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Maller T, Jubeh R, Perel N, Barbash IM, Segev A, Kornowski R, Vaknin Assa H, Finkelstein A, George J, Perlman G, Guetta V, Asher E, Karameh H, Glikson M, Dvir D. Large multicenter evaluation of clinical outcomes of transcatheter aortic valve implantation in different age groups: results from the Israeli TAVI registry. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Transcatheter aortic valve implantation (TAVI) is becoming the preferred treatment for elderly patients with severe aortic stenosis. Clinical outcomes of these patients according to different age groups and especially in the very old population are under reported.
Purpose
To describe clinical characteristics at baseline, according to different age groups, and to compare clinical outcomes in the very old population with other patients undergoing the procedure.
Methods
Data was extracted from the Israeli National TAVI Registry. Clinical outcomes in very old patients (above the age of 90 years) were compared with younger patients. Multivariable analysis for 30-day and 1-year mortality were performed. Procedural complication was defined as one or more of the following: need for permanent pacemaker, major vascular complication, severe acute kidney injury and major stroke.
Results
A total of 5,936 patients who underwent TAVI from 2008 to 2021 were analyzed (age 81.6±7.1 years, 50.6% female). Patients older than 90 years of age had more comorbidities than the younger population (STS score for mortality 6.4%±3.8% vs. 4.1%±4.8%, p<0.001). Independent correlates for 30-day mortality included STS score (OR=1.01, 95% CI [1.03–1.13], p<0.001) and procedural complication (OR=4.29, 95% CI [2.24–8.20], p<0.0001). Independent correlates for 1-year mortality included chronic obstructive pulmonary disease (OR=1.83, 95% CI [1.28–2.60]; p=0.001), atrial fibrillation (OR=1.71, 95% CI [1.31–2.23]; p<0.001 (STS score); OR=1.13 95% CI [1.09–1.18]; p<0.001), and procedural complication) OR=2.58, 95% [1.89–3.50]; p<0.001).
Conclusions
Although older patients undergoing TAVI had a higher risk profile, short- and long-term survival of these patients were associated significantly more with procedural complications than with patient age. It seems that extreme patient age alone should not be viewed as a consideration for not performing valve replacement, as long as the risk for procedural complications does not seem to be severely elevated.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- T Maller
- Shaare Zedek Medical Center , Jerusalem , Israel
| | - R Jubeh
- Shaare Zedek Medical Center , Jerusalem , Israel
| | - N Perel
- Shaare Zedek Medical Center , Jerusalem , Israel
| | | | - A Segev
- Sheba Medical Center , Ramat Gan , Israel
| | | | | | | | - J George
- Kaplan Medical Center , Rehovot , Israel
| | - G Perlman
- Hadassah University Medical Center , Jerusalem , Israel
| | - V Guetta
- Sheba Medical Center , Ramat Gan , Israel
| | - E Asher
- Shaare Zedek Medical Center , Jerusalem , Israel
| | - H Karameh
- Shaare Zedek Medical Center , Jerusalem , Israel
| | - M Glikson
- Shaare Zedek Medical Center , Jerusalem , Israel
| | - D Dvir
- Shaare Zedek Medical Center , Jerusalem , Israel
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2
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Fishman B, Sharon A, Itelman E, Tsur AM, Fefer P, Barbash IM, Segev A, Matetzky S, Guetta V, Grossman E, Maor E. Invasive management in elderly patients with non-ST elevation myocardial infarction is beneficial regardless of frailty status. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2822] [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: 11/12/2022] Open
Abstract
Abstract
Introduction
Elderly patients are underrepresented in clinical trials evaluating the management of non-ST elevation myocardial infarction (NSTEMI) patients. Moreover, frailty status is often not reported in these trials.
Purpose
To evaluate the association of invasive management with outcome among elderly (≥80) patients presenting with NSTEMI by frailty status.
Methods
Retrospective cohort of consecutive elderly patients who were hospitalized with NSTEMI as a primary clinical diagnosis between 2008 to 2019. Primary outcome was all-cause mortality. Frailty status was estimated as a continuous variable as well as categorized to low, medium, and high. Cox regression models were applied with stratification by frailty status. Additional sensitivity analyses were conducted including propensity score matching (PSM) and inverse probability treatment weighting (IPTW) models.
