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Stern LK, Grodin JL, Maurer MS, Ruberg FL, Patel AR, Khouri MG, Roth LR, Aras MA, Bhardwaj A, Bhattacharya P, Brailovsky Y, Drachman BM, Ebong IA, Fine NM, Gaggin H, Gopal D, Griffin J, Judge D, Kim P, Mitchell J, Mitter SS, Mohan RC, Ramos H, Reyentovich A, Sheikh FH, Sperry B, Carter S, Urey M, Vaishnav J, Vest AR, Kittleson MM, Patel JK. The Cardiac Amyloidosis Registry Study (CARS): Rationale, Design and Methodology. J Card Fail 2024; 30:669-678. [PMID: 37907148 DOI: 10.1016/j.cardfail.2023.09.016] [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: 03/01/2023] [Revised: 09/19/2023] [Accepted: 09/28/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND CARS (Cardiac Amyloidosis Registry Study) is a multicenter registry established in 2019 that includes patients with transthyretin (ATTR, wild-type and variant) and light chain (AL) cardiac amyloidosis (CA) evaluated at major amyloidosis centers between 1997 and 2025. CARS aims to describe the natural history of CA with attention to clinical and diagnostic variables at the time of diagnosis, real-world treatment patterns, and associated outcomes of patients in a diverse cohort that is more representative of the at-risk population than that described in CA clinical trials. METHODS AND RESULTS This article describes the design and methodology of CARS, including procedures for data collection and preliminary results. As of February 2023, 20 centers in the United States enrolled 1415 patients, including 1155 (82%) with ATTR and 260 (18%) with AL CA. Among those with ATTR, wild-type is the most common ATTR (71%), and most of the 305 patients with variant ATTR have the p.V142I mutation (68%). A quarter of the total population identifies as Black. More individuals with AL are female (39%) compared to those with ATTR (13%). CONCLUSIONS CARS will answer crucial clinical questions about CA natural history and permit comparison of different therapeutics not possible through current clinical trials. Future international collaboration will further strengthen the validity of observations of this increasingly recognized condition.
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Affiliation(s)
- Lily K Stern
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Justin L Grodin
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Mathew S Maurer
- Division of Cardiology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Frederick L Ruberg
- Section of Cardiovascular Medicine, Department of Medicine and Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Ayan R Patel
- Division of Cardiology, The CardioVascular Center, Tufts Medical Center, Boston, MA, USA
| | - Michel G Khouri
- Division of Cardiology, Duke University Hospital, Durham, NC, USA
| | - Lori R Roth
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Mandar A Aras
- Division of Cardiology, Department of Medicine, Division of Cardiology, University of California, San Francisco, CA, USA
| | - Anju Bhardwaj
- Department of Advanced Cardiopulmonary Therapies and Transplantation, McGovern Medical School, University of Texas-Houston, Houston, TX, USA
| | - Priyanka Bhattacharya
- Division of Cardiology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Yevgeniy Brailovsky
- Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Brian M Drachman
- Division of Cardiology, Department of Medicine, Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Imo A Ebong
- Division of Cardiology, Department of Medicine, Division of Cardiology, University of California, Davis, CA, USA
| | - Nowell M Fine
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Hanna Gaggin
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Deepa Gopal
- Section of Cardiovascular Medicine, Department of Medicine and Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Jan Griffin
- Division of Cardiology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA; Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Daniel Judge
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Paul Kim
- Division of Cardiology, Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Joshua Mitchell
- Cardiovascular Division, John T. Milliken Department of Internal Medicine, Cardio-Oncology Center of Excellence, Washington University in St Louis, St Louis, MO, USA
| | - Sumeet S Mitter
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rajeev C Mohan
- Division of Cardiology, Scripps Clinic, San Diego, CA, USA
| | - Hannia Ramos
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Alex Reyentovich
- The Leon H. Charney Division of Cardiology, NYU Langone Health, New York, New York, USA
| | - Farooq H Sheikh
- Infiltrative Cardiomyopathy and Advanced Heart Failure Programs, MedStar Heart and Vascular Institute, Georgetown University, Washington, DC, USA
| | - Brett Sperry
- Saint Luke's Mid America Heart Institute and the University of Kansas City-Missouri, Kansas City, Missouri, USA
| | - Spencer Carter
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Marcus Urey
- Division of Cardiology, Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Joban Vaishnav
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Amanda R Vest
- Division of Cardiology, The CardioVascular Center, Tufts Medical Center, Boston, MA, USA
| | - Michelle M Kittleson
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Jignesh K Patel
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA.
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Wang AY, Patel J, Kanter M, Olmos M, Maurer MS, McPhail ED, Patel AR, Arkun K, Kryzanski J, Riesenburger RI. The emerging significance of amyloid deposits in the ligamentum flavum of spinal stenosis patients: A review. World Neurosurg 2023:S1878-8750(23)00802-1. [PMID: 37331471 DOI: 10.1016/j.wneu.2023.06.037] [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: 05/22/2023] [Accepted: 06/11/2023] [Indexed: 06/20/2023]
Abstract
Spinal stenosis is one of the most common neurosurgical diseases and a leading cause of pain and disability. Wild-type transthyretin amyloid (ATTRwt) has been found in the ligamentum flavum (LF) of a significant subset of spinal stenosis patients who undergo decompression surgery. Histologic and biochemical analyses of ligamentum flavum specimens from spinal stenosis patients, normally discarded as waste, have the potential to help elucidate the underlying pathophysiology of spinal stenosis and possibly allow for medical treatment of stenosis as well screen for other systemic diseases. This review article discusses the utility of analyzing LF specimens following spinal stenosis surgery for wild-type transthyretin amyloid (ATTRwt) deposits. Screening of cardiac ATTRwt amyloidosis (ATTRwt-CM) through LF specimens have led to the early diagnosis and treatment of cardiac amyloidosis in several patients, with more expected to benefit from this process. Emerging evidence in the literature also point to ATTRwt as a contributor to a previously unrecognized subtype of spinal stenosis in patients who may in the future benefit from medical therapy. In this article, we review the current literature with regards to the early detection of ATTRwt-CM via LF screening as well the possible contribution of ATTRwt deposits in the LF to spinal stenosis development.
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Affiliation(s)
- Andy Y Wang
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jainith Patel
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Matthew Kanter
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Michelle Olmos
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Mathew S Maurer
- Department of Cardiology, Columbia University Irving Medical Center, New York, NY USA
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ayan R Patel
- CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Knarik Arkun
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA; Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - James Kryzanski
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ron I Riesenburger
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA.
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Upshaw JN, Parker S, Gregory D, Koethe B, Vest AR, Patel AR, Kiernan MS, DeNofrio D, Davidson E, Mohanty S, Arpin P, Strauss N, Sommer C, Brandon L, Butler R, Dwaah H, Nadeau H, Cantor M, Konstam MA. The effect of tablet computer-based telemonitoring added to an established telephone disease management program on heart failure hospitalizations: The Specialized Primary and Networked Care in Heart Failure (SPAN-CHF) III Randomized Controlled Trial. Am Heart J 2023; 260:90-99. [PMID: 36842486 DOI: 10.1016/j.ahj.2023.02.007] [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: 09/16/2022] [Revised: 02/12/2023] [Accepted: 02/13/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Mobile health applications are becoming increasingly common. Prior work has demonstrated reduced heart failure (HF) hospitalizations with HF disease management programs; however, few of these programs have used tablet computer-based technology. METHODS Participants with a diagnosis of HF and at least 1 high risk feature for hospitalization were randomized to either an established telephone-based disease management program or the same disease management program with the addition of remote monitoring of weight, blood pressure, heart rate and symptoms via a tablet computer for 90 days. The primary endpoint was the number of days hospitalized for HF assessed at 90 days. RESULTS From August 2014 to April 2019, 212 participants from 3 hospitals in Massachusetts were randomized 3:1 to telemonitoring-based HF disease management (n = 159) or telephone-based HF disease management (n = 53) with 98% of individuals in both study groups completing the 90 days of follow-up. There was no significant difference in the number of days hospitalized for HF between the telemonitoring disease management group (0.88 ± 3.28 days per patient-90 days) and the telephone-based disease management group (1.00 ± 2.97 days per patient-90 days); incidence rate ratio 0.82 (95% confidence interval, 0.43-1.58; P = .442). CONCLUSIONS The addition of tablet-based telemonitoring to an established HF telephone-based disease management program did not reduce HF hospitalizations; however, study power was limited.
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Affiliation(s)
- Jenica N Upshaw
- The CardioVascular Center, Tufts Medical Center, Boston, MA.
| | - Susan Parker
- New England Quality Care Alliance, Braintree, MA
| | | | - Benjamin Koethe
- Biostatics, Epidemiology, and Research Design Center, Tufts Medical Center, Boston MA
| | - Amanda R Vest
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Ayan R Patel
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | | | - David DeNofrio
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | | | | | - Patrick Arpin
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Nicole Strauss
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Crystal Sommer
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | | | - Rita Butler
- The CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Henry Dwaah
- Tufts University School of Medicine, Boston, MA
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Wessler BS, Huang Z, Long GM, Pacifici S, Prashar N, Karmiy S, Sandler RA, Sokol JZ, Sokol DB, Dehn MM, Maslon L, Mai E, Patel AR, Hughes MC. Automated Detection of Aortic Stenosis Using Machine Learning. J Am Soc Echocardiogr 2023; 36:411-420. [PMID: 36641103 PMCID: PMC10653158 DOI: 10.1016/j.echo.2023.01.006] [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: 12/02/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND Aortic stenosis (AS) is a degenerative valve condition that is underdiagnosed and undertreated. Detection of AS using limited two-dimensional echocardiography could enable screening and improve appropriate referral and treatment of this condition. The aim of this study was to develop methods for automated detection of AS from limited imaging data sets. METHODS Convolutional neural networks were trained, validated, and tested using limited two-dimensional transthoracic echocardiographic data sets. Networks were developed to accomplish two sequential tasks: (1) view identification and (2) study-level grade of AS. Balanced accuracy and area under the receiver operator curve (AUROC) were the performance metrics used. RESULTS Annotated images from 577 patients were included. Neural networks were trained on data from 338 patients (average n = 10,253 labeled images), validated on 119 patients (average n = 3,505 labeled images), and performance was assessed on a test set of 120 patients (average n = 3,511 labeled images). Fully automated screening for AS was achieved with an AUROC of 0.96. Networks can distinguish no significant (no, mild, mild to moderate) AS from significant (moderate or severe) AS with an AUROC of 0.86 and between early (mild or mild to moderate AS) and significant (moderate or severe) AS with an AUROC of 0.75. External validation of these networks in a cohort of 8,502 outpatient transthoracic echocardiograms showed that screening for AS can be achieved using parasternal long-axis imaging only with an AUROC of 0.91. CONCLUSION Fully automated detection of AS using limited two-dimensional data sets is achievable using modern neural networks. These methods lay the groundwork for a novel method for screening for AS.
