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Elkaryoni A, Saad M, Darki A, Abdelkarim I, Has P, Hyder ON, Mamdani ST, Sharaf BL, Gordon P, Lopez JJ, Abbott JD, Stone GW. Mitral Valve Transcatheter Edge-to-Edge Repair After TAVR: A Nationwide Analysis. Am J Cardiol 2023; 209:184-189. [PMID: 37858596 DOI: 10.1016/j.amjcard.2023.09.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/12/2023] [Accepted: 09/24/2023] [Indexed: 10/21/2023]
Abstract
Patients with persistent severe mitral regurgitation after transcatheter aortic valve replacement (TAVR) may benefit from mitral transcatheter edge-to-edge repair (M-TEER). Using the Nationwide Readmission Database, we identified patients who had M-TEER within 6 months after TAVR and compared their outcomes with patients who had M-TEER without previous recent TAVR during the same calendar year between 2014 and 2020. Because Nationwide Readmission Database data do not cross years, analysis was restricted to the last half of each calendar year. End points included in-hospital mortality and 30-day and 90-day postdischarge rehospitalization rates. In 23,885 M-TEER patients, 396 (1.7%) had a previous recent TAVR. The number of post-TAVR M-TEER procedures increased progressively over time from 16 in 2014 to 92 in 2020. Patients who had M-TEER after a recent TAVR versus those without previous TAVR had similar in-hospital mortality (adjusted odds ratio 0.38, 95% confidence interval [CI] 0.12 to 1.23, p = 0.11), but higher rates of 30-day all-cause hospitalization and heart failure hospitalization (adjusted odds ratios 1.34, 95% CI 1.11 to 1.79, p = 0.04 and 1.63, 95% CI 1.13 to 2.36, p = 0.009, respectively). Nonetheless, in patients who underwent M-TEER post-TAVR, the cumulative 90-day all-cause hospitalization and heart failure hospitalization rates were less after M-TEER compared with before M-TEER (from 45.7% to 31.5%, p = 0.007, and from 29.0% to 16.6%, respectively, both p = 0.005). In conclusion, M-TEER procedures after TAVR in the United States are increasing. Patients with M-TEER after TAVR had similar in-hospital mortality as those who underwent M-TEER without recent TAVR, but higher 30-day hospitalization rates. Nonetheless, 90-day hospitalization rates were decreased after M-TEER in patients with previous TAVR.
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Affiliation(s)
- Ahmed Elkaryoni
- Division of Cardiovascular Disease, Lifespan Cardiovascular Institute, Providence, Rhode Island; Division of Cardiovascular Disease, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
| | - Marwan Saad
- Division of Cardiovascular Disease, Lifespan Cardiovascular Institute, Providence, Rhode Island; Division of Cardiovascular Disease, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Amir Darki
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, Illinois
| | - Islam Abdelkarim
- Department of Internal Medicine, Kansas City University Medical Center, Kansas City, Kansas
| | - Phinnara Has
- Division of Cardiovascular Disease, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Omar N Hyder
- Division of Cardiovascular Disease, Lifespan Cardiovascular Institute, Providence, Rhode Island; Division of Cardiovascular Disease, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Shafiq T Mamdani
- Division of Cardiovascular Disease, Lifespan Cardiovascular Institute, Providence, Rhode Island; Division of Cardiovascular Disease, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Barry L Sharaf
- Division of Cardiovascular Disease, Lifespan Cardiovascular Institute, Providence, Rhode Island; Division of Cardiovascular Disease, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Paul Gordon
- Division of Cardiovascular Disease, Lifespan Cardiovascular Institute, Providence, Rhode Island; Division of Cardiovascular Disease, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - John J Lopez
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, Illinois
| | - J Dawn Abbott
- Division of Cardiovascular Disease, Lifespan Cardiovascular Institute, Providence, Rhode Island; Division of Cardiovascular Disease, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Gregg W Stone
- Division of Cardiovascular Disease, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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2
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Elkaryoni A, Elgendy IY, Qarajeh R, Allen S, Abdelkarim I, Mallas W, Leya FS, Lewis BE, Steen LH, Lopez JJ, Darki A. Outcomes of ST-elevation myocardial infarction due to left main coronary artery: a nationwide cohort sample. Coron Artery Dis 2022; 33:245-246. [PMID: 34010195 DOI: 10.1097/mca.0000000000001068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Ahmed Elkaryoni
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, Illinois, USA
| | - Islam Y Elgendy
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Raed Qarajeh
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Sorcha Allen
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, Illinois, USA
| | - Islam Abdelkarim
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Waddah Mallas
- Department of Internal Medicine, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, Illinois, USA
| | - Ferdinand S Leya
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, Illinois, USA
| | - Bruce E Lewis
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, Illinois, USA
| | - Lowell H Steen
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, Illinois, USA
| | - John J Lopez
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, Illinois, USA
| | - Amir Darki
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, Illinois, USA
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Shaladi A, Abdelkarim I, Kitson J. 1365 Analysis of Outcomes Pre- and Post-Physiotherapy Protocol for Centenarian Patients Presenting with Neck of Femur Fractures. Br J Surg 2021. [DOI: 10.1093/bjs/znab259.149] [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] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Aim
The number of centenarians has quadrupled over the last 2 decades with an increase in the number presenting with proximal femur fractures. Very little is known about mortality and morbidity in this age group. There is a subjective assumption that they are too frail and may not do well with surgery. This audit aims to outline improved outcomes of surgery in centenarian patients with NOF fractures following dedicated modified physiotherapy intervention.
