain clinical efficacy and patients with incomplete PFO closure may remain at risk of recurrent events. We sought to identify echocardiographic determinants and the clinical significance of persistent residual shunting after percutaneous PFO closure. METHODS From 2002 to 2008, 51 consecutive patients with recurrent stroke (n=46) or transient ischemic attack (TIA) (n=5) underwent percutaneous PFO closure at a tertiary care hospital. PFO size, degree of shunt, tunnel length, and atrial septal aneurysm geometry were documented at the time of device implantation. All patients received follow-up with transesophageal (n=43) or transthoracic (n=8) echocardiography 6.7+/-2 months post procedure and presence of residual shunting and recurrent stroke/TIA were recorded. RESULTS All patients underwent percutaneous PFO closure without complication. Ten patients (20%) demonstrated residual right-to-left shunting at the time of follow-up: color Doppler (2), mild (n=3), moderate (n=2) and severe (n=3). Univariate analysis revealed larger PFO size (F=4.71, p=0.036) as the only independent predictor of residual shunting after PFO closure. Ninety six percent of patients remained stroke and TIA free 3 years+/-8 months post closure, with no clinical differences between the two groups. CONCLUSIONS In patients undergoing percutaneous PFO closure for stroke or TIA, a larger PFO size predisposes to residual shunting approximately 6 months post PFO closure, but with no short term increased risk of recurrent thromboembolic events.
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Dada MR, Hirst JA, Kiernan FJ, Smally AJ, Lundbye JB, Thompson PD, McKay RG. Use of prehospital electrocardiograms for the treatment of patients with ST-segment elevation myocardial infarction. Conn Med 2009; 73:69-72. [PMID: 19263736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Use of prehospital electrocardiograms (ECG) by emergency medical personnel may reduce door-to-balloon (DTB) time in patients with ST-segment elevation myocardial infarction (STEMI) referred for urgent percutaneous coronary intervention (PCI). A 79-year-old female awoke from sleep with severe substernal chest pain and called 911 for assistance. The patient was initially evaluated by advanced life support paramedics who performed a 12-lead ECG at the patient's home. The ECG, which demonstrated an acute inferior STEMI, was transferred using a novel, web-based system to Hartford Hospital's Emergency Department. As a result of prehospital communication, the on-call catheterization team was mobilized prior to the patient's arrival. The patient underwent successful PCI of an occluded right coronary artery with a DTB time of 67 minutes and was subsequently discharged four days later. Use of prehospital electrocardiography combined with early catheterization laboratory mobilization allowed for timely STEMI reperfusion according to national guidelines, despite "off-hour" presentation.
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Affiliation(s)
- Marcin R Dada
- Chest Pain Center, Hartford Hospital, Hartford, CT 06102, USA.
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McKay RG, Dada MR, Mather JF, Mennet RR, Murphy DJ, Maloney KW, Hirst JA, Kiernan FJ. Comparison of outcomes and safety of "facilitated" versus primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction. Am J Cardiol 2009; 103:316-21. [PMID: 19166682 DOI: 10.1016/j.amjcard.2008.09.078] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Revised: 09/16/2008] [Accepted: 09/16/2008] [Indexed: 10/21/2022]
Abstract
Recent studies have documented that use of "facilitated" percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) may be harmful. In-hospital outcomes in 1,553 consecutive patients with STEMI without cardiogenic shock who underwent PCI at a single tertiary center within 6 hours of presentation were analyzed. The study group included 767 patients who underwent primary PCI who initially presented to the tertiary center and were triaged for emergent PCI and 786 patients who underwent facilitated PCI who were pretreated at a community hospital with a glycoprotein IIb/IIIa platelet inhibitor and/or intravenous thrombolytic therapy before transfer for catheter-based therapy. Compared with patients who underwent primary PCI, the facilitated PCI group had longer door-to-balloon times (162 +/- 57 vs 113 +/- 61 minutes), higher baseline infarct-vessel TIMI 3 flow rates (52.8% vs 25.4%; p <0.001), and no increase in major adverse in-hospital outcomes. In patients treated with door-to-balloon times >90 and < or =150 minutes, patients who underwent facilitated PCI had fewer composite major adverse clinical events (combined mortality, recurrent myocardial infarction, emergent repeated PCI, hemorrhagic and nonhemorrhagic stroke, and nonintracranial TIMI major bleeding) compared with patients who underwent primary PCI (relative risk 0.50, 95% confidence interval 0.26 to 0.96, p = 0.034). In conclusion, facilitated PCI can be safely used to increase pharmacologic reperfusion before catheter-based therapy in patients with STEMI without an increase in clinical hazard and with fewer major adverse clinical events in patients treated with door-to-balloon times >90 and < or =150 minutes.
