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Abadie BQ, Cremer PC, Vakamudi S, Gillinov AM, Svensson LG, Cho L. Sex-Specific Prognosis of Left Ventricular Size and Function Following Repair of Degenerative Mitral Regurgitation. J Am Coll Cardiol 2024; 83:303-312. [PMID: 38199708 DOI: 10.1016/j.jacc.2023.10.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/29/2023] [Accepted: 10/13/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Prior studies have demonstrated worse long-term outcomes for women after surgery for severe mitral regurgitation (MR). The current Class I indications for surgery for severe degenerative MR use cutoffs of left ventricular end-systolic dimension (LVESD) and left ventricular ejection fraction (EF) that do not account for known sex-related differences. OBJECTIVES The primary objective of this study was to assess long-term mortality following mitral valve repair in women compared with men on the basis of preoperative left ventricular systolic dimensions and EF. METHODS Consecutive patients who underwent isolated mitral valve repair for degenerative MR at a single institution between 1994 and 2016 were screened. Adjusted HRs for all-cause mortality were compared according to baseline LVESD, LVESD indexed to body surface area (LVESDi), and EF for men and women. RESULTS Among 4,589 patients, 1,825 were women (40%), and after a median follow-up period of 7.2 years, 344 patients (7.5%) had died. The risk for mortality for women increased from the baseline hazard at an LVESD of 3.6 cm, whereas an inflection point for increased risk with LVESD was not evident in men. Regarding LVESDi, the risk for women increased at 1.8 cm/m2 compared with 2.1 cm/m2 in men. For EF, women and men had a similar inflection point (58%); however, mortality was higher for women as EF decreased. CONCLUSIONS After mitral valve repair, women have a higher risk for all-cause mortality at lower LVESD and LVESDi and higher EF. These results support consideration of sex-specific thresholds for LVESDi in surgical decision making for patients with severe MR.
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Affiliation(s)
- Bryan Q Abadie
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul C Cremer
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sneha Vakamudi
- Ascension Texas Cardiovascular and the University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - A Marc Gillinov
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lars G Svensson
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Leslie Cho
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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Simonian NT, Liu H, Vakamudi S, Pirwitz MJ, Pouch AM, Gorman JH, Gorman RC, Sacks MS. Patient-Specific Quantitative In-Vivo Assessment of Human Mitral Valve Leaflet Strain Before and After MitraClip Repair. Cardiovasc Eng Technol 2023; 14:677-693. [PMID: 37670097 DOI: 10.1007/s13239-023-00680-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 08/23/2023] [Indexed: 09/07/2023]
Abstract
PURPOSE Mitral regurgitation (MR) is a highly prevalent and deadly cardiac disease characterized by improper mitral valve (MV) leaflet coaptation. Among the plethora of available treatment strategies, the MitraClip is an especially safe option, but optimizing its long-term efficacy remains an urgent challenge. METHODS We applied our noninvasive image-based strain computation pipeline [1] to intraoperative transesophageal echocardiography datasets taken from ten patients undergoing MitraClip repair, spanning a range of MR etiologies and MitraClip configurations. We then analyzed MV leaflet strains before and after MitraClip implementation to develop a better understanding of (1) the pre-operative state of human regurgitant MV, and (2) the MitraClip's impact on the MV leaflet deformations. RESULTS The MV pre-operative strain fields were highly variable, underscoring both the heterogeneity of the MR in the patient population and the need for patient-specific treatment approaches. Similarly, there were no consistent overall post-operative strain patterns, although the average A2 segment radial strain difference between pre- and post-operative states was consistently positive. In contrast, the post-operative strain fields were better correlated to their respective pre-operative strain fields than to the inter-patient post-operative strain fields. This quantitative result implies that the patient specific pre-operative state of the MV guides its post-operative deformation, which suggests that the post-operative state can be predicted using pre-operative data-derived modelling alone. CONCLUSIONS The pre-operative MV leaflet strain patterns varied considerably across the range of MR disease states and after MitraClip repair. Despite large inter-patient heterogeneity, the post-operative deformation appears principally dictated by the pre-operative deformation state. This novel finding suggests that though the variation in MR functional state and MitraClip-induced deformation were substantial, the post-operative state can be predicted from the pre-operative data alone. This study suggests that, with use of larger patient cohort and corresponding long-term outcomes, quantitative predictive factors of MitraClip durability can be identified.