Results
Study population included 2,317 patients with median age of 86 years (IQR 83–90) of whom 1,243 (54%) were men. Patients who were managed invasively (n=581 [25%]) were less likely to be frail (7% vs. 44%, p<.001). During the follow up (median of 19 months, [IQR 4–41]), 1,599 (69%) patients died. Kaplan Meier survival curves (Figure 1) show that the cumulative probability of death at 19 months was 50% among patients who were managed conservatively compared with 21% among invasively managed patients (p Log rank <.001). In the multivariable Cox model, invasive approach was associated with a significant 39% decrease in the risk of death (95% CI 0.53–0.71). The benefit of invasive approach was consistent among low, medium, and high frailty subgroups with adjusted HRs of 0.74 [0.58–0.93], 0.65 [0.50–0.85] and 0.52 [0.34–0.78], respectively; p for interaction NS). Results were consistent with PSM and IPTW analyses (HR of 0.6 [0.50–0.71] and 0.67 [0.55–0.82], respectively). Additional sensitivity analysis addressing potential immortal time bias and residual confounding yielded similar results.
Conclusions
Invasive approach is associated with improved survival among elderly patients with NSTEMI irrespective of frailty status. Our results support and extend recent ESC recommendations for the management of elderly patients with NSTEMI
Funding Acknowledgement
Type of funding sources: None. Figure 1
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Affiliation(s)
- B Fishman
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - A Sharon
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - E Itelman
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - A M Tsur
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - P Fefer
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - I M Barbash
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - A Segev
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - S Matetzky
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - V Guetta
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - E Grossman
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
| | - E Maor
- Sheba Medical Center, Heart Center, Ramat Gan, Israel
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3
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Tiosano S, Maor E, Berkovitch A, Fefer P, Feinberg M, Vatury O, Barbash IM, Guetta V, Segev A. Clinical and echocardiographic parameters associated with left ventricular recovery after TAVI. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2195] [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
Introduction
The relationship between severe Aortic Stenosis (AS) and Left Ventricular (LV) dysfunction is well established. However, there is a paucity of data regarding LV functional recovery after TAVI.
Purpose
To study the clinical and echocardiographic parameters associated with LV functional recovery after TAVI.
Methods
We evaluated all patients who underwent TAVI between 2009–2020 in a tertiary medical center. We included patients with pre-procedural LV Ejection Fraction (LVEF) of 40% and below. All patients had baseline and in-hospital post-procedural echo, and their clinical characteristics were recorded in a designated TAVI registry. LV functional recovery was defined as an absolute increase in at least 10% in LVEF post-procedurally. No LV recovery was defined as an absolute change of up to ±10% in post-procedure LVEF, and LVEF deterioration was defined as an absolute decrease of more than 10% in post-procedural LVEF compared to baseline. Univariate analysis consisting clinical and echocardiographic factors for LV functional recovery was performed, followed by logistic regression adjusting for confounders.
Results
Out of 1,349 consecutive TAVI patients, 100 (7.4%) had LVEF of 40% or less. There were 69 (69%) men with a mean age of 82±8 years, and average BMI of 27±4 kg/m2. Prior coronary artery disease and hypertension were present in 34 (34%) and 21 (21%) of patients, respectively. Out of these 100 patients, 32 (32%) had achieved LV functional recovery and no patient had experienced LVEF deterioration (FIGURE). Mean Left Ventricular End Systolic Diameter (LVESD) was 3.79 and 4.43 in the LV functional recovery and no LV recovery groups, respectively. Mean aortic pressure gradient was higher among patients who had LV functional recovery compared to no LV recovery (45.9 vs. 31.5 mmHg, respectively). Multivariable analysis revealed parameters that were independently associated with LV functional recovery: Coronary artery disease – OR 5.29 (95% CI 1.59–20.44), LVESD – OR 0.87 (95% CI 0.8–0.95) for each 1 mm increment and mean aortic pressure gradient – OR 1.91 (95% CI 1.21–3.28) per each 10 mmHg increment.