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Denktas AE, Athar H, Henry TD, Larson DM, Simons M, Chan RS, Niles NW, Thiele H, Schuler G, Ahn C, Sdringola S, Anderson HV, McKay RG, Smalling RW. Reduced-Dose Fibrinolytic Acceleration of ST-Segment Elevation Myocardial Infarction Treatment Coupled With Urgent Percutaneous Coronary Intervention Compared to Primary Percutaneous Coronary Intervention Alone. JACC Cardiovasc Interv 2008; 1:504-10. [DOI: 10.1016/j.jcin.2008.06.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Revised: 06/10/2008] [Accepted: 06/19/2008] [Indexed: 10/21/2022]
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McKay RG, Murphy DJ, Cloutier J, Mather JF, Mennett RA, Dada MR, Shah AR, Kiernan FJ. Long-term efficacy and safety of sirolimus-eluting vs bare-metal stents. Conn Med 2008; 72:453-463. [PMID: 18798379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Although previous studies have documented persistent clinical benefit of sirolimus-eluting stents (SES)in reducing the need for target vessel revascularization without an increase in myocardial infarction (MI) or mortality, the long-term safety and efficacy of CYPHER stent use in routine clinical practice, including off-label stent implantation, remains uncertain. METHODS We compared long-term clinical outcomes in 2,550 patients treated with one or more SES with 1,022 patients treated with one or more bare metal or heparin-coated stents (BMS). The study groups included 1,058 SES patients (41.5%) and 488 BMS patients (47.7%) with off-label indications. A propensity-score method was utilized to adjust for differences in baseline characteristics. Patients were followed for up to five years for the occurrence of all-cause mortality, MI and repeat target vessel revascularization. RESULTS Compared to BMS patients, SES patients demonstrated significantly improved event-free survival with respect to all-cause mortality (RR, 1.39; 95% CI, 1.07 to 1.80, P = 0.014) and repeat target vessel revascularization (RR, 2.72; 95% CI, 1.99 to 3.73, P < 0.001), with no significant difference in the incidence of cumulative MI. A landmark analysis, examining composite adverse events occurring six months after stent implantation in the two study groups, demonstrated no increased late hazard associated with SES use (relative risk, 1.08; 95% CI, 0.80 to 1.46). CONCLUSIONS Use of SES in routine clinical practice, including off-label indications, is associated with improved long-term mortality, reduced need for repeat target vessel revascularization and no increase in MI compared to BMS.
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Affiliation(s)
- Raymond G McKay
- Division of Interventional Cardiology, Hartford Hospital Cardiac Laboratory, 80 Seymour Street, Hartford CT 06115, USA.
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Mamkin I, Vaksman M, Kiernan FJ, McKay RG, Boden WE. Letter by Mamkin et al regarding article, "weekend onset of acute myocardial infarction does not have a negative impact on outcome in Japan". Circ J 2008; 72:864; author reply 865. [PMID: 18441476 DOI: 10.1253/circj.72.864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Mamkin I, Elkoustaf RA, Zhang Q, Mather JF, Kiernan FJ, McKay RG. Drug-eluting stent implantation results in effective treatment of small coronary artery disease (DESIRE Small CAD). Conn Med 2007; 71:517-522. [PMID: 17966720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVE Sirolimus-eluting stents (SES) have been shown to significantly reduce restenosis in the treatment of lesions in large coronary arteries. We assessed and compared the in-hospital and long-term outcomes of patients treated with SES and bare-metal stents (BMS) for small coronary artery disease. METHODS We compared 448 patients who underwent SES implantation in small coronary arteries (<2.5mm) with patients who received conventional BMS (n=124). In-hospital and nine-month events were evaluated. RESULTS The rate of angiographic restenosis at nine months was significantly lower in the SES group (1.6% vs 9.9%, P<0.001) than in the BMS group. The overall rate of MACE was 4.3% in SES and 13.9% in BMS groups (P<0.001). CONCLUSIONS As compared with BMS, SES placement in small coronary arteries is effective and associated with a marked reduction in restenosis rate and the subsequent need for target lesion revascularization at nine months.
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Affiliation(s)
- Igor Mamkin
- Division of Interventional Cardiology, The Henry Low Heart Center, Hartford Hospital, Hartford, USA.