Method
Data reviewing centenarian NOF outcomes over a two-year period (2015-2016) was compared with outcomes following a dedicated post-operative physiotherapy trust protocol for centenarian NOF patients. 16 patients (15 female, 1 male) from Jan 2017- August 2019 were identified. Data was analysed for patient demographics, surgical details including anaesthesia, post-operative complications, physiotherapy outcomes and mortality.
Results
10 patients had dynamic hip screws and 6 patients had hemiarthroplasties. Inpatient mortality was 0% compared to previous audit of 8.3%. The average length of stay had reduced from 23.3 days in previous audit to 18.5 days in current. 82% of patients could transfer with frame in the post-operative period.
Conclusions
Positive surgical outcomes are demonstrated even in centenarians particularly when given tailored post-operative physiotherapy with reduced length of stay, mortality, and high levels of physiotherapy compliance. Comparisons with younger elderly patients will help guide future management.
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Affiliation(s)
- A Shaladi
- Lister Hospital, Hertfordshire, United Kingdom
| | | | - J Kitson
- Lister Hospital, Hertfordshire, United Kingdom
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4
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Elkaryoni A, Qarajeh R, Muhanna A, Genev I, Barssoum K, Abdelkarim I, Arnason A, Darki A. TCT CONNECT-24 In-Hospital Outcomes and 30-Day Readmission for Patients Presented With Left Main Coronary Artery ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol 2020. [DOI: 10.1016/j.jacc.2020.09.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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5
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Elkaryoni A, Genev I, Muhanna A, Barssoum K, Abdelkarim I, Arnason A, Darki A. TCT CONNECT-243 Hospitalization Rates Before and After Percutaneous Coronary Intervention for Chronic Total Occlusion. A Nationwide Cohort Sample. J Am Coll Cardiol 2020. [DOI: 10.1016/j.jacc.2020.09.259] [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: 10/23/2022]
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Fukui M, Gupta A, Abdelkarim I, Sharbaugh MS, Althouse AD, Elzomor H, Mulukutla S, Lee JS, Schindler JT, Gleason TG, Cavalcante JL. Association of Structural and Functional Cardiac Changes With Transcatheter Aortic Valve Replacement Outcomes in Patients With Aortic Stenosis. JAMA Cardiol 2020; 4:215-222. [PMID: 30725109 DOI: 10.1001/jamacardio.2018.4830] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [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]
Abstract
Importance Severe aortic stenosis causes pressure overload of the left ventricle, resulting in progressive cardiac dysfunction that can extend beyond the left ventricle. A staging system for aortic stenosis has been recently proposed that quantifies the extent of structural and functional cardiac changes in aortic stenosis. Objectives To confirm the reproducibility of a proposed staging system and expand the study findings by performing a survival analysis and to evaluate the association of aortic stenosis staging with both cardiac and noncardiac post-transcatheter aortic valve replacement (TAVR) readmissions. Design, Setting, and Participants A cohort analysis was conducted involving patients with severe aortic stenosis who underwent TAVR at the University of Pittsburgh Medical Center between July 1, 2011, and January 31, 2017. Patients who had undergone TAVR for valve-in-valve procedures and had an incomplete or unavailable baseline echocardiogram study for review were excluded. Clinical, laboratorial, and procedural data were collected from the Society of Thoracic Surgeons database and augmented by electronic medical record review. Exposures The aortic stenosis staging system is based on echocardiographic markers of abnormal cardiac function. The stages are as follows: stage 1 (left ventricle changes - increased left ventricular mass index; early mitral inflow to early diastolic mitral annulus velocity (E/e') >14; and left ventricular