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Affiliation(s)
- Natalie T Simonian
- James T. Willerson Center for Cardiovascular Modeling and Simulation, The Oden Institute for Computational Engineering and Sciences and the Department of Biomedical Engineering, The University of Texas at Austin , 201 East 24th St., Stop C0200, Austin, TX, 78712-1229, USA
| | - Hao Liu
- James T. Willerson Center for Cardiovascular Modeling and Simulation, The Oden Institute for Computational Engineering and Sciences and the Department of Biomedical Engineering, The University of Texas at Austin , 201 East 24th St., Stop C0200, Austin, TX, 78712-1229, USA
| | - Sneha Vakamudi
- Ascension Texas Cardiovascular & Division of Cardiology, Department of Internal Medicine, Dell Medical School, University of Texas, Austin, TX, USA
| | - Mark J Pirwitz
- Ascension Texas Cardiovascular & Division of Cardiology, Department of Internal Medicine, Dell Medical School, University of Texas, Austin, TX, USA
| | - Alison M Pouch
- Gorman Cardiovascular Research Group, Smilow Center for Translational Research, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, Smilow Center for Translational Research, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, Smilow Center for Translational Research, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael S Sacks
- James T. Willerson Center for Cardiovascular Modeling and Simulation, The Oden Institute for Computational Engineering and Sciences and the Department of Biomedical Engineering, The University of Texas at Austin , 201 East 24th St., Stop C0200, Austin, TX, 78712-1229, USA.
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Mohammad KO, Fanous H, Vakamudi S, Liu Y. Refractory right ventricular myocarditis induced by immune checkpoint inhibitor despite therapy cessation and immune suppression. Cardiooncology 2023; 9:15. [PMID: 36941689 PMCID: PMC10026228 DOI: 10.1186/s40959-023-00165-2] [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] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 03/10/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are currently widely used for treatment of various types of cancers. ICI-induced myocarditis, though uncommon, accounts for high risk of major adverse cardiac events and mortality, which makes appropriate diagnosis important. We here present a unique, challenging case of ICI-induced, refractory and isolated right ventricular (RV) myocarditis. CASE PRESENTATION A 32-year-old female with breast cancer presented with newly onset chest pain and dyspnea shortly after initiation of Pembrolizumab. Coronary angiography showed normal coronary arteries and a cardiac magnetic resonance (CMR) revealed myocarditis involving the right ventricle with chamber dilation and severe dysfunction. ICI therapy was stopped, and high dose steroid therapy was initiated and symptoms resolved. However, three months after initial presentation, the patient was hospitalized for DKA and decompensated right heart failure, and a repeat cardiac MRI at that time showed recurrent, isolated right ventricular myocardial inflammation/edema without LV involvement. High dose steroid therapy was started again and at 6-month follow up, surveillance CMR continued to show persistent right-sided myocarditis, patient was eventually treated with Abatacept with resolution of HF symptoms, RV dysfunction and biomarkers at 10-month follow up. CONCLUSIONS We describe a unique case of isolated ICI-induced right ventricular myocarditis leading to right ventricular failure, that was refractory despite ICI therapy cessation and immune suppression by repeated high dose steroids. Co-stimulatory pathway modulation with Abatacept eventually lead to the normalization of RV function and dilation ten months after initial myocarditis onset.
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Affiliation(s)
- Khan O Mohammad
- Department of Internal Medicine, Dell Medical School at The University of Texas, Austin, TX, USA
| | - Hanna Fanous
- Department of Internal Medicine, Dell Medical School at The University of Texas, Austin, TX, USA
| | - Sneha Vakamudi
- Department of Internal Medicine, Dell Medical School at The University of Texas, Austin, TX, USA
| | - Yan Liu
- Department of Internal Medicine, Dell Medical School at The University of Texas, Austin, TX, USA.
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Harrison D, Montano S, Kessler W, Vakamudi S, Gajjar MM, Cauthen C, Pirwitz MJ. AN OFF-LABEL LIFESAVER: TRANSCATHETER MITRAL VALVE REPAIR FOR SEVERE MITRAL REGURGITATION ASSOCIATED WITH HYPERTROPHIC CARDIOMYOPATHY. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)03797-4] [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: 11/28/2022]
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Soneji N, Montano S, Benzing T, Vakamudi S, Liu Y. UNOPACIFIED METASTATIC INTRACARDIAC MASS IN A PATIENT WITH HEPATOCELLULAR CARCINOMA. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)04024-4] [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: 11/30/2022]
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Benzing T, Grzeskowiak M, Gajjar M, Kessler W, Pirwitz M, Vakamudi S. JUST ANOTHER BLEEDING HEART: HEYDE'S SYNDROME TREATED WITH TAVR. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)03732-3] [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: 10/21/2022]