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Mamkin I, Mather JF, Kiernan FJ, McKay RG. More studies are needed on gender-based outcomes in percutaneous coronary intervention with drug-eluting stents. Am J Cardiol 2007; 100:560-1. [PMID: 17659950 DOI: 10.1016/j.amjcard.2007.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2007] [Accepted: 03/15/2007] [Indexed: 10/23/2022]
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Elkoustaf RA, Mamkin I, Mather JF, Murphy D, Hirst JA, Kiernan FJ, McKay RG. Comparison of results of percutaneous coronary intervention for non-ST-elevation acute myocardial infarction or unstable angina pectoris in men versus women. Am J Cardiol 2006; 98:182-6. [PMID: 16828589 DOI: 10.1016/j.amjcard.2006.01.071] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2005] [Revised: 01/19/2006] [Accepted: 01/19/2006] [Indexed: 11/20/2022]
Abstract
Previous randomized trials have addressed the impact of gender on outcomes, showing worse results in women assigned to invasive strategies compared with men with non-ST-elevation (NSTE) acute coronary syndrome (ACS). However, there is still a significant amount of controversy on strategies of treatment on the basis of gender. This study evaluated the impact of gender on treatment strategies and outcomes in patients with NSTE ACS in a high-volume, single-site tertiary center. We identified 1,197 consecutive patients with NSTE ACS (381 women, 816 men) who underwent percutaneous coronary intervention during their index hospitalizations. Patients were stratified by gender and baseline clinical and angiographic characteristics, and in-hospital and 9-month clinical outcomes were compared between the 2 groups. There were clear differences in baseline characteristics between men and women with ACS at presentation. Women were, on average, slightly older than men, with more hypertension and morbid obesity, but there were no differences in racial backgrounds or the prevalence of diabetes or dyslipidemia, nor were there treatment disparities in pharmacologic interventions. Women and men with ACS had similar rates of percutaneous coronary intervention on index admission. Women had a greater incidence of bleeding complications requiring blood transfusions. Overall, in-hospital and 9-month event-free survival were equivalent for the 2 genders. In conclusion, in this single-site observational study, patients with NSTE ACS who underwent angiography followed by percutaneous coronary intervention demonstrated no significant gender differences in treatment or in-hospital or 9-month event-free survival. From these results, interventional strategies should not be based on gender.
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Affiliation(s)
- Rachid A Elkoustaf
- Division of Cardiology, The Henry Low Heart Center, Hartford Hospital, Hartford, and University of Connecticut School of Medicine, Farmington, USA.
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Coleman CI, McKay RG, Boden WE, Mather JF, White CM. Effectiveness and cost-effectiveness of facilitated percutaneous coronary intervention compared with primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction transferred from community hospitals. Clin Ther 2006; 28:1054-62. [PMID: 16990084 DOI: 10.1016/j.clinthera.2006.07.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND Primary percutaneous coronary intervention ([PCI], percutaneous transluminal coronary angioplasty+stenting) for ST-segment elevation myocardial infarction (STEMI) is regarded as superior to fibrinolysis even if it means that patients need to be transferred from one center to another to undergo the procedure. However, this inevitable delay between symptom onset and PCI, caused by the time required to travel, might increase the occurrence of cardiac events. A hybrid method called facilitated PCI uses fibrinolysis and/or glycoprotein (GP) IIb/IIIa inhibitors before transfer to a tertiary medical center where urgent PCI might be performed. This approach, however, has not been systematically evaluated. OBJECTIVE The purpose of this study was to compare the effectiveness (combined end point of in-hospital mortality, reinfarction, stroke, or emergency revascularization) and cost-effectiveness of utilizing a bolus thrombolytic agent with GP IIb/IIIa inhibitor followed by transfer to a tertiary institution for facilitated PCI or standard of care transfer without primary PCI drugs among patients presenting to a community hospital with STEMI. METHODS This was a prospective, single-center, cohort study comprising data from STEMI patients transferred from community hospitals to Hartford Hospital, Hartford, Connecticut, from the years 2000 to 2003. At the time of analysis, patients receiving primary PCI were matched (1:1) with those receiving facilitated PCI, utilizing propensity scores to assure similar demographics. The combined incidence of major adverse cardiac end points (MACE) and total hospital costs was compared between groups. Non-parametric bootstrapping was conducted to calculate CIs for the incremental cost-effectiveness ratio and generate a quadrant analysis. RESULTS Based on 254 propensity score-matched patients (127 facilitated PCI and 127 primary PCI), in-hospital MACE and total hospital costs were reduced by 61.3% and US 4563 dollars (2005), respectively, in patients receiving facilitated compared with primary PCI (P=0.021 and P=NS, respectively). Patients receiving facilitated PCI were more likely to have target lesion Thrombolysis in Myocardial Infarction (TIMI) III (normal) blood flow on cardiac catheterization than those receiving primary PCI (49.6% vs 30.7%; P=0.002). However, the rate of TIMI bleeding was similar in both groups (21.3% in the facilitated PCI group vs 18.9% in the primary PCI group). Nonsignificant reductions were observed in both intensive care unit (ICU) and total length of stay (LOS) (0.8 day and 1.0 day, respectively) compared with the primary PCI group. Bootstrap analysis revealed that of 25,000 samplings, facilitated PCI would likely be both more effective and less costly 94.6% of the time. CONCLUSIONS The use of facilitated PCI in STEMI patients who initially presented to community hospitals and were transferred for PCI appeared to significantly reduce the incidence of MACE, and increase the likelihood of having baseline TIMI III blood flow at time of catheterization. Nonsignificant reductions were observed in total ICU and hospital LOS. However, there did not appear to be a significant effect on the incidence of bleeding in patients receiving facilitated PCI. Bootstrap analysis confirmed that facilitated PCI would be both a more effective and less costly strategy.