Conclusion
In patients with severe AS and LV dysfunction undergoing TAVI, the presence of coronary artery disease, increased aortic pressure gradient and reduced LVESD were associated with early LV functional recovery.
Funding Acknowledgement
Type of funding sources: None. Figure 1
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Affiliation(s)
- S Tiosano
- Sheba Medical Center, Ramat Gan, Israel
| | - E Maor
- Sheba Medical Center, Ramat Gan, Israel
| | | | - P Fefer
- Sheba Medical Center, Ramat Gan, Israel
| | | | - O Vatury
- Sheba Medical Center, Ramat Gan, Israel
| | | | - V Guetta
- Sheba Medical Center, Ramat Gan, Israel
| | - A Segev
- Sheba Medical Center, Ramat Gan, Israel
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Berkovitch A, Barbash IM, Finkelstein A, Assali AR, Denenberg H, Fefer P, Maor E, Zhitomirsky S, Orvin K, Steinvil A, Barsheset A, Halkin A, Guetta V, Kornowski R, Segev A. P3857Validation of the cardiac damage classification and additional effects of albumin levels in a large cohort of patients undergoing transcatheter aortic valve replacement. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0695] [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: 11/12/2022] Open
Abstract
Abstract
Background
Risk stratification in patients undergoing transcatheter aortic valve replacement (TAVR) is limited and based on clinical judgment and surgical AVR scoring systems. Recently, extent of cardiac damage using an echocardiographic classification was purposed to assess prognosis of patients undergoing TAVR. We aimed to validate this new scoring system in a real-world cohort and to examine the addition of baseline albumin in risk assessment.
Methods
We investigated 2,608 patients undergoing TAVR. All subjects had an echocardiography test prior to TAVR. Subjects were divided into five groups based on their echocardiography findings: stage 0 – 758 (29%) patients, stage 1 – 769 (30%), stage 2 – 730 (28%), stage 3 – 320 (12%) and stage 4 (1.2%). Patients were further assessed by incorporating baseline albumin.
Results
Mean age of study population was 82±7 years. Kaplan-Meier's survival analysis showed that the cumulative probability of mortality was significantly higher among subjects with increased stage compared to the lower stages (p<0.001). Multivariable analysis demonstrated that each increase in stage was associated with significant increased risk of 1-year mortality (HR 1.37, 95% CI 1.23–1.54, p<0.001). Among patients at increased stage (3–4), incorporation of baseline of albumin identified the highest risk group, such that each 1 decrement in albumin levels was associated with more than triple increase in mortality among patients at stage 3 and 4 (HR 2.77, 95% CI 1.48–5.18, p-value=0.001)[figure]. When added to the scoring risk prediction model, albumin allowed more accurate risk stratification: continuous NRI analysis showed an overall improvement of 11% (95% CI 6%-16%) in the accuracy of classification.
KM according to stage and albumin
Conclusions
Cardiac damage classification is validated in a real-world cohort of patients undergoing TAVR. Incorporation of low baseline albumin may further identify patients at the highest risk group.
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Affiliation(s)
- A Berkovitch
- Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - I M Barbash
- Chaim Sheba Medical Center, Tel Hashomer, Israel
| | | | - A R Assali
- Rabin Medical Center, Petah Tikva, Israel
| | - H Denenberg
- Hadassah University Medical Center, The Heart Institute, Jerusalem, Israel
| | - P Fefer
- Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - E Maor
- Chaim Sheba Medical Center, Tel Hashomer, Israel
| | | | - K Orvin
- Rabin Medical Center, Petah Tikva, Israel
| | - A Steinvil
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - A Barsheset
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - A Halkin
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - V Guetta
- Chaim Sheba Medical Center, Tel Hashomer, Israel
| | | | - A Segev
- Chaim Sheba Medical Center, Tel Hashomer, Israel
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5
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Itzhaki Ben Zadok O, Orvin K, Finkelstein A, Barbash IM, Danenberg H, Segev A, Guetta V, Halkin A, Planer D, Bental D, Vaknin Assa H, Assali A, Barsheshet A, Kornowski R. 2165Temporal trends in sex-related differences in clinical characteristics and outcome of patients undergoing transcatheter aortic valve implantation - data from a national TAVI registry. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.2165] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - K Orvin