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Affiliation(s)
| | - Zhe Huang
- Department of Computer Science, Tufts University, Medford, Massachusetts
| | | | - Stefano Pacifici
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Nishant Prashar
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Samuel Karmiy
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | | | | | | | - Monica M Dehn
- CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Luisa Maslon
- CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Eileen Mai
- CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Ayan R Patel
- CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Michael C Hughes
- Department of Computer Science, Tufts University, Medford, Massachusetts
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5
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Abstract
PURPOSE OF REVIEW This review provides an overview of the available therapies for treating neuropathic and/or cardiac manifestations of transthyretin amyloidosis (ATTR), as well as investigational therapeutic agents in ongoing clinical trials. We discuss additional emergent approaches towards thwarting this life-threatening disease that until recently was considered virtually untreatable. RECENT FINDINGS Advances in noninvasive diagnostic methods for detecting ATTR have facilitated easier diagnosis and detection at an earlier stage of disease when therapeutic interventions are likely to be more effective. There are now several ATTR-directed treatments that are clinically available, as well as investigational agents that are being studied in clinical trials. Therapeutic strategies include tetramer stabilization, gene silencing, and fibril disruption. ATTR has been historically underdiagnosed. With advances in diagnostic methods and the advent of disease-modifying treatments, early diagnosis and initiation of treatment is revolutionizing management of this disease.
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Affiliation(s)
- Melissa R Tsoi
- Department of Medicine, Tufts Medical Center, MA, 02111, Boston, USA
| | - Jeffrey H Lin
- Department of Medicine, Tufts Medical Center, MA, 02111, Boston, USA
| | - Ayan R Patel
- Cardiac Amyloidosis Program, Tufts Medical Center, 800 Washington St., MA, 02111, Boston, USA.
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6
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Maurer MS, Smiley D, Simsolo E, Remotti F, Bustamante A, Teruya S, Helmke S, Einstein AJ, Lehman R, Giles JT, Kelly JW, Tsai F, Blaner WS, Brun PJ, Riesenburger RI, Kryzanski J, Varga C, Patel AR. Analysis of lumbar spine stenosis specimens for identification of amyloid. J Am Geriatr Soc 2022; 70:3538-3548. [PMID: 35929177 PMCID: PMC9771886 DOI: 10.1111/jgs.17976] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/26/2022] [Accepted: 07/01/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Lumbar spinal stenosis (LSS) is a common reason for spine surgery in which ligamentum flavum is resected. Transthyretin (TTR) amyloid is an often unrecognized and potentially modifiable mechanism for LSS that can also cause TTR cardiac amyloidosis. Accordingly, older adult patients undergoing lumbar spine (LS) surgery were evaluated for amyloid and if present, the precursor protein, as well as comprehensive characterization of the clinical phenotype. METHODS A prospective, cohort study in 2 academic medical centers enrolled 47 subjects (age 69 ± 7 years, 53% male) undergoing clinically indicated LS decompression. The presence of amyloid was evaluated by Congo Red staining and in those with amyloid, precursor protein was determined by laser capture microdissection coupled to mass spectrometry (LCM-MS). The phenotype was assessed by disease-specific questionnaires (Swiss Spinal Stenosis Questionnaire and Kansas City Cardiomyopathy Questionnaire) and the 36-question short-form health survey, as well as biochemical measures (TTR, retinol-binding protein, and TTR stability). Cardiac testing included technetium-99m-pyrophosphate scintigraphy, electrocardiograms, echocardiograms, and cardiac biomarkers as well as measures of functional capacity. RESULTS Amyloid was detected in 16 samples (34% of participants) and was more common in those aged ≥ 75 years of age (66.7%) compared with those <75 years (22.3%, p < 0.05). LCM-MS demonstrated TTR as the precursor protein in 62.5% of participants with amyloid while 37.5% had an indeterminant type of amyloid. Demographic, clinical, quality-of-life measures, electrocardiographic, echocardiographic, and biochemical measures did not differ between those with and without amyloid. Among those with TTR amyloid (n = 10), one subject had cardiac involvement by scintigraphy. CONCLUSIONS Amyloid is detected in more than a third of older adults undergoing LSS. Amyloid is more common with advancing age and is particularly common in those >75 years old. No demographic, clinical, biochemical, or cardiac parameter distinguished those with and without amyloid. In more than half of subjects with LS amyloid, the precursor protein was TTR indicating the importance of pathological assessment.
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Affiliation(s)
- Mathew S Maurer
- Columbia University Irving Medical Center/New York Presbyterian Hospital, Scripps Clinic, Tufts Medical Center, New York, New York, USA
| | - Dia Smiley
- Columbia University Irving Medical Center/New York Presbyterian Hospital, Scripps Clinic, Tufts Medical Center, New York, New York, USA
| | - Eli Simsolo
- Columbia University Irving Medical Center/New York Presbyterian Hospital, Scripps Clinic, Tufts Medical Center, New York, New York, USA
| | - Fabrizio Remotti
- Columbia University Irving Medical Center/New York Presbyterian Hospital, Scripps Clinic, Tufts Medical Center, New York, New York, USA
| | - Angela Bustamante
- Columbia University Irving Medical Center/New York Presbyterian Hospital, Scripps Clinic, Tufts Medical Center, New York, New York, USA
| | - Sergio Teruya
- Columbia University Irving Medical Center/New York Presbyterian Hospital, Scripps Clinic, Tufts Medical Center, New York, New York, USA
| | - Stephen Helmke
- Columbia University Irving Medical Center/New York Presbyterian Hospital, Scripps Clinic, Tufts Medical Center, New York, New York, USA
| | - Andrew J Einstein
- Columbia University Irving Medical Center/New York Presbyterian Hospital, Scripps Clinic, Tufts Medical Center, New York, New York, USA
| | - Ronald Lehman
- Columbia University Irving Medical Center/New York Presbyterian Hospital, Scripps Clinic, Tufts Medical Center, New York, New York, USA
| | - Jon T Giles
- Columbia University Irving Medical Center/New York Presbyterian Hospital, Scripps Clinic, Tufts Medical Center, New York, New York, USA
| | - Jeffery W Kelly
- Columbia University Irving Medical Center/New York Presbyterian Hospital, Scripps Clinic, Tufts Medical Center, New York, New York, USA
| | - Felix Tsai
- Columbia University Irving Medical Center/New York Presbyterian Hospital, Scripps Clinic, Tufts Medical Center, New York, New York, USA
| | - William S Blaner
- Columbia University Irving Medical Center/New York Presbyterian Hospital, Scripps Clinic, Tufts Medical Center, New York, New York, USA
| | - Pierre-Jacques Brun
- Columbia University Irving Medical Center/New York Presbyterian Hospital, Scripps Clinic, Tufts Medical Center, New York, New York, USA
| | - Ron I Riesenburger
- Columbia University Irving Medical Center/New York Presbyterian Hospital, Scripps Clinic, Tufts Medical Center, New York, New York, USA
| | - James Kryzanski
- Columbia University Irving Medical Center/New York Presbyterian Hospital, Scripps Clinic, Tufts Medical Center, New York, New York, USA
| | - Cindy Varga
- Columbia University Irving Medical Center/New York Presbyterian Hospital, Scripps Clinic, Tufts Medical Center, New York, New York, USA
| | - Ayan R Patel
- Columbia University Irving Medical Center/New York Presbyterian Hospital, Scripps Clinic, Tufts Medical Center, New York, New York, USA
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Annamalai SK, Koethe BC, Simsolo E, Huang D, Connors A, Resor CD, Weintraub AR, Pandian NG, Downey BC, Patel AR, Wessler BS. Left ventricular stroke volume index following transcatheter aortic valve replacement is an early predictor of 1-year survival. Clin Cardiol 2022; 46:76-83. [PMID: 36273422 PMCID: PMC9849436 DOI: 10.1002/clc.23937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 09/22/2022] [Accepted: 10/03/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Adverse cardiac events are common following transcatheter aortic valve replacement (TAVR). Our aim was to investigate the low left ventricular stroke volume index (LVSVI) 30 days after TAVR as an early echocardiographic marker of survival. HYPOTHESIS Steady-state (30-day) LVSVI after TAVR is associated with 1-year mortality. METHODS A single-center retrospective analysis of all patients undergoing TAVR from 2017 to 2019. Baseline and 30-day post-TAVR echocardiographic LVSVI were calculated. Patients were stratified by pre-TAVR transaortic gradient, surgical risk, and change in transvalvular flow following TAVR. RESULTS This analysis focuses on 238 patients treated with TAVR. The 1-year mortality rate was 9% and 124 (52%) patients had normal flow post-TAVR. Of those with pre-TAVR low flow, 67% of patients did not normalize LVSVI at 30 days. The 30-day normal flow was associated with lower 1-year mortality when compared to low flow (4% vs. 14%, p = .007). This association remained significant after adjusting for known predictors of risk (adjusted odds ratio [OR] of 3.45, 95% confidence interval: 1.02-11.63 [per 1 ml/m2 decrease], p = .046). Normalized transvalvular flow following TAVR was associated with reduced mortality (8%) when compared to those with persistent (15%) or new-onset low flow (12%) (p = .01). CONCLUSIONS LVSVI at 30 days following TAVR is an early echocardiographic predictor of 1-year mortality and identifies patients with worse intermediate outcomes. More work is needed to understand if this short-term imaging marker might represent a novel therapeutic target.
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Affiliation(s)
| | | | - Eli Simsolo
- The CardioVascular CenterTufts Medical CenterBostonMassachusettsUSA
| | - Dou Huang
- Department of MedicineTufts Medical CenterBostonMassachusettsUSA
| | - Ann Connors
- The CardioVascular CenterTufts Medical CenterBostonMassachusettsUSA
| | - Charles D. Resor
- The CardioVascular CenterTufts Medical CenterBostonMassachusettsUSA
| | | | | | - Brian C. Downey
- The CardioVascular CenterTufts Medical CenterBostonMassachusettsUSA
| | - Ayan R. Patel
- The CardioVascular CenterTufts Medical CenterBostonMassachusettsUSA
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8
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Sridharan A, Patel AR. Response to letter to the editor. Clin Cardiol 2022; 45:819. [PMID: 35702820 PMCID: PMC9346970 DOI: 10.1002/clc.23872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 06/01/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Aadhavi Sridharan
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ayan R Patel
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston, Massachusetts, USA.,Heart Failure and Cardiac Transplant Program, Tufts Medical Center, Boston, Massachusetts, USA
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9
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Dower J, Dima D, Lalla M, Patel AR, Comenzo RL, Varga C. The use of PYP scan for evaluation of ATTR cardiac amyloidosis at a tertiary medical centre. Br J Cardiol 2022; 29:19. [PMID: 36212788 PMCID: PMC9534106 DOI: 10.5837/bjc.2022.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Cardiac transthyretin amyloidosis (ATTR) is an often underdiagnosed disease that can lead to significant morbidity and mortality for patients. In recent years, technetium-99m pyrophosphate scintigraphy (PYP) imaging has become a standard of care diagnostic tool to help clinicians identify this disease. With newly emerging therapies for ATTR cardiomyopathy, it is critical to identify patients who are eligible for therapy as early as possible. At our institution, we sought to describe the frequency of PYP scanning and how it has impacted the management of a patient suspected to have amyloid cardiomyopathy. Between 1 January 2017 and 31 December 2020, we identified 273 patients who completed PYP scanning for evaluation of cardiac amyloidosis at Tufts Medical Center, a tertiary care centre. We reviewed pertinent clinical data for all study subjects. A PYP scan was considered positive when the heart to contralateral lung ratio was greater than or equal to 1.5, with a visual grade of 2 or 3, and confirmation with single-photon emission computerised tomography (SPECT) imaging. In total there were 55 positive, 202 negative, and 16 equivocal PYP scans. Endomyocardial biopsies were rarely performed following PYP results. Of the seven patients with a positive PYP scan who underwent biopsy, five were positive for ATTR amyloid; of the patients with a negative scan who were biopsied, none were positive for ATTR amyloidosis and two were positive for amyloid light-chain (AL) amyloidosis. The biomarkers troponin I, B-type naturietic peptide (BNP), and N-terminal pro-BNP (NT-proBNP), as well as the interventricular septal end-diastolic thickness (IVSd) seen on echocardiogram, were all found to be statistically higher in the PYP positive cohort than in the PYP negative cohort using Mann-Whitney U statistical analysis. In total, 27 out of the 55 patients with a positive PYP scan underwent therapy specific for cardiac amyloid. In conclusion, this study reinforces the clinical significance of the PYP scan in the diagnosis and management of cardiac amyloidosis. A positive scan allowed physicians to implement early amyloid-directed treatment while a negative scan encouraged physicians to pursue an alternative diagnosis.