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Affiliation(s)
- Craig I Coleman
- Division of Cardiology, Hartford Hospital, Hartford, CT 06102-5037, USA
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Wiviott SD, Antman EM, Winters KJ, Weerakkody G, Murphy SA, Behounek BD, Carney RJ, Lazzam C, McKay RG, McCabe CH, Braunwald E. Randomized comparison of prasugrel (CS-747, LY640315), a novel thienopyridine P2Y12 antagonist, with clopidogrel in percutaneous coronary intervention: results of the Joint Utilization of Medications to Block Platelets Optimally (JUMBO)-TIMI 26 trial. Circulation 2005; 111:3366-73. [PMID: 15967851 DOI: 10.1161/circulationaha.104.502815] [Citation(s) in RCA: 311] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Despite the current standard antiplatelet regimen of aspirin and clopidogrel (with or without glycoprotein IIb/IIIa inhibitors) in percutaneous coronary intervention patients, periprocedural and postprocedural ischemic events continue to occur. Prasugrel (CS-747, LY640315), a novel potent thienopyridine P2Y(12) receptor antagonist, has the potential to achieve higher levels of inhibition of ADP-induced platelet aggregation than currently approved doses of clopidogrel. METHODS AND RESULTS Joint Utilization of Medications to Block Platelets Optimally-Thrombolysis In Myocardial Infarction 26 (JUMBO-TIMI 26) was a phase 2, randomized, dose-ranging, double-blind safety trial of prasugrel versus clopidogrel in 904 patients undergoing elective or urgent percutaneous coronary intervention. Patients were randomized to either standard dosing with clopidogrel or 1 of 3 prasugrel regimens. Subjects were monitored for 30 days for bleeding and clinical events. The primary end point of the trial was clinically significant (TIMI major plus minor) non-CABG-related bleeding events in prasugrel- versus clopidogrel-treated patients. Hemorrhagic complications were infrequent, with no significant difference between patients treated with prasugrel or clopidogrel in the rate of significant bleeding (1.7% versus 1.2%; hazard ratio, 1.42; 95% CI, 0.40, 5.08). In prasugrel-treated patients, there were numerically lower incidences of the primary efficacy composite end point (30-day major adverse cardiac events) and of the secondary end points myocardial infarction, recurrent ischemia, and clinical target vessel thrombosis. CONCLUSIONS In this phase 2 study, which was designed to assess safety when administered at the time of percutaneous coronary intervention, prasugrel and clopidogrel both resulted in low rates of bleeding. The results of this trial serve as a foundation for the large phase 3 clinical trial designed to assess both efficacy and safety.
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Affiliation(s)
- Stephen D Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Department of Medicine, Harvard Medical School, Boston, Mass 02115, USA.
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Boden WE, Phinney AO, Low HBC, Kluger J, McLean C, Shapiro R, Hammond J, Kiernan FJ, Humphrey C, Rossi MA, Fieldman A, McKay RG, Gillam LD, Clyne CA, Heller GV, Thompson PD. The origins and development of the Cardiovascular Program at Hartford Hospital. 150th Anniversary of Hartford Hospital. Conn Med 2004; 68:259-68. [PMID: 15171261] [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] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- William E Boden
- Hartford Hospital, Hartford, 80 Seymour Street, Hartford, CT 06102, USA.