ejection fraction <50%), stage 2 (left atrial or mitral changes - left atrial volume index >34 mL/m2; moderate to severe mitral regurgitation; and atrial fibrillation), stage 3 (pulmonary artery or tricuspid changes - pulmonary artery systolic pressure ≥60 mm Hg; moderate to severe tricuspid regurgitation), and stage 4 (right ventricle changes - moderate to severe right ventricle dysfunction). Main Outcomes and Measures Primary outcome was post-TAVR all-cause mortality. Secondary outcomes were composite outcomes of all-cause mortality and post-TAVR all-cause and cardiac-cause readmissions. Results A total of 689 consecutive patients (351 [50.9%] were male, with a mean [SD] age of 82.4 [7.6] years) were included. The prevalence of stage 1 was 13%; stage 2, 62%; stage 3, 21%; and stage 4, 4%. Patients with higher staging had a greater burden of comorbidities as captured by the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM). Despite adjustment for STS-PROM, a graded association was found between aortic stenosis staging and all-cause mortality (hazard ratio [HR] stage 2 vs stage 1: 1.37 [95% CI, 0.81-2.31; P = .25]; stage 3 vs stage 1: 2.24 [95% CI, 1.28-3.92; P = .005]; and stage 4 vs stage 1: 2.83 [95% CI, 1.39-5.76; P = .004]). Stage 3 patients had higher post-TAVR readmission rates for both cardiac (HR, 1.84; 95% CI, 1.13-3.00; P = .01) and noncardiac causes. Conclusions and Relevance Aortic stenosis staging appears to show a strong graded association between the extent of cardiac changes and post-TAVR all-cause mortality; such staging may improve patient care, risk stratification, assessment of prognosis, and shared decision making for patients undergoing TAVR.
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Affiliation(s)
- Miho Fukui
- Division of Cardiovascular Diseases, Department of Internal Medicine, Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Aman Gupta
- Division of Cardiovascular Diseases, Department of Internal Medicine, Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Islam Abdelkarim
- Division of Cardiovascular Diseases, Department of Internal Medicine, Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael S Sharbaugh
- Division of Cardiovascular Diseases, Department of Internal Medicine, Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew D Althouse
- Division of Cardiovascular Diseases, Department of Internal Medicine, Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hesham Elzomor
- Division of Cardiovascular Diseases, Department of Internal Medicine, Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Suresh Mulukutla
- Division of Cardiovascular Diseases, Department of Internal Medicine, Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joon S Lee
- Division of Cardiovascular Diseases, Department of Internal Medicine, Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John T Schindler
- Division of Cardiovascular Diseases, Department of Internal Medicine, Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Thomas G Gleason
- Division of Cardiovascular Diseases, Department of Internal Medicine, Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - João L Cavalcante
- Division of Cardiovascular Diseases, Department of Internal Medicine, Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
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Elkaryoni A, Ramakrishnan D, Abdelkarim I, Noman A, Qintar M, Baweja P. Vasopressor-Induced Generalized Coronary Vasospasm Presenting as Inferior ST-Segment Elevation in Post-Cardiopulmonary Resuscitation. JACC Case Rep 2019; 1:94-98. [PMID: 34316757 PMCID: PMC8301242 DOI: 10.1016/j.jaccas.2019.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 04/22/2019] [Accepted: 05/14/2019] [Indexed: 11/23/2022]
Abstract
ST-segment elevation in post-return of spontaneous circulation after cardiac arrest is a major concern for underlying acute coronary syndrome. This case report presents a rare case of vasopressor-induced coronary vasospasm as an underlying cause for this ST-segment elevation with complete reversal of EKG changes after reducing the vasopressor dose. (Level of Difficulty: Beginner.).