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Affiliation(s)
| | - Danai Dima
- Fellow Physician Division of Hematology/Oncology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Mumtu Lalla
- Resident Physician, Department of Internal Medicine Tufts Medical Center, Boston, MA 02111, USA
| | - Ayan R Patel
- Attending Physician, Cardiac Amyloid Program, The CardioVascular Center Tufts Medical Center, Boston, MA 02111, USA
| | - Raymond L Comenzo
- Attending Physician, The John Conant Davis Myeloma and Amyloid Program, Division of Hematology-Oncology Tufts Medical Center, Boston, MA 02111, USA
| | - Cindy Varga
- Attending Physician The Levine Cancer Institute Morehead, Charlotte, NC 28204, USA
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10
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Sridharan A, Dehn MM, Cooper C, Madineedi VS, Ordway LJ, DeNofrio D, Patel AR. Accuracy of echocardiographic estimations of right heart pressures in adult heart transplant recipients. Clin Cardiol 2022; 45:752-758. [PMID: 35451518 PMCID: PMC9286333 DOI: 10.1002/clc.23835] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/27/2022] [Accepted: 04/07/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Accurate assessment of right atrial pressure (RAP) and pulmonary artery systolic pressure (PASP) is critical in the management of heart transplant recipients. The accuracy of echocardiography in estimating these pressures has been debated. OBJECTIVE To assess the correlation and agreement between echocardiographic estimations of right heart pressures with those of respective invasive hemodynamic measurements by right heart catheterization (RHC) in adult heart transplant recipients. METHODS This is a prospective evaluation of 84 unique measurements from heart transplant recipients who underwent RHC followed by standard echocardiographic evaluation within 159 ± 64 min with no intervening medication changes. The relationship between noninvasive pressure estimations and invasive hemodynamic measurements was examined. RESULTS Mean RAP was 7 ± 5 mmHg and mean PASP was 33 ± 8 mmHg by RHC. There was no significant correlation between echocardiographic estimation of RAP and invasive RAP (Spearman's rho = -0.05, p = .7), and no significant agreement between these two variables (weighted kappa = -0.1). There was a modest correlation between echocardiographic estimation of PASP and invasive PASP (r = .39, p = .002). Bland-Altman analysis showed a mean bias of 2.1 ± 9 mmHg (limits of agreement = -15 to 20 mmHg). CONCLUSION In heart transplant recipients, there is no significant correlation or agreement between echocardiographic RAP estimation and invasively determined RAP. Noninvasive PASP estimation correlates significantly but modestly with invasively measured PASP. Further refinement of echocardiographic methods for assessment of RAP is warranted in this unique patient population.
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Affiliation(s)
- Aadhavi Sridharan
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston, Massachusetts, USA
| | - Monica M Dehn
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston, Massachusetts, USA
| | - Craig Cooper
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston, Massachusetts, USA
| | - Vidya S Madineedi
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston, Massachusetts, USA
| | - Linda J Ordway
- Heart Failure and Cardiac Transplant Program, Tufts Medical Center, Boston, Massachusetts, USA
| | - David DeNofrio
- Heart Failure and Cardiac Transplant Program, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ayan R Patel
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston, Massachusetts, USA.,Heart Failure and Cardiac Transplant Program, Tufts Medical Center, Boston, Massachusetts, USA
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11
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Daaboul Y, Rowin EJ, Couper GS, Arkun K, Patel AR. Congenital Left Ventricular Diverticulum Complicated by Cardioembolic Stroke. CASE 2022; 6:55-58. [PMID: 35492295 PMCID: PMC9050602 DOI: 10.1016/j.case.2021.11.010] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Congenital LVD is a rare cause of stroke in young patients. LVD results from replacing myocardium with fibrous or muscular tissue. Diverticulum and pseudoaneurysm are in the differential diagnosis of LV outpouching. LVD forms a cavity that communicates with the LV through a short neck. LVDs that result in thrombus formation and stroke should be resected.
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Affiliation(s)
- Yazan Daaboul
- Correspondence: Yazan Daaboul, MD, CardioVascular Center, Tufts Medical Center, Boston, MA 02111
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12
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Kadwalwala M, Dehn M, Downey B, Patel AR, Wessler BS. BLOOD PRESSURE CHANGES DURING ROUTINE TRANSTHORACIC ECHOCARDIOGRAPHY. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02262-8] [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: 10/18/2022]
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13
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Godara A, Riesenburger RI, Zhang DX, Varga C, Fogaren T, Siddiqui NS, Yu A, Wang A, Mastroianni M, Dowd R, Nail TJ, McPhail ED, Kurtin PJ, Theis JD, Toskic D, Arkun K, Pilichowska M, Kryzanski J, Patel AR, Comenzo R. Association between spinal stenosis and wild-type ATTR amyloidosis. Amyloid 2021; 28:226-233. [PMID: 34263670 DOI: 10.1080/13506129.2021.1950681] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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: 01/21/2023]
Abstract
Age-related cardiac amyloidosis results from deposits of wild-type tranthyretin amyloid (ATTRwt) in cardiac tissue. ATTR may play a role in carpal tunnel syndrome (CTS) and in spinal stenosis (SS), indicating or presaging systemic amyloidosis. We investigated consecutive patients undergoing surgery for SS for ATTR deposition in the resected ligamentum flavum (LF) and concomitant risk of cardiac amyloidosis. Each surgical specimen (LF) was stained with Congo red, and if positive, the amyloid deposits were typed by mass spectrometry. Patients with positive specimens underwent standard of care evaluation with fat pad aspirates, serum and urine protein electrophoresis with immunofixation, free light-chain assay, TTR gene sequencing and technetium 99 m-pyrophosphate-scintigraphy. In 2018-2019, 324 patients underwent surgery for SS and 43 patients (13%) had ATTR in the LF with wild-type TTR gene sequences. Two cases of ATTRwt cardiac amyloidosis were diagnosed and received treatment. In this large series, ATTRwt was identified in 13% of the patients undergoing laminectomy for SS. Patients with amyloid in the ligamentum flavum were older and had a higher prevalence of CTS, suggesting a systemic form of ATTR amyloidosis involving connective tissue. Further prospective study of patients with SS at risk for systemic amyloidosis is warranted.
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Affiliation(s)
- Amandeep Godara
- John Conant Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA.,Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City, UT, USA
| | | | - Diana X Zhang
- Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Cindy Varga
- John Conant Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA
| | - Teresa Fogaren
- John Conant Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA
| | - Nauman S Siddiqui
- John Conant Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA.,Division of Hematology, Medical Oncology and Palliative Care, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Anthony Yu
- School of Medicine, Tufts University, Boston, MA, USA
| | - Andy Wang
- School of Medicine, Tufts University, Boston, MA, USA
| | | | - Richard Dowd
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Tara J Nail
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Paul J Kurtin
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jason D Theis
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Denis Toskic
- John Conant Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA
| | - Knarik Arkun
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA
| | - Monika Pilichowska
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA
| | - James Kryzanski
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Ayan R Patel
- Division of Cardiology, Tufts Medical Center, Boston, MA, USA
| | - Raymond Comenzo
- John Conant Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA
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14
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Rowin EJ, Maron BJ, Wells S, Burrows A, Firely C, Koethe B, Patel AR, Maron MS. Usefulness of Global Longitudinal Strain to Predict Heart Failure Progression in Patients With Nonobstructive Hypertrophic Cardiomyopathy. Am J Cardiol 2021; 151:86-92. [PMID: 34167691 DOI: 10.1016/j.amjcard.2021.04.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/07/2021] [Accepted: 04/13/2021] [Indexed: 01/26/2023]
Abstract
While predicting prognosis to anticipate adverse disease course has long been an aspiration in hypertrophic cardiomyopathy (HC), reliable markers of progressive and unrelenting heart failure symptoms in the absence of obstruction are not well characterized. We sought to evaluate markers of systolic function, including the role of global longitudinal strain (GLS), to identify nonobstructive HC patients at risk for future heart failure. A cohort of 296 consecutive nonobstructive HC patients (42 ± 18years; 75% male) with NYHA class I/II symptoms and preserved systolic function at study entry (EF: 65 ± 6%), were followed for progressive heart failure symptoms (increase in ≥ 1 NYHA functional class) and/or development of systolic dysfunction (EF < 50%). Over median follow-up of 4 ± 3 years, 35 study patients (10%) experienced new heart failure events, including 31 with progressive symptoms and 4 who developed systolic dysfunction. Abnormal GLS < 16% was associated with a 5-fold increase in risk for heart failure compared to GLS > 18% (p < 0.001). GLS remained an independent predictor of heart failure even after adjustment for other relevant disease variables including EF (OR 1.23, p = 0.005). However, notably, when GLS and EF were combined, the prediction of heart failure for individual patients was enhanced (net reclassification improvement 0.55; p = 0.002). Together, GLS < 16% and EF 50% to 59% were associated with a 12.5-fold greater risk for heart failure versus patients with GLS > 18% and EF ≥ 60%, who were at the lowest risk. In conclusion, in nonobstructive HC with no or mild symptoms and preserved EF, abnormal GLS is a strong independent predictor for subsequent development of progressive heart failure symptoms and/or systolic dysfunction. Furthermore, the greatest power in predicting outcome in nonobstructive HC is achieved by combining GLS with EF to identify HC patients at the highest risk for heart failure progression and systolic dysfunction.