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Donnellan E, Elshazly MB, Vakamudi S, Wazni OM, Cohen JA, Kanj M, Hanna M, Baranowski B, Saliba W, Jaber W. No Association Between CHADS-VASc Score and Left Atrial Appendage Thrombus in Patients With Transthyretin Amyloidosis. JACC Clin Electrophysiol 2020; 5:1473-1474. [PMID: 31857048 DOI: 10.1016/j.jacep.2019.10.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/09/2019] [Accepted: 10/17/2019] [Indexed: 02/07/2023]
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Donnellan E, Wazni OM, Hanna M, Elshazly MB, Puri R, Saliba W, Kanj M, Vakamudi S, Patel DR, Baranowski B, Cantillon D, Dresing T, Jaber WA. Atrial Fibrillation in Transthyretin Cardiac Amyloidosis. JACC Clin Electrophysiol 2020; 6:1118-1127. [DOI: 10.1016/j.jacep.2020.04.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/10/2020] [Accepted: 04/16/2020] [Indexed: 01/02/2023]
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Randhawa VK, Vakamudi S, Phelan DM, Samaras CJ, McKenney JK, Hanna M, Perez AL. Mitral and tricuspid stenosis caused by light chain cardiac amyloid deposition. ESC Heart Fail 2020; 7:1130-1135. [PMID: 32175673 PMCID: PMC7261535 DOI: 10.1002/ehf2.12668] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 02/07/2020] [Accepted: 02/14/2020] [Indexed: 01/12/2023] Open
Abstract
Cardiac amyloidosis results in an infiltrative restrictive cardiomyopathy, with a number of characteristic features: biventricular hypertrophy, abnormal myocardial global longitudinal strain with relative apical sparing, biatrial dilation, and small pericardial effusion along with conduction abnormalities. Amyloid deposits leading to hemodynamically significant valvular heart disease are very rare. We describe a rare case of concomitant moderately severe tricuspid and mitral valve stenosis because of ongoing amyloid deposition in a patient with progressive multiple myeloma and fat pad biopsy‐proven light chain amyloidosis. Worsening infiltrative cardiomyopathy and valvulopathy despite evidence‐based chemotherapy and heart failure pharmacotherapy led to end‐stage disease and death. Valvular involvement in cardiac amyloidosis requires early recognition of the underlying disease condition to guide directed medical therapy and prevent its progression. In this instance, valvuloplasty or valve replacement is not a viable option.
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Affiliation(s)
- Varinder K Randhawa
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, 44195, USA.,Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Sneha Vakamudi
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Dermot M Phelan
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Christy J Samaras
- Department of Hematology and Oncology, Cleveland Clinic, 9500 Euclid Ave, Desk J3-4, Cleveland, OH, 44195, USA
| | - Jesse K McKenney
- Department of Pathology, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Mazen Hanna
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, 44195, USA.,Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Antonio L Perez
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, 44195, USA.,Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
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Vakamudi S, Jellis C, Mick S, Wu Y, Gillinov AM, Mihaljevic T, Cosgrove DM, Svensson L, Cho L. Sex Differences in the Etiology of Surgical Mitral Valve Disease. Circulation 2018; 138:1749-1751. [DOI: 10.1161/circulationaha.118.035789] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sneha Vakamudi
- Departments of Cardiovascular Medicine (S.V., C.J., L.C.), Heart and Vascular Institute, Cleveland Clinic, OH
| | - Christine Jellis
- Departments of Cardiovascular Medicine (S.V., C.J., L.C.), Heart and Vascular Institute, Cleveland Clinic, OH
| | - Stephanie Mick
- Thoracic and Cardiovascular Surgery (S.M., A.M.G., T.M., D.M.C., L.S.), Heart and Vascular Institute, Cleveland Clinic, OH
| | - Yuping Wu
- Department of Mathematics, Cleveland State University, OH (Y.W.)
| | - A. Marc Gillinov
- Thoracic and Cardiovascular Surgery (S.M., A.M.G., T.M., D.M.C., L.S.), Heart and Vascular Institute, Cleveland Clinic, OH
| | - Tomislav Mihaljevic
- Thoracic and Cardiovascular Surgery (S.M., A.M.G., T.M., D.M.C., L.S.), Heart and Vascular Institute, Cleveland Clinic, OH
| | - Delos M. Cosgrove
- Thoracic and Cardiovascular Surgery (S.M., A.M.G., T.M., D.M.C., L.S.), Heart and Vascular Institute, Cleveland Clinic, OH
| | - Lars Svensson
- Thoracic and Cardiovascular Surgery (S.M., A.M.G., T.M., D.M.C., L.S.), Heart and Vascular Institute, Cleveland Clinic, OH
| | - Leslie Cho
- Departments of Cardiovascular Medicine (S.V., C.J., L.C.), Heart and Vascular Institute, Cleveland Clinic, OH
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Vakamudi S, Wu Y, Jellis C, Mick S, Gillinov A, Svensson L, Mihaljevic T, Cho L. GENDER DIFFERENCES IN OUTCOMES FOLLOWING MITRAL VALVE SURGERY. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)32517-8] [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: 10/17/2022]
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Krishnamoorthy A, Vakamudi S, Watson MH, Byrns JS, Rajagopal S, Felker GM, Rogers JG, Patel CB. Hemodynamic Response to Continuous Outpatient Milrinone Infusion in Advanced Heart Failure Patients with Mixed Pulmonary Hypertension. J Card Fail 2014. [DOI: 10.1016/j.cardfail.2014.06.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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