- Rabin Medical Center, Department of Cardiology, Petah Tikva, Israel
| | - A Finkelstein
- Sourasky Medical Center, Department of Cardiology, Tel Aviv, Israel
| | - I M Barbash
- Sheba Medical Center, Department of Cardiology, Ramat Gan, Israel
| | - H Danenberg
- Hadassah University Medical Center, Department of Cardiology, Jerusalem, Israel
| | - A Segev
- Sheba Medical Center, Department of Cardiology, Ramat Gan, Israel
| | - V Guetta
- Sheba Medical Center, Department of Cardiology, Ramat Gan, Israel
| | - A Halkin
- Sourasky Medical Center, Department of Cardiology, Tel Aviv, Israel
| | - D Planer
- Hadassah University Medical Center, Department of Cardiology, Jerusalem, Israel
| | - D Bental
- Rabin Medical Center, Department of Cardiology, Petah Tikva, Israel
| | - H Vaknin Assa
- Rabin Medical Center, Department of Cardiology, Petah Tikva, Israel
| | - A Assali
- Rabin Medical Center, Department of Cardiology, Petah Tikva, Israel
| | - A Barsheshet
- Rabin Medical Center, Department of Cardiology, Petah Tikva, Israel
| | - R Kornowski
- Rabin Medical Center, Department of Cardiology, Petah Tikva, Israel
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6
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Zusman O, Landes U, Barbash IM, Finkelstein A, Danenberg H, Segev A, Guetta V, Orvin K, Assali A, Barsheshet A, Kornowski R. 4993Transcatheter aortic valve implantation futility risk model: insight on a national registry. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.4993] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- O Zusman
- Rabin Medical Center, Cardiology, Petah Tikva, Israel
| | - U Landes
- Rabin Medical Center, Cardiology, Petah Tikva, Israel
| | - I M Barbash
- Chaim Sheba Medical Center, Cardiollogy, Tel Hashomer, Israel
| | - A Finkelstein
- Tel Aviv Sourasky Medical Center, Cardiology, Tel Aviv, Israel
| | - H Danenberg
- Hadassah-Hebrew University, Cardiology, Jerusalem, Israel
| | - A Segev
- Chaim Sheba Medical Center, Cardiollogy, Tel Hashomer, Israel
| | - V Guetta
- Chaim Sheba Medical Center, Cardiollogy, Tel Hashomer, Israel
| | - K Orvin
- Rabin Medical Center, Cardiology, Petah Tikva, Israel
| | - A Assali
- Rabin Medical Center, Cardiology, Petah Tikva, Israel
| | - A Barsheshet
- Rabin Medical Center, Cardiology, Petah Tikva, Israel
| | - R Kornowski
- Rabin Medical Center, Cardiology, Petah Tikva, Israel
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7
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Barbash IM, Cecchini S, Faranesh AZ, Virag T, Li L, Yang Y, Hoyt RF, Kornegay JN, Bogan JR, Garcia L, Lederman RJ, Kotin RM. MRI roadmap-guided transendocardial delivery of exon-skipping recombinant adeno-associated virus restores dystrophin expression in a canine model of Duchenne muscular dystrophy. Gene Ther 2013; 20:274-82. [PMID: 22551778 PMCID: PMC3424392 DOI: 10.1038/gt.2012.38] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 03/29/2012] [Indexed: 01/16/2023]
Abstract
Duchenne muscular dystrophy (DMD) cardiomyopathy patients currently have no therapeutic options. We evaluated catheter-based transendocardial delivery of a recombinant adeno-associated virus (rAAV) expressing a small nuclear U7 RNA (U7smOPT) complementary to specific cis-acting splicing signals. Eliminating specific exons restores the open reading frame resulting in translation of truncated dystrophin protein. To test this approach in a clinically relevant DMD model, golden retriever muscular dystrophy (GRMD) dogs received serotype 6 rAAV-U7smOPT via the intracoronary or transendocardial route. Transendocardial injections were administered with an injection-tipped catheter and fluoroscopic guidance using X-ray fused with magnetic resonance imaging (XFM) roadmaps. Three months after treatment, tissues were analyzed for DNA, RNA, dystrophin protein, and histology. Whereas intracoronary delivery did not result in effective transduction, transendocardial injections, XFM guidance, enabled 30±10 non-overlapping injections per animal. Vector DNA was detectable in all samples tested and ranged from <1 to >3000 vector genome copies per cell. RNA analysis, western blot analysis, and immunohistology demonstrated extensive expression of skipped RNA and dystrophin protein in the treated myocardium. Left ventricular function remained unchanged over a 3-month follow-up. These results demonstrated that effective transendocardial delivery of rAAV-U7smOPT was achieved using XFM. This approach restores an open reading frame for dystrophin in affected dogs and has potential clinical utility.