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15
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George KM, Hernandez NS, Breton J, Cooper B, Dowd RS, Nail J, Yu A, Mastroianni M, Wang A, Godara A, Zhang D, Arkun K, Patel AR, Varga C, Soto O, Kryzanski J, Comenzo R, Riesenburger R. Lumbar ligamentum flavum burden: Evaluating the role of ATTRwt amyloid deposition in ligamentum flavum thickness at all lumbar levels. Clin Neurol Neurosurg 2021; 206:106708. [PMID: 34053807 DOI: 10.1016/j.clineuro.2021.106708] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Wild-type transthyretin (ATTRwt) amyloid deposition has been found in the ligamentum flavum (LF) of patients undergoing spinal stenosis surgery. Our group previously reported that ATTRwt amyloid is associated with an increased lumbar ligamentum flavum thickness at symptomatic levels that required surgery. A comprehensive evaluation of LF thickness at asymptomatic levels in addition to symptomatic, treated levels has never been performed in ATTRwt patients. In this study, we compare the total LF thickness of all lumbar levels (lumbar LF burden) in ATTRwt and non-ATTRwt patients. METHODS We retrospectively identified 177 patients who underwent lumbar spine surgery. Ligamentum flavum thickness of 885 lumbar levels was measured on T2-weighted axial MRI. Amyloid presence was confirmed through Congo red staining of specimens, and subtype of ATTRwt was confirmed using mass-spectrometry and gene sequencing. RESULTS Of the 177 patients, 30 (16.9%) were found to have ATTRwt in the ligamentum flavum. One hundred and fifty ATTRwt levels and 735 non-ATTRwt levels were measured by four different reviewers, with an intraclass coefficient (ICC) of 0.79. Mean ligamentum flavum thickness was 4.64 (±1.31) mm in the ATTRwt group and 3.99 (±1.45) mm in the non-ATTRwt group (p < 0.001). The lumbar LF burden (sum of ligamentum flavum thickness at all lumbar levels) for ATTRwt patients was 23.22 (±4.48) mm, and for non-ATTRwt patients was 19.96 (±5.49) mm (p = 0.003) CONCLUSION: The lumbar LF burden is greater in patients with ATTRwt amyloid compared to non-ATTRwt patients. This supports prior evidence that ATTRwt amyloid deposition might be associated with increased LF thickness and lumbar stenosis. This potential association requires more research and could be an important finding, as medications have recently become available that can treat patients with ATTRwt amyloid deposition.
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Affiliation(s)
- Keith M George
- Tufts University School of Medicine, 145 Harrison Ave., Boston, MA 02111, USA; Tufts Department of Neurosurgery, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA
| | - Nicholas S Hernandez
- Tufts University School of Medicine, 145 Harrison Ave., Boston, MA 02111, USA; Tufts Department of Neurosurgery, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA
| | - Jeffrey Breton
- Tufts University School of Medicine, 145 Harrison Ave., Boston, MA 02111, USA; Tufts Department of Neurosurgery, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA
| | - Baillee Cooper
- Tufts University School of Medicine, 145 Harrison Ave., Boston, MA 02111, USA; Tufts Department of Neurosurgery, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA
| | - Richard S Dowd
- Tufts Department of Neurosurgery, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA
| | - Jayde Nail
- Tufts Department of Neurosurgery, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA
| | - Anthony Yu
- Tufts University School of Medicine, 145 Harrison Ave., Boston, MA 02111, USA; Tufts Department of Neurosurgery, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA
| | - Michael Mastroianni
- Tufts University School of Medicine, 145 Harrison Ave., Boston, MA 02111, USA; Tufts Department of Neurosurgery, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA
| | - Andy Wang
- Tufts University School of Medicine, 145 Harrison Ave., Boston, MA 02111, USA; Tufts Department of Neurosurgery, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA
| | - Amandeep Godara
- University of Utah Health Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute, 2000 Circle of Hope, Salt Lake City, UT 84112, USA
| | - Diana Zhang
- Tufts Department of Internal Medicine, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA
| | - Knarik Arkun
- Tufts Department of Pathology, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA
| | - Ayan R Patel
- Tufts Department of CardioVascular Center, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA
| | - Cindy Varga
- Tufts Department of Hematology and Oncology, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA
| | - Oscar Soto
- Tufts Department of Neurology, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA
| | - James Kryzanski
- Tufts Department of Neurosurgery, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA
| | - Raymond Comenzo
- Tufts Department of Hematology and Oncology, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA
| | - Ron Riesenburger
- Tufts Department of Neurosurgery, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA.
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16
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Singer AJ, Fuggle NR, Gill CB, Patel AR, Medeiros AP, Greenspan SL. COVID-19 and effects on osteoporosis management: the patient perspective from a National Osteoporosis Foundation survey. Osteoporos Int 2021; 32:619-622. [PMID: 33558958 PMCID: PMC7869916 DOI: 10.1007/s00198-021-05836-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 01/06/2021] [Indexed: 11/16/2022]
Affiliation(s)
- A J Singer
- Departments of Medicine and Obstetrics and Gynecology, MedStar Georgetown University Hospital and Georgetown University Medical Center, Washington, DC, USA.
- Department of Obstetrics and Gynecology, MedStar Georgetown University Hospital, Washington, DC, USA.
| | - N R Fuggle
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- Alan Turing Institute, London, UK
| | - C B Gill
- National Osteoporosis Foundation, Arlington, VA, USA
| | - A R Patel
- National Osteoporosis Foundation, Arlington, VA, USA
| | - A P Medeiros
- National Osteoporosis Foundation, Arlington, VA, USA
| | - S L Greenspan
- Department of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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17
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George KM, Hernandez NS, Breton J, Cooper B, Dowd RS, Nail J, Yu A, Mastroianni M, Wang A, Godara A, Zhang D, Arkun K, Patel AR, Varga C, Soto O, Kryzanski J, Comenzo R, Riesenburger R. Increased thickness of lumbar spine ligamentum flavum in wild-type transthyretin amyloidosis. J Clin Neurosci 2020; 84:33-37. [PMID: 33485595 DOI: 10.1016/j.jocn.2020.11.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 07/04/2020] [Revised: 10/17/2020] [Accepted: 11/23/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Wild-type transthyretin (ATTRwt) amyloid deposits have been found in the ligamentum flavum of patients undergoing surgery for spinal stenosis. The relationship between ATTRwt and ligamentum flavum thickness is unclear. We used pre-operative magnetic resonance imaging (MRI) to analyze ligamentum flavum thickness in lumbar spinal stenosis patients with and without ATTRwt amyloid. METHODS We retrospectively identified 178 patients who underwent lumbar spine surgery. Ligamentum flavum thickness of 253 specimens was measured on T2-weighted axial MRI. Amyloid presence was confirmed through Congo red staining of specimens, and ATTRwt was confirmed using mass-spectrometry and gene sequencing. RESULTS Twenty four of the 178 patients (13.5%) were found to have ATTRwt in the ligamentum flavum. Forty ATTRwt specimens and 213 non-ATTRwt specimens were measured. Mean ligamentum flavum thickness was 4.92 (±1.27) mm in the ATTRwt group and 4.00 (±1.21) mm in the non-ATTRwt group (p < 0.01). The ligamentum flavum was thickest at L4-L5, with a thickness of 5.15 (±1.27) mm and 4.23 (±1.29) mm in the ATTRwt and non-ATTRwt group, respectively (p = 0.007). There was a significant difference in ligamentum flavum thickness between ATTRwt and non-ATTRwt case for both patients younger than 70 years (p = 0.016) and those older than 70 years (p = 0.004). ATTRwt patients had greater ligamentum flavum thickness by 0.83 mm (95% confidence interval (CI): 0.41-1.25 mm, p < 0.001) when controlled for age and lumbar level. CONCLUSION Patients with ATTRwt had thicker ligamentum flavum compared to patients without ATTRwt. Further studies are needed to investigate the pathophysiology of ATTRwt in ligamentum flavum thickening.
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Affiliation(s)
- Keith M George
- Tufts Medical Center, Department of Neurology, United States; Tufts Medical Center, Department of Neurosurgery, United States
| | - Nicholas S Hernandez
- Tufts Medical Center, Department of Neurology, United States; Tufts Medical Center, Department of Neurosurgery, United States
| | - Jeffrey Breton
- Tufts Medical Center, Department of Neurology, United States; Tufts Medical Center, Department of Neurosurgery, United States
| | - Baillee Cooper
- Tufts Medical Center, Department of Neurology, United States; Tufts Medical Center, Department of Neurosurgery, United States
| | - Richard S Dowd
- Tufts Medical Center, Department of Neurosurgery, United States
| | - Jayde Nail
- Tufts Medical Center, Department of Neurosurgery, United States
| | - Anthony Yu
- Tufts Medical Center, Department of Neurology, United States; Tufts Medical Center, Department of Neurosurgery, United States
| | - Michael Mastroianni
- Tufts Medical Center, Department of Neurology, United States; Tufts Medical Center, Department of Neurosurgery, United States
| | - Andy Wang
- Tufts Medical Center, Department of Neurology, United States; Tufts Medical Center, Department of Neurosurgery, United States
| | - Amandeep Godara
- Tufts Medical Center, Department of Hematology and Oncology, United States
| | - Diana Zhang
- Tufts Medical Center, Department of Internal Medicine, United States
| | - Knarik Arkun
- Tufts Medical Center, Department of Neurosurgery, United States; Tufts Medical Center, Department of Pathology, United States
| | - Ayan R Patel
- Tufts Medical Center, CardioVascular Center, United States
| | - Cindy Varga
- Tufts Medical Center, Department of Hematology and Oncology, United States
| | - Oscar Soto
- Tufts University School of Medicine, United States
| | - James Kryzanski
- Tufts Medical Center, Department of Neurosurgery, United States
| | - Raymond Comenzo
- Tufts Medical Center, Department of Hematology and Oncology, United States
| | - Ron Riesenburger
- Tufts Medical Center, Department of Neurosurgery, United States.
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18
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Hosadurg N, Koethe B, Huang D, Weintraub AR, Patel AR, Wessler BS. Paradoxical Low-Flow Low-Gradient Aortic Stenosis: Effect of Low Transvalvular Flow Conditions on Indexed Stroke Volume after Transcatheter Aortic Valve Replacement. J Am Soc Echocardiogr 2020; 33:1528-1531. [PMID: 32888758 DOI: 10.1016/j.echo.2020.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/16/2020] [Accepted: 07/18/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Nisha Hosadurg
- Division of Internal Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Benjamin Koethe
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Tufts Medical Center, Boston, Massachusetts
| | - Dou Huang
- Division of Internal Medicine, Tufts Medical Center, Boston, Massachusetts
| | | | - Ayan R Patel
- Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Benjamin S Wessler
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Tufts Medical Center, Boston, Massachusetts; Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
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19
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Rowin E, Maron B, Wells SB, Burrows A, Firely C, Patel AR, Maron M. GLOBAL LONGITUDINAL STRAIN PREDICTS PROGRESSIVE HEART FAILURE IN NONOBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)31542-4] [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: 10/24/2022]
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20
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Abstract
Left atrial ridge may affect planning of trans-septal approach for interventions. Left atrial septal pouch may become a nidus for thrombus and source of embolus. Complete interrogation of the atrial septum can identify these anatomic variants.
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Affiliation(s)
- David Zisa
- CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | | | | | - Neil J Halin
- CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Pranitha Reddy
- CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Ayan R Patel
- CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Natesa G Pandian
- CardioVascular Center, Tufts Medical Center, Boston, Massachusetts.,Hoag Heart and Vascular Institute, Hoag Hospital, Newport Beach, California
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21
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Stathogiannis K, Mor-Avi V, Lang R, Patel AR. P5253Does regional myocardial strain by cardiac magnetic resonance feature tracking reflect scar in ischemic heart disease? Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Cardiac magnetic resonance (CMR) late gadolinium enhancement (LGE) is the gold standard for detection of myocardial scar. We hypothesized that CMR Feature Tracking (FT)-derived regional myocardial strain may reflect the presence of scar and could thus potentially be used instead of LGE imaging.