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Affiliation(s)
- Ahmed Elkaryoni
- Division of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Dushyant Ramakrishnan
- Division of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Islam Abdelkarim
- Division of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Anas Noman
- Division of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Mohammed Qintar
- Division of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
- Division of Cardiovascular Disease, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Paramdeep Baweja
- Division of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
- Division of Cardiovascular Disease, Truman Medical Center, Kansas City, Missouri
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8
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Elkaryoni A, Othman HF, Barakat A, Abdelkarim I. TRENDS OF IMPLANTABLE CARDIOVERTER DEFIBRILLATOR USE IN ADVANCED HEART FAILURE PATIENTS SUPPORTED WITH LEFT VENTRICULAR ASSIST DEVICE: INSIGHTS FROM THE NATIONWIDE INPATIENT SAMPLE. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)30994-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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9
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Fukui M, Xu J, Abdelkarim I, Sharbaugh MS, Thoma FW, Althouse AD, Pedrizzetti G, Cavalcante JL. Global longitudinal strain assessment by computed tomography in severe aortic stenosis patients - Feasibility using feature tracking analysis. J Cardiovasc Comput Tomogr 2019; 13:157-162. [DOI: 10.1016/j.jcct.2018.10.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/19/2018] [Accepted: 10/23/2018] [Indexed: 10/28/2022]
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10
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Fukui M, Gupta A, Abdelkarim I, Sharbaugh MS, Althouse AD, Elzomor H, Mulukutla S, Lee JS, Schindler JT, Gleason TG, Cavalcante JL. 600.07 Extent of Cardiac Damage is Associated with Outcomes after Transthoracic Aortic Valve Replacement. JACC Cardiovasc Interv 2019. [DOI: 10.1016/j.jcin.2019.01.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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11
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Sultan I, Cardounel A, Abdelkarim I, Kilic A, Althouse AD, Sharbaugh MS, Gupta A, Xu J, Fukui M, Simon MA, Schindler JT, Lee JS, Gleason TG, Cavalcante JL. Right ventricle to pulmonary artery coupling in patients undergoing transcatheter aortic valve implantation. Heart 2018; 105:117-121. [PMID: 30093545 DOI: 10.1136/heartjnl-2018-313385] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/05/2018] [Accepted: 07/09/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To evaluate the prognostic value of the ratio between tricuspid annular plane systolic excursion (TAPSE)-pulmonary artery systolic pressure (PASP) as a determinant of right ventricular to pulmonary artery (RV-PA) coupling in patients undergoing transcatheter aortic valve replacement (TAVI). BACKGROUND RV function and pulmonary hypertension (PH) are both prognostically important in patients receiving TAVI. RV-PA coupling has been shown to be prognostic important in patients with heart failure but not previously evaluated in TAVI patients. METHODS Consecutive patients with severe aortic stenosis who received TAVI from July 2011 through January 2016 and with comprehensive baseline echocardiogram were included. All individual echocardiographic images and Doppler data were independently reviewed and blinded to the clinical information and outcomes. Cox models quantified the effect of TAPSE/PASP quartiles on subsequent all-cause mortality while adjusting for confounders. RESULTS A total of 457 patients were included with mean age of 82.8±7.2 years, left ventricular ejection fraction (LVEF) 54%±13%, PASP 44±17 mm Hg. TAPSE/PASP quartiles showed a dose-response relationship with survival. This remained significant (HR for lowest quartile vs highest quartile=2.21, 95% CI 1.07 to 4.57, p=0.03) after adjusting for age, atrial fibrillation, LVEF, stroke volume index, Society of Thoracic Surgeons Predicted Risk of Mortality. CONCLUSION Baseline TAPSE/PASP ratio is associated with all-cause mortality in TAVI patients as it evaluates RV systolic performance at a given degree of afterload. Incorporation of right-side unit into the risk stratification may improve optimal selection of patients for TAVI.
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Affiliation(s)
- Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Arturo Cardounel
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Islam Abdelkarim
- Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Arman Kilic
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew D Althouse
- Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael S Sharbaugh
- Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Aman Gupta
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeff Xu
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Miho Fukui
- Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Marc A Simon
- Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John T Schindler
- Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joon S Lee
- Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Thomas G Gleason
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - João L Cavalcante
- Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Fukui M, Gupta A, Abdelkarim I, Sharbaugh M, Althouse A, Elzomor H, Katz W, Crock F, Kliner D, Lee JS, Schindler JT, Gleason TG, Cavalcante JL. 231Impact of cardiac damage extent on transcatheter aortic valve replacement outcome - a validation of a new staging system. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy564.231] [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: 11/12/2022] Open
Affiliation(s)
- M Fukui
- University of Pittsburgh, Department of Medicine, Division of Cardiovascular Diseases, Heart & Vascular Institute, UPMC, Pittsburgh, United States of America
| | - A Gupta
- University of Pittsburgh, Department of Medicine, Division of Cardiovascular Diseases, Heart & Vascular Institute, UPMC, Pittsburgh, United States of America
| | - I Abdelkarim
- University of Pittsburgh, Department of Medicine, Division of Cardiovascular Diseases, Heart & Vascular Institute, UPMC, Pittsburgh, United States of America
| | - M Sharbaugh
- University of Pittsburgh, Department of Medicine, Division of Cardiovascular Diseases, Heart & Vascular Institute, UPMC, Pittsburgh, United States of America
| | - A Althouse
- University of Pittsburgh, Department of Medicine, Division of Cardiovascular Diseases, Heart & Vascular Institute, UPMC, Pittsburgh, United States of America
| | - H Elzomor
- University of Pittsburgh, Department of Medicine, Division of Cardiovascular Diseases, Heart & Vascular Institute, UPMC, Pittsburgh, United States of America
| | - W Katz
- University of Pittsburgh, Department of Medicine, Division of Cardiovascular Diseases, Heart & Vascular Institute, UPMC, Pittsburgh, United States of America
| | - F Crock
- University of Pittsburgh, Department of Medicine, Division of Cardiovascular Diseases, Heart & Vascular Institute, UPMC, Pittsburgh, United States of America
| | - D Kliner
- University of Pittsburgh, Department of Medicine, Division of Cardiovascular Diseases, Heart & Vascular Institute, UPMC, Pittsburgh, United States of America
| | - J S Lee
- University of Pittsburgh, Department of Medicine, Division of Cardiovascular Diseases, Heart & Vascular Institute, UPMC, Pittsburgh, United States of America
| | - J T Schindler
- University of Pittsburgh, Department of Medicine, Division of Cardiovascular Diseases, Heart & Vascular Institute, UPMC, Pittsburgh, United States of America
| | - T G Gleason
- University of Pittsburgh, Department of Medicine, Division of Cardiovascular Diseases, Heart & Vascular Institute, UPMC, Pittsburgh, United States of America
| | - J L Cavalcante
- University of Pittsburgh, Department of Medicine, Division of Cardiovascular Diseases, Heart & Vascular Institute, UPMC, Pittsburgh, United States of America
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13
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Cavalcante JL, Rijal S, Abdelkarim I, Althouse AD, Sharbaugh MS, Fridman Y, Soman P, Forman DE, Schindler JT, Gleason TG, Lee JS, Schelbert EB. Cardiac amyloidosis is prevalent in older patients with aortic stenosis and carries worse prognosis. J Cardiovasc Magn Reson 2017; 19:98. [PMID: 29212513 PMCID: PMC5719789 DOI: 10.1186/s12968-017-0415-x] [Citation(s) in RCA: 132] [Impact Index Per Article: 18.9] [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: 05/22/2017] [Accepted: 11/23/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Non-invasive cardiac imaging allows detection of cardiac amyloidosis (CA) in patients with aortic stenosis (AS). Our objective was to estimate the prevalence of clinically suspected CA in patients with moderate and severe AS referred for cardiovascular magnetic resonance (CMR) in age and gender categories, and assess associations between AS-CA and all-cause mortality. METHODS We retrospectively identified consecutive AS patients defined by echocardiography referred for further CMR assessment of valvular, myocardial, and aortic disease. CMR identified CA based on typical late-gadolinium enhancement (LGE) patterns, and ancillary clinical evaluation identified suspected CA. Survival analysis with the Log rank test and Cox regression compared associations between CA and mortality. RESULTS There were 113 patients (median age 74 years, Q1-Q3: 62-82 years), 96 (85%) with severe AS. Suspected CA was present in 9 patients (8%) all > 80 years. Among those over the median age of 74 years, the prevalence of CA was 9/57 (16%), and excluding women, the prevalence was 8/25 (32%). Low-flow, low-gradient physiology was very common in CA (7/9 patients or 78%). Over a median follow-up of 18 months, 40 deaths (35%) occurred. Mortality in AS + CA patients was higher than AS alone (56% vs. 20% at 1-year, log rank 15.0, P < 0.0001). Adjusting for aortic valve replacement modeled as a time-dependent covariate, Society of Thoracic Surgery predicted risk of mortality, left ventricular ejection fraction, CA remained associated with all-cause mortality (HR = 2.92, 95% CI = 1.09-7.86, P = 0.03). CONCLUSIONS Suspected CA appears prevalent among older male patients with AS, especially with low flow, low gradient AS, and associates with all-cause mortality. The importance of screening for CA in older AS patients and optimal treatment strategies in those with CA warrant further investigation, especially in the era of transcatheter aortic valve implantation.