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Affiliation(s)
- I M Barbash
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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Barbash IM, Leor J, Feinberg MS, Tessone A, Aboulafia-Etzion S, Orenstein A, Ruiz-Cabello J, Cohen JS, Mardor Y. Interventional magnetic resonance imaging for guiding gene and cell transfer in the heart. Heart 2004; 90:87-91. [PMID: 14676253 PMCID: PMC1768020 DOI: 10.1136/heart.90.1.87] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Interventional magnetic resonance imaging (iMRI) has the potential for guiding interventional cardiac procedures in real time. OBJECTIVES To test the feasibility of iMRI guided gene and cell transfer to the heart and to monitor myocardial remodelling after myocardial infarction in a rat model. METHODS The MRI contrast agent GdDTPA, together with either Evans blue dye, or a recombinant adenovirus encoding the LacZ gene, or primary fibroblasts tagged by BrdU, were injected into the myocardium of rats under iMRI guidance. Rats were killed seven days after the injection and the hearts sectioned to identify the blue dye, LacZ expression, or fibroblast presence, respectively. In a parallel study, left ventricular area was measured before and after myocardial infarction and in sham operated rats by T1 weighted MRI and by echocardiography. RESULTS Location of GdDTPA enhancement observed with iMRI at the time of injection was correlated with Evans blue stain, beta-gal expression, and the primary fibroblast location in histological studies. iMRI and echocardiography measured a comparable increase in left ventricular area at seven and 30 days after myocardial infarction. A good correlation was found between the iMRI and echocardiographic assessment of left ventricular area (r = 0.70; p < 0.0001) and change in left ventricular area with time (r = 0.75; p < 0.0001). CONCLUSIONS The results show the feasibility and efficiency of iMRI guided intramyocardial injections, and the ability to monitor heart remodelling using iMRI. Genes, proteins, or cells for tissue engineering could be injected accurately into the myocardial scar under iMRI guidance.
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Affiliation(s)
- I M Barbash
- Neufeld Cardiac Research Institute, Sheba Medical Centre, Tel-Hashomer, Israel
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Barbash IM, Battler A, Behar S, Boyko V, Gottlieb S, Hasdai D, Leor J. Aspirin and percutaneous coronary angioplasty are associated with a decline in mortality from cardiogenic shock. Results from a national Israeli survey, 1992--1998. Cardiology 2001; 95:119-25. [PMID: 11474156 DOI: 10.1159/000047357] [Citation(s) in RCA: 4] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND METHODS Despite the significant progress in the care and outcome of patients with acute myocardial infarction (AMI), the impact of evolving therapies on the incidence and outcome of patients with cardiogenic shock complicating AMI has been questioned. We analyzed trends in the incidence, care and outcome of cardiogenic shock from four national surveys conducted during 1992--1998. RESULTS Of the 5,351 AMI patients admitted to all coronary care units in Israel, 254 (4.7%) developed cardiogenic shock. The incidence of cardiogenic shock decreased over time (5.8, 5.1, 4.3 and 4.4% for the years 1992, 1994, 1996 and 1998, respectively, p = 0.08). Concomitantly, there was an increase in utilization of coronary angiography, urgent angioplasty and intra-aortic balloon counterpulsation. In addition, there was an increase in hospital use of aspirin, nitrates, ACE inhibitors and beta-blockers. Patients with shock were more likely to die within 7 days compared with AMI patients not having shock (65 vs. 4%; p < 0.001). During the study period, the mortality of patients with shock decreased: at 7 days (72% in 1992 to 60% in 1998; p = 0.09), at 30 days (87 to 70%, respectively; p = 0.01) and at 6 months (89 to 77%, respectively; p = 0.02). Both aspirin and angioplasty were independently associated with improved outcome after adjustment for baseline characteristics and study period. CONCLUSIONS Although the mortality rate of cardiogenic shock complicating AMI remains high, the increased utilization of aspirin and angioplasty is associated with improved outcome.