Purpose
The aim of this study was to determine the relationship between FT-derived regional myocardial strain and LGE in patients with coronary artery disease (CAD).
Methods
Seventy-five patients with CAD and typical ischemic LGE patterns on CMR (1.5T) were included (mean age 60±12 years, 70% males). Myocardial strain analysis and LGE identification were performed using dedicated commercial software. Scar was defined by presence of LGE in the same area of the myocardium in both short- and long-axis views. Peak systolic regional longitudinal and circumferential strain (RLS, RCS) values were calculated in the region of interest corresponding to the LGE area and also in a non-LGE myocardial region as a reference in each patient. These comparisons were repeated for a subgroup of 36 patients with left ventricular (LV) ejection fraction (EF) <40% to determine whether the relationship between strain and LGE holds in the presence of reduced LV function, when strain measurements may be altered as a reflection of reduced LVEF itself.
Results
Both global longitudinal and circumferential strain values were abnormal (−12.8±5.1% and −11.4±4.1%, respectively), reflecting LV dysfunction in this CAD cohort (EF = 40±16%). The magnitude of both RLS and RCS was significantly reduced in areas of LGE, compared to those without LGE: RLS −10.0±5.8% versus −20.4±7.5% (p<0.001); RCS −10.1±5.3±% versus −18.9±7.5%, respectively (p<0.001). Same pattern was noted in the reduced EF subgroup: RLS −8.0±4.7% versus −16.9±6.6% (p<0.001), RCS −7.7±4.3±% versus −16.0±7.9%, respectively (p<0.001). The figure depicts 2 representative cases in long and short axis views, LGE detection and concomitant regional strain analysis.
LGE and regional strain analysis.
Conclusion
Reduced magnitude of regional longitudinal and circumferential strain by CMR-FT correlates with presence of LGE. Pending further validation, this finding may constitute the basis for detection of scar without contrast enhanced imaging, and would result in reduced cost, scan time and risk associated with gadolinium.
Acknowledgement/Funding
ARP: Research support (software) from Neosoft and Philips
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Affiliation(s)
- K Stathogiannis
- University of Chicago Medicine, Chicago, United States of America
| | - V Mor-Avi
- University of Chicago Medicine, Chicago, United States of America
| | - R Lang
- University of Chicago Medicine, Chicago, United States of America
| | - A R Patel
- University of Chicago Medicine, Chicago, United States of America
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22
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DuPont JJ, Kenney RM, Patel AR, Jaffe IZ. Sex differences in mechanisms of arterial stiffness. Br J Pharmacol 2019; 176:4208-4225. [PMID: 30767200 DOI: 10.1111/bph.14624] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 01/08/2019] [Accepted: 01/21/2019] [Indexed: 12/24/2022] Open
Abstract
Arterial stiffness progressively increases with aging and is an independent predictor of cardiovascular disease (CVD) risk. Evidence supports that there are sex differences in the time course of aging-related arterial stiffness and the associated CVD risk, which increases disproportionately in postmenopausal women. The association between arterial stiffness and mortality is almost twofold higher in women versus men. The differential clinical characteristics of the development of arterial stiffness between men and women indicate the involvement of sex-specific mechanisms. This review summarizes the current literature on sex differences in vascular stiffness induced by aging, obesity, hypertension, and sex-specific risk factors as well as the impact of hormonal status, diet, and exercise on vascular stiffness in males and females. An understanding of the mechanisms driving sex differences in vascular stiffness has the potential to identify novel sex-specific therapies to lessen CVD risk, the leading cause of death in males and females. LINKED ARTICLES: This article is part of a themed section on The Importance of Sex Differences in Pharmacology Research. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.21/issuetoc.
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Affiliation(s)
- Jennifer J DuPont
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, Massachusetts, United States of America
| | - Rachel M Kenney
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, Massachusetts, United States of America
| | - Ayan R Patel
- Division of Cardiology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, United States of America
| | - Iris Z Jaffe
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, Massachusetts, United States of America.,Division of Cardiology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, United States of America
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Kawabori M, Benkert AR, Warner KG, Patel AR, Arkun K, Chen FY, Zhan Y. Uncommon Cause of Fever and Embolism: Staphylococcus epidermidis Infected Myxoma. Ann Thorac Surg 2018; 107:e283. [PMID: 30447187 DOI: 10.1016/j.athoracsur.2018.09.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 09/25/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Masashi Kawabori
- Division of Cardiac Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts.
| | - Abigail R Benkert
- Division of Cardiac Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Kenneth G Warner
- Division of Cardiac Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Ayan R Patel
- Division of Cardiac Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Knarik Arkun
- Division of Cardiac Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Frederick Y Chen
- Division of Cardiac Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Yong Zhan
- Division of Cardiac Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
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Margoles L, DeNofrio D, Patel AR, Golan Y, Vest AR, Arkun K, Boucher HW, Kiernan MS, Upshaw JN. Disseminated mucormycosis masquerading as rejection early after orthotopic heart transplantation. Transpl Infect Dis 2018; 20. [DOI: 10.1111/tid.12820] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 08/05/2017] [Accepted: 08/25/2017] [Indexed: 12/23/2022]
Affiliation(s)
- Lindsay Margoles
- Division of Infectious Disease; Department of Medicine; Tufts Medical Center; Boston MA USA
| | - David DeNofrio
- Division of Cardiology; Department of Medicine; Tufts Medical Center; Boston MA USA
| | - Ayan R. Patel
- Division of Cardiology; Department of Medicine; Tufts Medical Center; Boston MA USA
| | - Yoav Golan
- Division of Infectious Disease; Department of Medicine; Tufts Medical Center; Boston MA USA
| | - Amanda R. Vest
- Division of Cardiology; Department of Medicine; Tufts Medical Center; Boston MA USA
| | - Knarik Arkun
- Department of Pathology; Tufts Medical Center; Boston MA USA
| | - Helen W. Boucher
- Division of Infectious Disease; Department of Medicine; Tufts Medical Center; Boston MA USA
| | - Michael S. Kiernan
- Division of Cardiology; Department of Medicine; Tufts Medical Center; Boston MA USA
| | - Jenica N. Upshaw
- Division of Cardiology; Department of Medicine; Tufts Medical Center; Boston MA USA
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Patel AR, Caffarelli A, Pandian NG. Aortic Disorders. Echocardiography 2018. [DOI: 10.1007/978-3-319-71617-6_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Annamalai SK, Buiten L, Esposito ML, Paruchuri V, Mullin A, Breton C, Pedicini R, O'Kelly R, Morine K, Wessler B, Patel AR, Kiernan MS, Karas RH, Kapur NK. Acute Hemodynamic Effects of Intra-aortic Balloon Counterpulsation Pumps in Advanced Heart Failure. J Card Fail 2017; 23:606-614. [DOI: 10.1016/j.cardfail.2017.05.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 05/21/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022]
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Affiliation(s)
- Amanda R Vest
- From the Division of Cardiology, Tufts Medical Center, Boston, MA.
| | - Ayan R Patel
- From the Division of Cardiology, Tufts Medical Center, Boston, MA
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Sharma KK, Shukla VR, Patel AR, Vaghela KM, Patel HK, Shah PG, Banerjee H, Banerjee T, Hudait RK, Sharma D, Sahoo SK, Singh B, Tripathy V. Multilocation field trials for risk assessment of a combination fungicide Fluopicolide + Propamocarb in tomato. Environ Monit Assess 2016; 188:604. [PMID: 27709463 DOI: 10.1007/s10661-016-5610-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 09/21/2016] [Indexed: 06/06/2023]
Abstract
Dissipation kinetics of two systemic fungicides, namely fluopicolide and propamocarb used as a combination formulation (Infinito 68.75 SC), were studied on tomato at four different locations by the All India Network Project on Pesticide Residues to recommend their pre-harvest interval (PHI) and to propose the maximum residue limits (MRL) for the two fungicides based on chronic hazard exposure assessment. The combination fungicide was sprayed thrice at the recommended dosage of 93.75 g a.i./ha fluopicolide and 937.50 g a.i./ha propamocarb as well as at double the recommended dosage of 187.50 g a.i./ha fluopicolide and 1875.0 g a.i./ha propamocarb on tomato crops and the residues were monitored periodically by GC-MS. The fungicides dissipated to below the limit of quantification (LOQ) within 10 to 15 days, with a half-life of 2-4 days for fluopicolide and 1-2 days for propamocarb. Taking into consideration the MRLs of codex and calculations made using the method of MRL fixation of the Food Safety and Standard Authority of India (FSSAI) as well as the Organization for Economic Co-operation and Development (OECD) calculator, MRL of 5 mg/kg is proposed for fluopicolide and 15 mg/kg for propamocarb, following critical exposure of the commodity considering PHI of 1 day.
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Affiliation(s)
- K K Sharma
- All India Network Project on Pesticide Residues, ICAR-Indian Agricultural Research Institute, New Delhi, 110012, India.
| | - V R Shukla
- Anand Agricultural University, Anand, Gujarat, India
| | - A R Patel
- Anand Agricultural University, Anand, Gujarat, India
| | - K M Vaghela
- Anand Agricultural University, Anand, Gujarat, India
| | - H K Patel
- Anand Agricultural University, Anand, Gujarat, India
| | - Paresh G Shah
- Anand Agricultural University, Anand, Gujarat, India
| | - Hemanta Banerjee
- Bidhan Chandra Krishi Vishwavidyalaya, Kalyani, West Bengal, India
| | | | - Ram K Hudait
- Bidhan Chandra Krishi Vishwavidyalaya, Kalyani, West Bengal, India
| | - Debi Sharma
- ICAR-Indian Horticultural Research Institute, Bangalore, Karnataka, India
| | - S K Sahoo
- Punjab Agricultural University, Ludhiana, Punjab, India
| | | | - Vandana Tripathy
- All India Network Project on Pesticide Residues, ICAR-Indian Agricultural Research Institute, New Delhi, 110012, India
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Urbano-Moral JA, Gangadharamurthy D, Comenzo RL, Pandian NG, Patel AR. Ecocardiografía speckle tracking (rastreo de marcas) tridimensional en la amiloidosis cardiaca de cadenas ligeras: estudio de los parámetros de mecánica miocárdica ventricular izquierda y derecha. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2015.01.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Polak JF, Alessi-Chinetti JM, Estes JM, Patel AR. Left Ventricular Ejection Time Derived From the Common Carotid Artery Doppler Waveform: Association With Left Ventricular Ejection Fraction and Prediction of Heart Failure. J Ultrasound Med 2015; 34:1237-1242. [PMID: 26112626 DOI: 10.7863/ultra.34.7.1237] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES Left ventricular ejection time (LVET) is measured from blood pressure tracings as the interval from end diastole to the dicrotic notch and shows associations with left ventricular ejection fraction (LVEF) and heart failure. LVET can be measured on common carotid artery Doppler waveforms. We therefore studied the possible associations of common carotid artery LVET with LVEF measured by echocardiography and heart failure. METHODS We performed a retrospective study of 110 patients who had transthoracic echocardiography and carotid Doppler evaluations within 1 day of each other. LVEF was determined by the biplane modified Simpson method. LVET was measured from left common carotid artery Doppler tracings. Linear regression was used to evaluate associations between LVET and LVEF. We also used logistic regression with LVEF of less than 40% as a cut point for heart failure to generate a receiver operating characteristic curve, estimate the area under the curve, and calculate sensitivity and specificity. RESULTS LVET was associated with LVEF (P < .0001). The area under the curve of LVET for heart failure was 0.81 (95% confidence interval [CI], 0.72-0.87), and the sensitivity and specificity were 76.9% (95% CI, 65.4%-88.4%) and 65.5% (95% CI, 53.4%-77.8%), respectively, for LVET of 321 milliseconds. CONCLUSIONS LVET measured on common carotid artery Doppler tracings decreases with LVEF and is strongly associated with prevalent heart failure. Based on what is known of blood pressure-measured LVET, common carotid artery Doppler waveform-derived LVET could be used to serially monitor cardiac function.