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Turcot DB, Kiernan FJ, McKay RG, Grey NJ, Boden W, Perdrizet GA. Acute hyperglycemia: implications for contrast-induced nephropathy during cardiac catheterization. Diabetes Care 2004; 27:620-1. [PMID: 14747256 DOI: 10.2337/diacare.27.2.620] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Silverman IE, Kiernan FJ, Kelsey AM, Brakoniecki JJ, Kazi FA, Dougherty JE, Boden WE, McKay RG. Initial experience with a transcatheter septal closure system for secondary stroke prevention in patients with interatrial septal defects. Conn Med 2003; 67:135-44. [PMID: 12687787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Percutaneous transcatheter closure of a patent foramen ovale (PFO) has been utilized over the last several years to prevent thromboembolic events in selected patients with a prior cryptogenic stroke. We describe our initial experience at Hartford Hospital with a transcatheter PFO closure system and our multidisciplinary approach. METHODS From March to November 2002, we performed percutaneous transcatheter closure of a PFO in 16 patients with a prior history of cryptogenic stroke(s) and/or transient ischemic attack using the CardioSEAL Septal Occluder system. All 16 patients had a PFO visualized on their transesophageal echocardiogram (TEE) study, and 15 patients also had an atrial septal aneurysm. PFO closure was performed with a CardioSEAL Septal Occluder in the cardiac catheterization laboratory under general anesthesia with TEE guidance. Following device placement, all patients were discharged on a regimen of aspirin and clopidigrel, with follow-up in the Stroke Clinic. RESULTS Successful deployment of the septal occluder and effective PFO closure was achieved in all 16 patients with no major procedural or in-hospital complications. Short-term clinical follow-up has demonstrated no recurrent neurologic thromboembolic events, but one patient was rehospitalized for de novo atrial fibrillation. Follow-up transthoracic echocardiographic assessment at three to six months postprocedure, obtained in eight patients thus far, has demonstrated no residual interatrial shunting. CONCLUSION Our early results suggest that percutaneous PFO closure with the CardioSEAL Septal Occluder system is a safe option for secondary stroke prevention in carefully selected patients with interatrial septal defects and a history of cryptogenic stroke or TIA. Patient selection and the long-term effectiveness and safety of this approach require further assessment.
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Affiliation(s)
- Isaac E Silverman
- Stroke Center, Hartford Hospital, University of Connecticut School of Medicine, CT, USA.
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McKay RG. "Ischemia-guided" versus "early invasive" strategies in the management of acute coronary syndrome/non-ST-segment elevation myocardial infarction: the interventionalist's perspective. J Am Coll Cardiol 2003; 41:96S-102S. [PMID: 12644347 DOI: 10.1016/s0735-1097(02)02688-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Conventional therapy for non-ST-segment elevation acute coronary syndrome (ACS) has traditionally employed an "ischemia-guided" strategy. In this approach, diagnostic cardiac catheterization and revascularization are only used in patients with objective evidence of myocardial ischemia as identified by recurrent symptoms or provocative stress testing. More recent studies, however, have demonstrated improved clinical outcomes with the use of an "early invasive" approach, employing routine coronary angiography early in the patient's hospital course, followed by percutaneous intervention or bypass surgery where appropriate. Improved clinical outcomes associated with an "early invasive" strategy may have evolved as a consequence of recent advances in both adjunctive pharmacotherapy and revascularization technique. In particular, use of glycoprotein IIb/IIIa inhibitors and/or low-molecular-weight heparin before catheterization have been shown to reduce clinical events in patients with ACS, and may reduce the risk of an invasive approach by plaque passivation before interventional therapy. Perhaps more importantly, the combined use of glycoprotein IIb/IIIa inhibitors and intracoronary stenting may reduce the potential early hazard of an invasive approach by specifically decreasing the incidence of death and nonfatal myocardial infarction associated with percutaneous intervention. In spite of the benefits of this synergistic combination of pharmacology and mechanical revascularization, risk stratification remains important in identifying high-risk individuals most likely to benefit from an "early invasive" approach. In addition, angiography with possible percutaneous coronary intervention of "culprit" lesions should always be used in combination with aggressive medical therapy to treat the widespread coronary atherosclerosis commonly seen in patients with ACS.
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Affiliation(s)
- Raymond G McKay
- Henry Low Heart Center, Hartford Hospital, Hartford, Connecticut 06102, USA.
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Affiliation(s)
- Alan H B Wu
- Department of Pathology and Laboratory Medicine, Hartford, Connecticut 06102, USA.
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