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Affiliation(s)
- I M Barbash
- Cardiology Department, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Barbash IM, Behar S, Battler A, Hasdai D, Boyko V, Gottlieb S, Leor J. Management and outcome of cardiogenic shock complicating acute myocardial infarction in hospitals with and without on-site catheterisation facilities. Heart 2001. [DOI: 10.1136/hrt.86.2.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVETo determine whether the availability of on-site catheterisation and revascularisation facilities influenced hospital management and outcome of patients with acute myocardial infarction complicated by cardiogenic shock.METHODSPatients with acute myocardial infarction were enrolled prospectively in four nationwide surveys during 1992, 1994, 1996, and 1998. The characteristics, management, and outcome of patients with cardiogenic shock were compared between hospitals with on-site catheterisation facilities (group 1; 18 hospitals) and without such facilities (group 2; 8 hospitals).RESULTSOf 5351 patients with acute myocardial infarction, 254 (4.7%) developed cardiogenic shock. Group 1 patients (n = 186 of 3854; 4.6%) were younger (mean (SD) age, 69.6 (12) v 73.7 (10) years, p = 0.006) and had a lower proportion of women (36% v 52%, p = 0.03) than group 2 (n = 68 of 1243; 5.2%). There was no difference in other characteristics including the use of thrombolysis. Group 1 patients more often underwent coronary angiography (26%v 4%, p < 0.001), angioplasty (21%v 4%, p = 0.002), and intra-aortic balloon counterpulsation (28% v 4%, p < 0.001). Seven day mortality was lower among group 1 than among group 2 patients (61% v 77%, p = 0.02), even after age and sex adjustment (odds ratio (OR) 0.54; 95% confidence interval (CI) 0.28 to 1.02). This outcome benefit persisted at 30 days (74%v 88%, p = 0.01; OR 0.45, 95% CI 0.18 to 0.98), and at 6 months (80% v 90%, p = 0.06; OR 0.57, 95% CI 0.22 to 1.33).CONCLUSIONSThe greater use of invasive and interventional procedures in hospitals with catheterisation facilities is associated with improved survival of patients with acute myocardial infarction complicated by cardiogenic shock. Immediate availability of invasive care facilities will improve the outcome of cardiogenic shock in the community setting.
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11
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Barbash IM, Behar S, Battler A, Hasdai D, Boyko V, Gottlieb S, Leor J. Management and outcome of cardiogenic shock complicating acute myocardial infarction in hospitals with and without on-site catheterisation facilities. Heart 2001; 86:145-9. [PMID: 11454827 PMCID: PMC1729837 DOI: 10.1136/heart.86.2.145] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine whether the availability of on-site catheterisation and revascularisation facilities influenced hospital management and outcome of patients with acute myocardial infarction complicated by cardiogenic shock. METHODS Patients with acute myocardial infarction were enrolled prospectively in four nationwide surveys during 1992, 1994, 1996, and 1998. The characteristics, management, and outcome of patients with cardiogenic shock were compared between hospitals with on-site catheterisation facilities (group 1; 18 hospitals) and without such facilities (group 2; 8 hospitals). RESULTS Of 5351 patients with acute myocardial infarction, 254 (4.7%) developed cardiogenic shock. Group 1 patients (n = 186 of 3854; 4.6%) were younger (mean (SD) age, 69.6 (12) v 73.7 (10) years, p = 0.006) and had a lower proportion of women (36% v 52%, p = 0.03) than group 2 (n = 68 of 1243; 5.2%). There was no difference in other characteristics including the use of thrombolysis. Group 1 patients more often underwent coronary angiography (26% v 4%, p < 0.001), angioplasty (21% v 4%, p = 0.002), and intra-aortic balloon counterpulsation (28% v 4%, p < 0.001). Seven day mortality was lower among group 1 than among group 2 patients (61% v 77%, p = 0.02), even after age and sex adjustment (odds ratio (OR) 0.54; 95% confidence interval (CI) 0.28 to 1.02). This outcome benefit persisted at 30 days (74% v 88%, p = 0.01; OR 0.45, 95% CI 0.18 to 0.98), and at 6 months (80% v 90%, p = 0.06; OR 0.57, 95% CI 0.22 to 1.33). CONCLUSIONS The greater use of invasive and interventional procedures in hospitals with catheterisation facilities is associated with improved survival of patients with acute myocardial infarction complicated by cardiogenic shock. Immediate availability of invasive care facilities will improve the outcome of cardiogenic shock in the community setting.