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Affiliation(s)
- Joseph F Polak
- Departments of Radiology (J.F.P.) and Vascular Surgery (J.M.A.-C., J.M.E.) and Division of Cardiology, Cardiovascular Center (J.M.A.-C., A.R.P.), Tufts Medical Center, Boston, Massachusetts USA.
| | - Jean M Alessi-Chinetti
- Departments of Radiology (J.F.P.) and Vascular Surgery (J.M.A.-C., J.M.E.) and Division of Cardiology, Cardiovascular Center (J.M.A.-C., A.R.P.), Tufts Medical Center, Boston, Massachusetts USA
| | - James M Estes
- Departments of Radiology (J.F.P.) and Vascular Surgery (J.M.A.-C., J.M.E.) and Division of Cardiology, Cardiovascular Center (J.M.A.-C., A.R.P.), Tufts Medical Center, Boston, Massachusetts USA
| | - Ayan R Patel
- Departments of Radiology (J.F.P.) and Vascular Surgery (J.M.A.-C., J.M.E.) and Division of Cardiology, Cardiovascular Center (J.M.A.-C., A.R.P.), Tufts Medical Center, Boston, Massachusetts USA
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Urbano-Moral JA, Gangadharamurthy D, Comenzo RL, Pandian NG, Patel AR. Three-dimensional Speckle Tracking Echocardiography in Light Chain Cardiac Amyloidosis: Examination of Left and Right Ventricular Myocardial Mechanics Parameters. ACTA ACUST UNITED AC 2015; 68:657-64. [PMID: 26092748 DOI: 10.1016/j.rec.2015.01.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 01/30/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION AND OBJECTIVES The study of myocardial mechanics has a potential role in the detection of cardiac involvement in patients with amyloidosis. This study aimed to characterize 3-dimensional-speckle tracking echocardiography-derived left and right ventricular myocardial mechanics in light chain amyloidosis and examine their relationship with brain natriuretic peptide. METHODS In patients with light chain amyloidosis, left ventricular longitudinal and circumferential strain (n=40), and right ventricular longitudinal strain and radial displacement (n=26) were obtained by 3-dimensional-speckle tracking echocardiography. Brain natriuretic peptide levels were determined. RESULTS All myocardial mechanics measurements showed differences when compared by brain natriuretic peptide level tertiles. Left and right ventricular longitudinal strain were highly correlated (r=0.95, P<.001). Left ventricular longitudinal and circumferential strain were reduced in patients with cardiac involvement (-9±4 vs -16±2; P<.001, and -24±6 vs -29±4; P=.01, respectively), with the most prominent impairment at the basal segments. Right ventricular longitudinal strain and radial displacement were diminished in patients with cardiac involvement (-9±3 vs -17±3; P<.001, and 2.7±0.8 vs 3.8±0.3; P=.002). On multivariate analysis, left ventricular longitudinal strain was associated with the presence of cardiac involvement (odds ratio = 1.6; 95% confidence interval, 1.04 to 2.37; P=.03) independent of the presence of brain natriuretic peptide and troponin I criteria for cardiac amyloidosis. CONCLUSIONS Three-dimensional-speckle tracking echocardiography-derived left and right ventricular myocardial mechanics are increasingly altered as brain natriuretic peptide increases in light chain amyloidosis. There appears to be a strong association between left ventricular longitudinal strain and cardiac involvement, beyond biomarkers such as brain natriuretic peptide and troponin I.
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Affiliation(s)
- Jose Angel Urbano-Moral
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston Massachusetts, United States.
| | - Dakshin Gangadharamurthy
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston Massachusetts, United States
| | - Raymond L Comenzo
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston Massachusetts, United States
| | - Natesa G Pandian
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston Massachusetts, United States
| | - Ayan R Patel
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston Massachusetts, United States
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Polak JF, Alessi-Chinetti JM, Patel AR, Estes JM. Association of common carotid artery Doppler-determined dicrotic notch velocity with the left ventricular ejection fraction. J Ultrasound Med 2015; 34:461-7. [PMID: 25715367 DOI: 10.7863/ultra.34.3.461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
OBJECTIVES The appearance of the dicrotic notch on blood pressure tracings is associated with impaired cardiac function. Common carotid artery waveforms have similar fiduciary markers, yet they have not been related to cardiac function. We studied associations of common carotid artery dicrotic notch velocities with the left ventricular ejection fraction (LVEF) determined by echocardiography. METHODS We conducted a retrospective study of 37 patients who had cardiac echocardiography and carotid Doppler evaluations within 1 day of each other. The LVEF was determined by the biplane modified Simpson rule. Doppler parameters were measured from tracings of the left common carotid artery 4 cm from the flow divider. Linear regression and stepwise multivariable linear regression models were used to evaluate any association between the LVEF and the following variables: age, sex, peak systolic velocity (PSV), end-diastolic velocity (EDV), dicrotic notch velocity, rise time (EDV to PSV), resistive index, and cardiac cycle length. RESULTS The dicrotic notch velocity was the only variable associated with the LVEF (P = .028) in a bivariate analyses. A backward selection stepwise multivariable equation predicting the LVEF had the dicrotic notch (P = .001) and resistive index (P = .01) as significant predictors, whereas the cardiac cycle length (P = .08) and PSV (P = .08) were borderline not significant. Model goodness of fit was R(2) = 0.37 (P = .004). CONCLUSIONS Dicrotic notch velocities measured from common carotid artery Doppler waveforms are associated with the LVEF and might offer some clinical value in selected cases.
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Affiliation(s)
- Joseph F Polak
- Departments of Radiology (J.F.P.) and Vascular Surgery (J.M.A.-C., J.M.E.) and Division of Cardiology/Cardiovascular Center (J.M.A.-C., A.R.P.), Tufts Medical Center, Boston, Massachusetts USA.
| | - Jean M Alessi-Chinetti
- Departments of Radiology (J.F.P.) and Vascular Surgery (J.M.A.-C., J.M.E.) and Division of Cardiology/Cardiovascular Center (J.M.A.-C., A.R.P.), Tufts Medical Center, Boston, Massachusetts USA
| | - Ayan R Patel
- Departments of Radiology (J.F.P.) and Vascular Surgery (J.M.A.-C., J.M.E.) and Division of Cardiology/Cardiovascular Center (J.M.A.-C., A.R.P.), Tufts Medical Center, Boston, Massachusetts USA
| | - James M Estes
- Departments of Radiology (J.F.P.) and Vascular Surgery (J.M.A.-C., J.M.E.) and Division of Cardiology/Cardiovascular Center (J.M.A.-C., A.R.P.), Tufts Medical Center, Boston, Massachusetts USA
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Kiernan MS, French AL, DeNofrio D, Parmar YJ, Pham DT, Kapur NK, Pandian NG, Patel AR. Preoperative Three-Dimensional Echocardiography to Assess Risk of Right Ventricular Failure After Left Ventricular Assist Device Surgery. J Card Fail 2015; 21:189-97. [DOI: 10.1016/j.cardfail.2014.12.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 11/21/2014] [Accepted: 12/16/2014] [Indexed: 12/31/2022]
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Hansen JC, Patel AR, Nayak HN, Moss JD, Sweiss N, Beshai JF. Cardiac sarcoidosis and coronary artery disease: a two-hit mechanism to left ventricular dysfunction (or is it)? Sarcoidosis Vasc Diffuse Lung Dis 2013; 30:237-240. [PMID: 24284299] [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] [Received: 11/25/2013] [Accepted: 11/25/2013] [Indexed: 06/02/2023]
Abstract
This report describes a case of cardiac sarcoidosis in a 40-year-old man with minimal risk factors for coronary artery disease who was found to have a critical coronary lesion on angiography performed for declining left ventricular function. The case highlights the diagnostic and therapeutic issues surrounding cardiac sarcoidosis and raises the question of a possible link between sarcoidosis and premature coronary artery disease. It also stresses the importance of ruling out ischemia in any patient with declining left ventricular function.
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Affiliation(s)
- J C Hansen
- Section of Cardiology, University of Chicago, Chicago, Illinois.
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Gheorghiade M, Greene SJ, Ponikowski P, Maggioni AP, Korewicki J, Macarie C, Metra M, Grzybowski J, Bubenek-Turconi SI, Radziszewski W, Olson A, Bueno OF, Ghosh A, Deckelbaum LI, Li LY, Patel AR, Koester A, Konstam MA. Haemodynamic effects, safety, and pharmacokinetics of human stresscopin in heart failure with reduced ejection fraction. Eur J Heart Fail 2013; 15:679-89. [PMID: 23471413 DOI: 10.1093/eurjhf/hft023] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [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: 12/20/2022] Open
Abstract
AIMS Human stresscopin is a corticotropin-releasing factor (CRF) type 2 receptor (CRFR2) selective agonist and a member of the CRF peptide family. Stimulation of CRFR2 improves cardiac output and left ventricular ejection fraction (LVEF) in patients with stable heart failure (HF) with reduced LVEF. We examined the safety, pharmacokinetics, and effects on haemodynamics and serum biomarkers of intravenous human stresscopin acetate (JNJ-39588146) in patients with stable HF with LVEF ≤ 35% and cardiac index (CI) ≤ 2.5 L/min/m(2). METHODS AND RESULTS Sixty-two patients with HF and LVEF ≤ 35% were instrumented with a pulmonary artery catheter and randomly assigned (ratio 3:1) to receive an intravenous infusion of JNJ-39588146 or placebo. The main study was an ascending dose study of three doses (5, 15, and 30 ng/kg/min) of study drug or placebo administered in sequential 1 h intervals (3 h total). Statistically significant increases in CI and reduction in systemic vascular resistance (SVR) were observed with both the 15 ng/kg/min (2 h time point) and 30 ng/kg/min (3 h time point) doses of JNJ-39588146 without significant changes in heart rate (HR) or systolic blood pressure (SBP). No statistically significant reductions in pulmonary capillary wedge pressure (PCWP) were seen with any dose tested in the primary analysis, although a trend towards reduction was seen. CONCLUSION In HF patients with reduced LVEF and CI, ascending doses of JNJ-39588146 were associated with progressive increases in CI and reductions in SVR without significant effects on PCWP, HR, or SBP. TRIAL REGISTRATION NCT01120210.
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Affiliation(s)
- Mihai Gheorghiade
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, 645 North Michigan Ave., Suite 1006, Chicago, IL 60611, USA.