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Affiliation(s)
- João L. Cavalcante
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, 200 Lothrop Street, Scaife Hall S-558, Pittsburgh, PA 15213 USA
- UPMC Cardiovascular Magnetic Resonance Center, Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Shasank Rijal
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, 200 Lothrop Street, Scaife Hall S-558, Pittsburgh, PA 15213 USA
| | - Islam Abdelkarim
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, 200 Lothrop Street, Scaife Hall S-558, Pittsburgh, PA 15213 USA
| | - Andrew D. Althouse
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, 200 Lothrop Street, Scaife Hall S-558, Pittsburgh, PA 15213 USA
| | - Michael S. Sharbaugh
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, 200 Lothrop Street, Scaife Hall S-558, Pittsburgh, PA 15213 USA
| | - Yaron Fridman
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, 200 Lothrop Street, Scaife Hall S-558, Pittsburgh, PA 15213 USA
- UPMC Cardiovascular Magnetic Resonance Center, Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Prem Soman
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, 200 Lothrop Street, Scaife Hall S-558, Pittsburgh, PA 15213 USA
| | - Daniel E. Forman
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, 200 Lothrop Street, Scaife Hall S-558, Pittsburgh, PA 15213 USA
| | - John T. Schindler
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, 200 Lothrop Street, Scaife Hall S-558, Pittsburgh, PA 15213 USA
| | - Thomas G. Gleason
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, 200 Lothrop Street, Scaife Hall S-558, Pittsburgh, PA 15213 USA
| | - Joon S. Lee
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, 200 Lothrop Street, Scaife Hall S-558, Pittsburgh, PA 15213 USA
| | - Erik B. Schelbert
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, 200 Lothrop Street, Scaife Hall S-558, Pittsburgh, PA 15213 USA
- UPMC Cardiovascular Magnetic Resonance Center, Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
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Masri A, Abdelkarim I, Sharbaugh MS, Althouse AD, Xu J, Han W, Chan SY, Katz WE, Crock FW, Harinstein ME, Kliner DE, Navid F, Lee JS, Gleason TG, Schindler JT, Cavalcante JL. Outcomes of persistent pulmonary hypertension following transcatheter aortic valve replacement. Heart 2017; 104:821-827. [PMID: 28970276 DOI: 10.1136/heartjnl-2017-311978] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 09/18/2017] [Accepted: 09/19/2017] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES To determine the prevalence and factors associated with persistent pulmonary hypertension (PH) following transcatheter aortic valve replacement (TAVR) and its relationship with long-term mortality. METHODS Consecutive patients who underwent TAVR from July 2011 through January 2016 were studied. The prevalence of baseline PH (mean pulmonary artery pressure ≥25 mm Hg on right heart catheterisation) and the prevalence and the predictors of persistent≥moderate PH (pulmonary artery systolic pressure (PASP)>45 mm Hg on 1 month post-TAVR transthoracic Doppler echocardiography) were collected. Cox models quantified the effect of persistent PH on subsequent mortality while adjusting for confounders. RESULTS Of the 407 TAVR patients, 273 (67%) had PH at baseline. Of these, 102 (25%) had persistent≥moderate PH. Mortality at 2 years in patients with no baseline PH versus those with PH improvement (follow-up PASP≤45 mm Hg) versus those with persistent≥moderate PH was 15.4%, 16.6% and 31.3%, respectively (p=0.049). After adjusting for Society of Thoracic Surgeons Predicted Risk of Mortality and baseline right ventricular function (using tricuspid annular plane systolic excursion), persistent≥moderate PH remained associated with all-cause mortality (HR=1.82, 95% CI 1.06 to 3.12, p=0.03). Baseline characteristics associated with increased likelihood of persistent≥moderate PH were ≥moderate tricuspid regurgitation, ≥moderate mitral regurgitation, atrial fibrillation/flutter, early (E) to late (A) ventricular filling velocities (E/A ratio) and left atrial volume index. CONCLUSIONS Persistency of even moderate or greater PH at 1 month post-TAVR is common and associated with higher all-cause mortality.