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Affiliation(s)
- I M Barbash
- Cardiology Department, Soroka Medical Centre, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Etzion S, Battler A, Barbash IM, Cagnano E, Zarin P, Granot Y, Kedes LH, Kloner RA, Leor J. Influence of embryonic cardiomyocyte transplantation on the progression of heart failure in a rat model of extensive myocardial infarction. J Mol Cell Cardiol 2001; 33:1321-30. [PMID: 11437538 DOI: 10.1006/jmcc.2000.1391] [Citation(s) in RCA: 147] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cell transplantation has been proposed as a future therapy for various myocardial diseases. It is unknown, however, whether the encouraging results obtained in animal models of ischemia and reperfusion, cryoinjury or cardiomyopathy can be reproduced in the setting of permanent coronary artery occlusion and extensive myocardial infarction (MI). Embryonic cardiac cells were isolated and cultured for 3 days to confirm viability, morphology and to label cells with BrdU or the reporter gene LacZ. Seven days after extensive MI, rats were randomized to cell (1.5x10(6)) transplantation (n=11) or culture medium injection (n=16) into the myocardial scar. Echocardiography study was performed before and 53+/-3 days after implantation to assess left ventricular (LV) remodeling and function. During follow-up, there was no mortality among cell-treated rats v 4 of 16 control rats (P=0.12). X-gal staining, BrdU and alpha -SMA immunohistochemistry identified the engrafted cells 1 week, 4 weeks and 8 weeks after transplantation, respectively. Antibodies against alpha -SMA, connexin-43, fast and slow myosin heavy chain revealed grafts in various stages of differentiation in 10 of 11 cell-treated hearts. Many of them, however, kept their embryonic phenotype and were isolated from the host myocardium by scar tissue. Serial echocardiography studies revealed that cell transplantation prevented scar thinning, LV dilatation and dysfunction while control animals developed scar thinning, significant LV dilatation accompanied by progressive deterioration in LV contractility. Transplantation of embryonic cardiomyocytes after extensive MI in a rat model attenuate LV dilatation, infarct thinning, and myocardial dysfunction. Still, many grafts remain isolated and do not differentiate into an adult phenotype, even when studied 2 months after grafting.
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Affiliation(s)
- S Etzion
- Cardiac Research Center, Faculty of Health Sciences, Beer-Sheva, Israel
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Barbash IM, Hasdai D, Behar S, Boyko V, Gottlieb S, Ilia R, Battler A, Leor J. Usefulness of pre- versus postadmission cardiogenic shock during acute myocardial infarction in predicting survival. Am J Cardiol 2001; 87:1200-3; A7. [PMID: 11356399 DOI: 10.1016/s0002-9149(01)01495-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- I M Barbash
- Neufeld Cardiac Research Institute, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Israel
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Affiliation(s)
- I M Barbash
- Neufeld Cardiac Research Institute, Sheba Medical Center, Tel Aviv University, Tel-Hashomer, Israel
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Abstract
BACKGROUND The myocardium is unable to regenerate because cardiomyocytes cannot replicate after injury. The heart is therefore an attractive target for tissue engineering to replace infarcted myocardium and enhance cardiac function. We tested the feasibility of bioengineering cardiac tissue within novel 3-dimensional (3D) scaffolds. METHODS AND RESULTS We isolated and grew fetal cardiac cells within 3D porous alginate scaffolds. The cell constructs were cultured for 4 days to evaluate viability and morphology before implantation. Light microscopy revealed that within 2 to 3 days in culture, the dissociated cardiac cells form distinctive, multicellular contracting aggregates within the scaffold pores. Seven days after myocardial infarction, rats were randomized to biograft implantation (n=6) or sham-operation (n=6) into the myocardial scar. Echocardiography study was performed before and 65+/-5 days after implantation to assess left ventricular (LV) remodeling and function. Hearts were harvested 9 weeks after implantation. Visual examination of the biograft revealed intensive neovascularization from the neighboring coronary network. Histological examination revealed the presence of myofibers embedded in collagen fibers and a large number of blood vessels. The specimens showed almost complete disappearance of the scaffold and good integration into the host. Although control animals developed significant LV dilatation accompanied by progressive deterioration in LV contractility, in the biograft-treated rats, attenuation of LV dilatation and no change in LV contractility were observed. CONCLUSIONS Alginate scaffolds provide a conducive environment to facilitate the 3D culturing of cardiac cells. After implantation into the infarcted myocardium, the biografts stimulated intense neovascularization and attenuated LV dilatation and failure in experimental rats compared with controls. This strategy can be used for regeneration and healing of the infarcted myocardium.