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Ramamurthi A, Pandian NG, Gangadharamurthy D, Urbano-Moral JA, Kuvin JT, Patel AR, Weintraub AR. The syndrome of degenerative calcific aortic stenosis: prevalence of multiple pathophysiologic disorders in association with valvular stenosis and their implications. Echocardiography 2012; 30:1-7. [PMID: 22963399 DOI: 10.1111/j.1540-8175.2012.01799.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND We hypothesized that degenerative calcific aortic stenosis (DCAS) is a syndrome influenced by factors beyond aortic valve stenosis (AS). The aim of this study was to assess how frequently DCAS is complicated by increased vascular load, systolic and/or diastolic left ventricular (LV) dysfunction, and comorbid disorders. METHODS In 215 consecutive patients > 60 years of age with severe and moderate AS, we analyzed systemic arterial compliance, global hemodynamic load, LV ejection fraction (EF), the presence of diastolic dysfunction, and other valvular or systemic disorders. RESULTS A total of 164 patients had severe AS and 51 had moderate AS. In patients with severe AS, the prevalence of increased vascular load was 42%; LV systolic and diastolic dysfunction was present in 27% and 42%; other valve diseases in 23%; and comorbid disorders in 82%. In the moderate AS group, abnormal vascular load was found in 52%; LV systolic and diastolic dysfunction was prevalent in 26% and 31%; other valve diseases in 17%; and comorbid disorders in 78% patients. More than half the patients in both groups had symptoms. In both severe and moderate AS groups, the prevalence of increased vascular load and systolic dysfunction was higher in the symptomatic group. CONCLUSION Considerable number of patients with DCAS have abnormal vascular load, abnormal LV function, and significant coexisting disorders. These could influence the total pathophysiologic burden on the heart and symptom expression. Thus, DCAS should not be considered just as valvular stenosis, but a syndrome of DCAS because of the diagnostic, prognostic, and therapeutic implications of various factors associated with it.
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Affiliation(s)
- Alamelu Ramamurthi
- Tufts Heart Valve Center, Tufts Medical Center, Boston, Massachusetts 02111, USA
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Ruberg FL, Maurer MS, Judge DP, Zeldenrust S, Skinner M, Kim AY, Falk RH, Cheung KN, Patel AR, Pano A, Packman J, Grogan DR. Prospective evaluation of the morbidity and mortality of wild-type and V122I mutant transthyretin amyloid cardiomyopathy: the Transthyretin Amyloidosis Cardiac Study (TRACS). Am Heart J 2012; 164:222-228.e1. [PMID: 22877808 DOI: 10.1016/j.ahj.2012.04.015] [Citation(s) in RCA: 187] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Accepted: 04/10/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND TRACS sought to describe the clinical outcomes and disease progression of transthyretin (TTR) cardiac amyloidosis (ATTR) in an observational study. Clinical course is largely determined by disease type with ATTR categorized as wild-type (ATTRwt) or genetic-variant protein (ATTRm). Prospective data are lacking in the most common TTR mutation, V122I, present in approximately 3.5% of African Americans. METHODS Patients with ATTRwt (n = 18) and V122I ATTRm (n = 11) were longitudinally assessed every 6 months for up to 2 years by functional class assessments, biochemical markers, and echocardiography. RESULTS At baseline, no differences in clinical characteristics, biomarkers, or echocardiographic parameters were noted between patients with ATTRwt and patients with ATTRm. After 15.5 ± 8 months, there were 11 deaths and 1 cardiac transplant, with higher mortality (73% vs 22%, P = .03) and cardiovascular hospitalization (64% vs 28%, P = .02) among patients with ATTRm. The median survival from diagnosis was 25.6 months for ATTRm vs 43.0 months for ATTRwt (P = .04). Univariate predictors of mortality included disease duration, heart rate ≥ 70 beats/min, baseline stroke volume, left ventricular ejection fraction <50%, and ATTRm status. For each 6-month increment, the mean 6-minute walk distance declined by 25.8 m, N-terminal pro b-type natriuretic peptide increased by 1,816 pg/mL, and left ventricular ejection fraction fell by 3.2%, for the entire cohort. CONCLUSIONS In this prospective study, disease progression, morbidity, and mortality were observed in ATTR cardiomyopathy, particularly due to V122I, over a short duration. Given the prevalence of this mutation, further study of V122I in at-risk African American patients is warranted.
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Urbano-Moral JA, Patel AR, Maron MS, Arias-Godinez JA, Pandian NG. Three-dimensional speckle-tracking echocardiography: methodological aspects and clinical potential. Echocardiography 2012; 29:997-1010. [PMID: 22783969 DOI: 10.1111/j.1540-8175.2012.01773.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Speckle-tracking echocardiography (STE) is an advanced echocardiographic technique that allows a novel approach to the assessment of cardiac physiology through the study of myocardial mechanics. In its three-dimensional (3D) modality, it overcomes the drawbacks inherent to other echocardiographic techniques, namely two-dimensional echocardiography and tissue Doppler imaging. Several research studies and software improvements have led 3D-STE to become a promising tool for accurate evaluation of global and regional cardiac function. This article addresses the image acquisition, analytical methods, and parameters of myocardial mechanics that could be derived from 3D-STE. This systematic guidance may help to establish its usefulness in the global and regional evaluation of cardiac function, and to facilitate its clinical application.
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Affiliation(s)
- Jose A Urbano-Moral
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston, Massachusetts 02111, USA
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Abstract
OBJECTIVE To evaluate retention of two resin based fissure sealants (Embrace and Delton FS+) for a period of twelve months. MATERIALS AND METHODS Sixty eight first permanent molars were sealed for seventeen healthy children in the age group of six-eight years. According to random selection, the first permanent molars on the right side of both arches were sealed with Embrace (Group A) and on the left side of both arches were sealed with Delton FS+ (Group B). RESULTS The total retention of Embrace was 23.50% and for Delton FS+ was 17.60% at one year. CONCLUSION At one year the total retention of Embrace was 23.50% and for Delton FS+ was 17.60%, however the results were statistically insignificant.
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Affiliation(s)
- M R Bhatia
- Department of Pediatric and Preventive Dentistry, Bharati Vidyapeeth Dental College and Hospital, Pune, India.
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Pandher S, Sahoo SK, Battu RS, Singh B, Saiyad MS, Patel AR, Shah PG, Reddy CN, Reddy DJ, Reddy KN, Rao CS, Banerjee T, Banerjee D, Hudait R, Banerjee H, Tripathy V, Sharma KK. Persistence and dissipation kinetics of deltamethrin on chili in different agro-climatic zones of India. Bull Environ Contam Toxicol 2012; 88:764-768. [PMID: 22411176 DOI: 10.1007/s00128-012-0588-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 02/28/2012] [Indexed: 05/31/2023]
Abstract
Multi-location supervised field trials were conducted at four different agro climatic locations in India to evaluate the dissipation pattern of deltamethrin on chili. Deltamethrin 10 EC was applied on chili @17.5 and 35 g a.i. ha(-1), samples of green chili were drawn at different time intervals and that of red chili and soil at harvest time and quantified by gas liquid chromatography equipped with electron capture detector. The identity of residues were confirmed by Gas Chromatograph-Mass Spectrophotometer in selective ion monitoring mode in mass range 181, 253 m/z. Limit of quantification of the method was found to be 0.01 mg kg(-1). Half-life of deltamethrin at application rate of 17.5 g a.i. ha(-1) varied from 0.36 to 1.99 days and at double the application rate was found to range from 0.38 to 2.06 days. Residues of deltamethrin were found below its determination limit of 0.01 mg kg(-1) in red chili and soil. On the basis of the data generated, Deltamethrin 10 EC has been registered for use on chili in India and its Maximum Residue Limit has been fixed as 0.05 μg/g.
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Quraini D, Pandian NG, Patel AR. Three-Dimensional Echocardiographic Analysis of Right Atrial Volume in Normal and Abnormal Hearts: Comparison of Biplane and Multiplane Methods. Echocardiography 2012; 29:608-13. [DOI: 10.1111/j.1540-8175.2011.01640.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Korabathina R, Heffernan KS, Paruchuri V, Patel AR, Mudd JO, Prutkin JM, Orr NM, Weintraub A, Kimmelstiel CD, Kapur NK. The pulmonary artery pulsatility index identifies severe right ventricular dysfunction in acute inferior myocardial infarction. Catheter Cardiovasc Interv 2012; 80:593-600. [DOI: 10.1002/ccd.23309] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Accepted: 07/08/2011] [Indexed: 12/17/2022]
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Urbano Moral JA, Arias Godinez JA, Maron MS, Malik R, Eagan JE, Patel AR, Pandian NG. Left ventricular twist mechanics in hypertrophic cardiomyopathy assessed by three-dimensional speckle tracking echocardiography. Am J Cardiol 2011; 108:1788-95. [PMID: 21924393 DOI: 10.1016/j.amjcard.2011.07.047] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [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: 05/30/2011] [Revised: 07/20/2011] [Accepted: 07/20/2011] [Indexed: 11/16/2022]
Abstract
Left ventricular (LV) twist represents a phenomenon that links systolic contraction with diastolic relaxation and plays a major role in cardiac physiology; thus, the study of twist mechanics is of particular interest in hypertrophic cardiomyopathy (HC). Three-dimensional speckle tracking echocardiography (3D-STE) has the potential to overcome the limitations of 2-dimensional imaging and provide a greater understanding of LV twist in HC. We aimed to examine LV twist mechanics in HC using 3D-STE. Echocardiograms from subjects with a diagnosis of HC were examined for 3D-STE analysis. Age- and gender-matched healthy subjects were tested as a control group. Forty patients with HC (age 37 ± 16 years; 42.5% women) and 40 control subjects (age 35 ± 10 years; 42.5% women) were examined. Compared with the controls, the patients with HC showed increased peak LV twist (16.5 ± 4.7° vs 12.0 ± 3.9°, p <0.001) mainly because of increased apical rotation of those with LV outflow tract obstruction (obstruction, 12.7 ± 4.4° vs nonobstruction, 9.7 ± 2.8°, p = 0.02). In addition, the patients with HC displayed onset of torsion recoil occurring closer to the aortic valve closure (94 ± 6% vs 85 ± 6%, p <0.001; time normalized by the length of systole), limited completion of untwist during early diastole (31 ± 12% vs 62 ± 15%, p <0.001), and delayed peak untwist velocity (22 ± 7% vs 13 ± 9%, p <0.001; time normalized by the length of diastole). In conclusion, the evaluation of twist mechanics using 3D-STE provides novel insight regarding alterations in LV mechanics in patients with HC. Elucidating the characteristics of the wringing motion of the heart might help to broaden the understanding of the hyperdynamic contraction and impaired relaxation observed in these patients.
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Affiliation(s)
- Jose A Urbano Moral
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston Massachusetts, USA.