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Affiliation(s)
- Ahmad Masri
- Department of Medicine, Division of Cardiovascular Diseases, University of Pittsburgh, UPMC-Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Islam Abdelkarim
- Department of Medicine, Division of Cardiovascular Diseases, University of Pittsburgh, UPMC-Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Michael S Sharbaugh
- Department of Medicine, Division of Cardiovascular Diseases, University of Pittsburgh, UPMC-Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Andrew D Althouse
- Department of Medicine, Division of Cardiovascular Diseases, University of Pittsburgh, UPMC-Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Jeffrey Xu
- Department of Medicine, Division of Cardiovascular Diseases, University of Pittsburgh, UPMC-Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Wei Han
- Department of Medicine, Division of Cardiovascular Diseases, University of Pittsburgh, UPMC-Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Stephen Y Chan
- Department of Medicine, Division of Cardiovascular Diseases, University of Pittsburgh, UPMC-Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - William E Katz
- Department of Medicine, Division of Cardiovascular Diseases, University of Pittsburgh, UPMC-Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Frederick W Crock
- Department of Medicine, Division of Cardiovascular Diseases, University of Pittsburgh, UPMC-Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Matthew E Harinstein
- Department of Medicine, Division of Cardiovascular Diseases, University of Pittsburgh, UPMC-Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Dustin E Kliner
- Department of Medicine, Division of Cardiovascular Diseases, University of Pittsburgh, UPMC-Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Forozan Navid
- Department of Medicine, Division of Cardiovascular Diseases, University of Pittsburgh, UPMC-Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Joon S Lee
- Department of Medicine, Division of Cardiovascular Diseases, University of Pittsburgh, UPMC-Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Thomas G Gleason
- Department of Medicine, Division of Cardiovascular Diseases, University of Pittsburgh, UPMC-Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - John T Schindler
- Department of Medicine, Division of Cardiovascular Diseases, University of Pittsburgh, UPMC-Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - João L Cavalcante
- Department of Medicine, Division of Cardiovascular Diseases, University of Pittsburgh, UPMC-Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
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15
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Abdelkarim I, Althouse AD, Thoma FW, Lee JS, Schindler JT, Gleason TG, Cavalcante JL. The Importance of Invasive Hemodynamics for Pulmonary Hypertension Screening in TAVR Patients. J Am Coll Cardiol 2017; 70:510-511. [DOI: 10.1016/j.jacc.2017.04.061] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 04/04/2017] [Indexed: 10/19/2022]
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16
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Cavalcante J, Abdelkarim I, Sharbaugh M, Althouse A, Xu J, Han W, Katz W, Crock F, Harinstein M, Kliner D, Navid F, Lee J, Schindler J, Gleason T. PROGNOSTIC VALUE OF RIGHT VENTRICLE-PULMONARY ARTERY COUPLING IN TAVR PATIENTS: TIME TO INTEGRATE THE RIGHT SIDE UNIT. J Am Coll Cardiol 2017. [DOI: 10.1016/s0735-1097(17)35332-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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17
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Abdelkarim I, Xu J, Sharbaugh M, Althouse A, Katz W, Crock F, Harinstein M, Kliner D, Navid F, Lee J, Schindler J, Gleason T, Cavalcante JL. POOR AGREEMENT BETWEEN TRANSTHORACIC ECHOCARDIOGRAPHY AND RIGHT HEART CATHETERIZATION FOR ASSESSMENT OF PULMONARY HYPERTENSION SEVERITY: CLINICAL APPLICATIONS IN THE TAVR ERA. J Am Coll Cardiol 2017. [DOI: 10.1016/s0735-1097(17)35385-8] [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: 10/20/2022]
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Koschutnik M, Ionin VA, Boeckstaens S, Zakhama L, Hinojar R, Chiu DYY, Kovacs A, Kochmareva EA, Saliba E, Stanojevic D, Aalen J, Chen XH, Zito C, Demerouti E, Smarz K, Krljanac G, Christensen NL, Cavalcante JL, Pal M, Magne J, Giannakopoulos G, Liu D, Chien CY, Moustafa TAMER, Schwaiger M, Zotter-Tufaro C, Aschauer S, Duca F, Kammerlander A, Bonderman D, Mascherbauer J, Zaslavskaya EL, Soboleva AV, Listopad OV, Malikov KN, Baranova EI, Shlyakhto EV, Van Der Hoogstraete M, Coltel N, De Laet N, Beernaerts C, Desmet K, Gillis K, Droogmans S, Cosyns B, Antit S, Herbegue B, Slama I, Belaouer A, Chenik S, Boussabah E, Thameur M, Masmoudi M, Benyoussef S, Fernandez-Golfin C, Gonzalez-Gomez A, Casas E, Garcia Martin A, Pardo A, Del Val D, Ruiz S, Moya