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Affiliation(s)
- J Leor
- Cardiac Research Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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Barbash IM, Goldbourt U, Gottlieb S, Behar S, Leor J. Possible interaction between aspirin and ACE inhibitors: update on unresolved controversy. Congest Heart Fail 2000; 6:313-318. [PMID: 12189336 DOI: 10.1111/j.1527-5299.2000.80174.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The widespread use of aspirin and angiotensin converting enzyme (ACE) inhibitors in patients with coronary artery disease contributes significantly to the reduction in morbidity and mortality from this common health problem. These agents are widely and concomitantly used, and they share mechanisms that may interact in negative or positive pathways. Data derived from in vitro preparations, animal studies, human studies, and case-control studies are inconsistent. No study has established firm evidence regarding the safety or adverse effect of aspirin on patients who are on ACE inhibitors. The efficacy and safety of aspirin in combination with ACE inhibitors has been questioned and debated. If a negative interaction does exist, it will affect daily practice in treating patients with coronary artery disease and heart failure. This article reviews the available data regarding the safety of combined aspirin and ACE-inhibitor treatment among patients with ischemic heart disease, to assess the possible interaction between the two drugs and to discuss the significance and implications of the data. (c)2000 by CHF, Inc.
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Affiliation(s)
- I M Barbash
- Cardiology Department, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Abstract
BACKGROUND The beneficial effect of on-site catheterization facilities on the survival of all patients with myocardial infarction complicated by cardiogenic shock has been questioned. Our objective was to evaluate the impact of the availability of on-site catheterization facilities on the outcome of unselected patients with cardiogenic shock. METHODS AND RESULTS We studied the hospital records of 70 consecutive patients with cardiogenic shock admitted to our intensive coronary care unit during 1990-1996, and compared two groups of patients: those admitted before (n = 34) and after (n = 36) the opening of our catheterization laboratory. Patients admitted when the catheterization laboratory was available were of similar age, but included fewer males and fewer patients with prior myocardial infarction. Following the activation of the catheterization laboratory, utilization rates of coronary angiography, percutaneous transluminal coronary angioplasty and intra-aortic balloon pump increased, compared with the previous period. However, there was no improvement in in-hospital (88 vs. 83%; p = 0.7) and 30-day mortality (91 vs. 86%; p = 0.7) before versus after the activation of our catheterization laboratory. Twelve patients selected to cardiac catheterization (9 underwent percutaneous transluminal coronary angioplasty) experienced lower in-hospital and 30-day mortality compared with patients who were not selected (58 vs. 96, and 67 vs. 96%, respectively; p < 0.02). CONCLUSIONS Following the activation of the catheterization laboratory, the mortality of the entire population of cardiogenic shock patients remained relatively unchanged. Still, a small subgroup of these patients selected for urgent cardiac catheterization had a lower mortality compared with patients who were not selected.
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Affiliation(s)
- I M Barbash
- Cardiology Department, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Aboulafia-Etzion S, Leor J, Barbash IM, Battler A. [Fixing a failing heart: molecular and cellular approaches]. Harefuah 1999; 136:284-8. [PMID: 10914220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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