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Heffernan KS, Kuvin JT, Patel AR, Karas RH, Kapur NK. Endothelial function and soluble endoglin in smokers with heart failure. Clin Cardiol 2011; 34:729-33. [PMID: 22120636 DOI: 10.1002/clc.20979] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [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: 08/09/2011] [Accepted: 08/25/2011] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Although cigarette smoking is a risk factor for heart failure (HF), smokers with HF have lower mortality rates during/following hospitalization compared to nonsmokers. We examined vascular endothelial function in chronic smokers and nonsmokers with HF as it relates to this smoker's paradox. HYPOTHESIS Smokers with HF will have attenuated endothelial dysfunction compared to non-smokers with HF. METHODS Brachial artery flow-mediated dilation (FMD), a measure of conduit vessel endothelial function, was measured in 33 smoking and nonsmoking patients with HF vs controls. In addition, soluble endoglin (sEng), a circulating mediator of endothelial function, was measured in a separate group of 36 smoking and nonsmoking patients with HF vs controls. RESULTS FMD was significantly lower in smokers without HF compared to the nonsmokers without HF (P < 0.05). FMD was significantly higher in smokers with HF vs nonsmokers with HF (P < 0.05) and did not differ from values seen in nonsmokers without HF (P > 0.05). There were no differences in sEng between smokers and nonsmokers without HF (P > 0.05). sEng was lower in smokers with HF vs nonsmokers with HF (P < 0.05) and did not differ from values seen in nonsmokers without HF (P > 0.05). CONCLUSIONS Smokers with HF had higher brachial FMD and lower sEng than nonsmokers with HF, and values were comparable to nonsmokers without HF. These findings offer novel insight into the smoker's paradox and suggest that improved short-term outcome in patients hospitalized with HF may in part be mediated by preservation of vascular endothelial function in this setting.
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Affiliation(s)
- Kevin S Heffernan
- Department of Exercise Science, Human Performance Laboratory, Syracuse University, Syracuse, New York 13244, USA.
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Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, Picard MH, Polk DM, Ragosta M, Ward RP, Weiner RB. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance Endorsed by the American College of Chest Physicians. J Am Coll Cardiol 2011; 57:1126-66. [PMID: 21349406 DOI: 10.1016/j.jacc.2010.11.002] [Citation(s) in RCA: 456] [Impact Index Per Article: 35.1] [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: 12/16/2022]
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Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, Picard MH, Polk DM, Ragosta M, Parker Ward R, Weiner RB. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance American College of Chest Physicians. J Am Soc Echocardiogr 2011; 24:229-67. [PMID: 21338862 DOI: 10.1016/j.echo.2010.12.008] [Citation(s) in RCA: 357] [Impact Index Per Article: 27.5] [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] [Indexed: 12/31/2022]
Abstract
The American College of Cardiology Foundation (ACCF), in partnership with the American Society of Echocardiography (ASE) and along with key specialty and subspecialty societies, conducted a review of common clinical scenarios where echocardiography is frequently considered. This document combines and updates the original transthoracic and transesophageal echocardiography appropriateness criteria published in 2007 (1) and the original stress echocardiography appropriateness criteria published in 2008 (2). This revision reflects new clinical data, reflects changes in test utilization patterns,and clarifies echocardiography use where omissions or lack of clarity existed in the original criteria.The indications (clinical scenarios)were derived from common applications or anticipated uses, as well as from current clinical practice guidelines and results of studies examining the implementation of the original appropriate use criteria (AUC).The 202 indications in this document were developed by a diverse writing group and scored by a separate independent technical panel on a scale of 1 to 9,to designate appropriate use(median 7 to 9), uncertain use(median 4 to 6), and inappropriate use (median 1 to 3). Ninety-seven indications were rated as appropriate, 34 were rated as uncertain, and 71 were rated as inappropriate. In general,the use of echocardiography for initial diagnosis when there is a change in clinical status or when the results of the echocardiogram are anticipated to change patient management were rated appropriate. Routine testing when there was no change in clinical status or when results of testing were unlikely to modify management were more likely to be inappropriate than appropriate/uncertain.The AUC for echocardiography have the potential to impact physician decision making,healthcare delivery, and reimbursement policy. Furthermore,recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research.
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Konstam MA, Kramer DG, Patel AR, Maron MS, Udelson JE. Left ventricular remodeling in heart failure: current concepts in clinical significance and assessment. JACC Cardiovasc Imaging 2011; 4:98-108. [PMID: 21232712 DOI: 10.1016/j.jcmg.2010.10.008] [Citation(s) in RCA: 514] [Impact Index Per Article: 39.5] [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: 08/06/2010] [Revised: 09/24/2010] [Accepted: 10/04/2010] [Indexed: 10/18/2022]
Abstract
Ventricular remodeling, first described in animal models of left ventricular (LV) stress and injury, occurs progressively in untreated patients after large myocardial infarction and in those with dilated forms of cardiomyopathy. The gross pathologic changes of increased LV volume and perturbation in the normal elliptical LV chamber configuration is driven, on a histologic level, by myocyte hypertrophy and apoptosis and by increased interstitial collagen. Each of the techniques used for tracking this process-echocardiography, radionuclide ventriculography, and cardiac magnetic resonance-carries advantages and disadvantages. Numerous investigations have demonstrated the value of LV volume measurement at a single time-point and over time in predicting clinical outcomes in patients with heart failure and in those after myocardial infarction. The structural pattern of LV remodeling and evidence of scarring on cardiac magnetic resonance have additional prognostic value. Beyond the impact of abnormal cardiac structure on cardiovascular events, the relationship between LV remodeling and clinical outcomes is likely linked through common local and systemic factors driving vascular as well as myocardial pathology. As demonstrated by a recent meta-analysis of heart failure trials, LV volume stands out among surrogate markers as strongly correlating with the impact of a particular drug or device therapy on patient survival. These findings substantiate the importance of ventricular remodeling as central in the pathophysiology of advancing heart failure and support the role of measures of LV remodeling in the clinical investigation of novel heart failure treatments.
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Affiliation(s)
- Marvin A Konstam
- Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts, USA
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Arias-Godínez JA, Guadalajara-Boo JF, Patel AR, Pandian NG. Function and mechanics of the left ventricle: from tissue Doppler imaging to three dimensional speckle tracking. Arch Cardiol Mex 2011; 81:114-125. [PMID: 21775245] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
One of the most common indications in echocardiography is the evaluation of left ventricular function. The traditional measurement of ejection fraction is based upon tracing the left ventricular borders and calculating left ventricular volumes using geometric assumptions. Now, with the introduction of three-dimensional echocardiography, the evaluation of left ventricular function is easier to carry out and with superior accuracy and reproducibility. However, regional myocardial function is more difficult to evaluate because it relies on visual assessment of endocardial motion and wall thickening. Currently, new techniques like tissue Doppler and speckle tracking imaging allow regional and global quantification of myocardial function through new parameters, like deformation/strain, rotation and twist. In this regard, speckletracking echocardiography (STE) has been introduced as a technique for angle-independent quantification of multidirectional myocardial strain and rotation. With the arrival of three-dimensional systems, the entire left ventricle can be evaluated with this technique, lacking the inherent weakness of two- dimensional and tissue Doppler methods. Three dimensional speckle tracking (3DST) has potential to be an ideal tool to assess not only global myocardial function but regional function through deformation, rotation, twist and untwisting parameters.
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Bhuiyan T, Helmke S, Patel AR, Ruberg FL, Packman J, Cheung K, Grogan D, Maurer MS. Pressure-volume relationships in patients with transthyretin (ATTR) cardiac amyloidosis secondary to V122I mutations and wild-type transthyretin: Transthyretin Cardiac Amyloid Study (TRACS). Circ Heart Fail 2010; 4:121-8. [PMID: 21191093 DOI: 10.1161/circheartfailure.109.910455] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND ATTR cardiac amyloidosis can result from a mutated variant of transthyretin (eg, V122I) or wild-type variant (ATTRwt). We evaluated pressure-volume (PV) indices at baseline and over time to further characterize abnormal pump function in these subjects. METHODS AND RESULTS Twenty-nine subjects (18 with ATTRwt and 11 with ATTRm (V122I) had 2-dimensional echocardiograms with complete Doppler measures at baseline and every 6 months for up to 2 years. PV indices were derived from echocardiographic measures of ventricular volume coupled with sphygmomanometer-measured pressure and Doppler estimates of filling pressure. The end-systolic and end-diastolic PV relations and the area between them as a function of end-diastolic pressure, the isovolumic PV area (PVA(iso)), were calculated. Clinical, demographic, and PV indices were compared between V122I and ATTRwt subjects and between survivors and nonsurvivors at baseline and over time. Cox proportional hazards model identified correlates for mortality. Stroke volume decline was associated with alterations in ventricular-vascular coupling and a decrease in ventricular capacitance with significant decrement in ejection fraction (56±12% to 48±14%, P=0.0001) over 18 months. PVA(iso) was lower in V122I subjects compared with wild-type at baseline and declined over time. Twelve (41%) subjects died or underwent a cardiac transplant after a mean follow-up of 478 days (range, 31 to 807). Multivariable survival analysis demonstrated that initial ejection fraction (a measure of ventricular-vascular coupling) <50% was associated with increased mortality (hazard ratio, 6.6; 95% confidence interval, 1.1 to 40.3). CONCLUSIONS In ATTR cardiac amyloidosis secondary to a V122I mutation and wild-type transthyretin, PV analysis reveals alterations that are associated with reductions in the ability of the ventricle to perform work and, ultimately, with reduced survival in these subjects.
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Affiliation(s)
- Taslima Bhuiyan
- Clinical Cardiovascular Research Laboratory for the Elderly, Columbia University, New York, NY 10034, USA
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Haffajee JA, Finley JJ, Brooks EL, Kuvin JT, Patel AR. Echocardiographic characterization of left ventricular apical hypoplasia accompanied by a patent ductus arteriosus. Eur Heart J Cardiovasc Imaging 2010; 12:E17. [PMID: 21131656 DOI: 10.1093/ejechocard/jeq170] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Left ventricular (LV) apical hypoplasia is an unusual, recently identified cardiomyopathy, whose clinical course is uncertain. In this report, we describe a case of this cardiomyopathy occurring in an asymptomatic 50-year-old male with a remote history of a surgically corrected patent ductus arteriosus (PDA), primarily using transthoracic echocardiography (TTE) to illustrate the imaging characteristics. This patient had been referred to our institution for an abnormal electrocardiogram, and TTE subsequently (Figure 1) revealed a dilated left ventricle with moderately to severely reduced function; LV ejection fraction was 30% by two- and three-dimensional quantification. The left ventricle had a spherical appearance with a thin-walled, truncated, and akinetic distal LV. The right ventricle appeared elongated and was noted to wrap around the distal left ventricle, but right ventricular systolic function was normal. There were no significant valvular abnormalities, and no evidence of residual PDA flow. Subsequent cardiac magnetic resonance (CMR) imaging confirmed these findings (Figure 1). The TTE and CMR findings seen in this patient are consistent with LV apical hypoplasia. Until now, this cardiomyopathy has been described only as an isolated congenital anomaly primarily using CMR and cardiac computed tomography. To our knowledge, this is the first reported case of LV apical hypoplasia in conjunction with another congenital cardiac abnormality, and the findings demonstrate that the distinctive appearance of this cardiomyopathy can be easily identified with echocardiography. As more cases are recognized and patients are followed over time, the natural history and optimal treatment for this cardiomyopathy may be further elucidated.
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Affiliation(s)
- Jessica A Haffajee
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston 02111 MA, USA.
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