JL, Barrios V, Jimenez Nacher JJ, Zamorano JL, Kalra PA, Green D, Hughes J, Sinha S, Abidin N, Muraru D, Lakatos BK, Surkova E, Peluso D, Toser Z, Tokodi M, Merkely B, Badano LP, Volkova AL, Rusina VA, Kokorin VA, Gordeev IG, Baudet M, Chartrand Lefebvre C, Chen-Tournoux A, Hodzic A, Tournoux F, Apostolovic S, Jankovic-Tomasevic R, Djordjevic-Radojkovic D, Salinger-Martinovic S, Kostic T, Tahirovic E, Dungen HD, Andersen OS, Gude E, Andreassen A, Aalen OO, Larsen CK, Remme EW, Smiseth OA, Xu HG, Liu FC, Zha DG, Cui K, Zhang AD, Trio O, Soraci E, Cusma Piccione M, D'amico G, Ioppolo A, Alibani L, Falanga G, Todaro MC, Oreto L, Nucifora G, Vizzari G, Pizzino F, Di Bella G, Carerj S, Boutsikou M, Perreas K, Katselis CH, Samanidis G, Antoniou TH, Karatasakis G, Zaborska B, Jaxa-Chamiec T, Maciejewski P, Bartoszewicz Z, Budaj A, Trifunovic D, Asanin M, Savic L, Matovic D, Petrovic M, Zlatic N, Mrdovic I, Dahl JS, Carter-Storch R, Bakkestroem R, Soendergaard E, Videbaek L, Moeller JE, Rijal S, Abdelkarim I, Althouse AD, Sharbaugh MS, Fridman Y, Han W, Soman P, Forman DE, Schindler JT, Gleason TG, Lee JE, Schelbert EB, Dekany G, Mandzak A, Chaurasia AK, Gyovai J, Hegedus N, Piroth ZS, Szabo GY, Fontos G, Andreka P, Cosyns B, Popescu BA, Carstensen HG, Dahl J, Desai M, Kearney L, Marwick T, Sato K, Takeuchi M, Zito C, Mohty D, Lancellotti P, Habib G, Noble S, Frei A, Mueller H, Hu K, Liebner E, Weidemann F, Herrmann S, Ertl G, Voelker W, Gorski A, Leyh R, Stoerk S, Nordbeck P, Tsai WC, Moustafa TAMER, Aldydamony MOHAMD, Aldydamony MOHAMD. Poster Session 5The imaging examination and quality assessmentP1064The natural course of heart failure with preserved ejection fraction (HFpEF) - insights from an exploratory echocardiographic registryP1065Epicardial fat and effectiveness of catheter radiofrequency ablation in patients with atrial fibrillation and metabolic syndromeP1066Systematic disinfection of echocardiographic probe after each examination to reduce the persistence of pathogens as a potential source of nosocomial infectionsP1067Left atrial mechanical function assessed by two-dimensional echocardiography in hypertensive patientsP1068Real live applications of three-dimensional echocardiographic quantification of the left ventricular volumes and function using an automated adaptive analytics algorithmP10693D echocardiographic left ventricular dyssynchrony indices in end stage kidney disease: associations and outcomesP1070Relative contribution of right ventricular longitudinal shortening and radial displacement to global pump function in healthy volunteersP1071ECHO-parameters, associated with short-term mortality and long-term complications in patients with pulmonary embolism of high and intermediate riskP1072Increased epicardial fat is an independent marker of heart failure with preserved ejection fraction.P1073Influence of optimized beta-blocker therapy on diastolic dysfunction determined echocardiographically in heart failure patientsP1074Early diastolic mitral flow velocity/ annular velocity ratio is a sensitive marker of elevated filling pressure in left ventricular dyssynchronyP1075Left ventricular diastolic function in STEMI patients receiving early and late reperfusion by percutaneous coronary intervention P1076Could anatomical and functional features predict cerebrovascular events in patients with patent foramen ovale?P1077Efficacy of endarterectomy of the left anterior descending artery: evaluation by adenosine echocardiography?P1078Left ventricular diastolic dysfunction after acute myocardial infarction with preserved ejection fraction is related to lower exercise capacityP1079Potentially predictors of ventricular arrhythmia during six months follow up in STEMI patientsP1080Association between left atrial dilatation and invasive haemodynamics at rest and during exercise in asymptimatic aortic stenosisP1081Cardiac amyloidosis and aortic stenosis - the convergence of two aging processes and its association with outcomesP1082Prognostic impact of initial left ventricular dysfunction and mean gradient after transcatheter aortic valve implantationP1083Distribution and prognostic significance of left ventricular global longitudinal strain in asymptomatic significant aortic stenosis: an individual participant data meta-analysisP1084Discrepancies between echocardiographic and invasive assessment of aortic stenosis in multimorbid elderly patientsP1085Echocardiographic determinants and outcome of patients with low-gradient moderate and severe aortic valve stenosis: implications for aortic valve replacementP1086Atrial deformation correlated with functional capacity in mitral stenosisP1087Net atrioventricular compliance can predict reduction of pulmonary artery pressure after percutaneous mitral balloon commissurotomy. Eur Heart J Cardiovasc Imaging 2016. [DOI: 10.1093/ehjci/jew262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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