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Saad AF, Kennedy JLW, Sharma G. Reply: Ischemic heart disease in pregnancy: a practical approach to management. Am J Obstet Gynecol MFM 2024; 6:101353. [PMID: 38492639 DOI: 10.1016/j.ajogmf.2024.101353] [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] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/08/2024] [Indexed: 03/18/2024]
Affiliation(s)
- Antonio F Saad
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, VA.
| | - Jamie L W Kennedy
- Department of Cardiology, Inova Schar Heart and Vascular Institute, Falls Church, VA
| | - Garima Sharma
- Department of Cardiology, Inova Schar Heart and Vascular Institute, Falls Church, VA
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Williams S, Kalakoutas A, Olusanya S, Schrage B, Tavazzi G, Carnicelli AP, Montero S, Vandenbriele C, Luk A, Lim HS, Bhagra S, Ott SC, Farrero M, Samsky MD, Kennedy JLW, Sen S, Agrawal R, Rampersad P, Coniglio A, Pappalardo F, Barnett C, Proudfoot AG. The management of heart failure cardiogenic shock: an international RAND appropriateness panel. Crit Care 2024; 28:105. [PMID: 38566212 PMCID: PMC10988801 DOI: 10.1186/s13054-024-04884-5] [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] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/20/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Observational data suggest that the subset of patients with heart failure related CS (HF-CS) now predominate critical care admissions for CS. There are no dedicated HF-CS randomised control trials completed to date which reliably inform clinical practice or clinical guidelines. We sought to identify aspects of HF-CS care where both consensus and uncertainty may exist to guide clinical practice and future clinical trial design, with a specific focus on HF-CS due to acute decompensated chronic HF. METHODS A 16-person multi-disciplinary panel comprising of international experts was assembled. A modified RAND/University of California, Los Angeles, appropriateness methodology was used. A survey comprising of 34 statements was completed. Participants anonymously rated the appropriateness of each statement on a scale of 1 to 9 (1-3 as inappropriate, 4-6 as uncertain and as 7-9 appropriate). RESULTS Of the 34 statements, 20 were rated as appropriate and 14 were rated as inappropriate. Uncertainty existed across all three domains: the initial assessment and management of HF-CS; escalation to temporary Mechanical Circulatory Support (tMCS); and weaning from tMCS in HF-CS. Significant disagreement between experts (deemed present when the disagreement index exceeded 1) was only identified when deliberating the utility of thoracic ultrasound in the immediate management of HF-CS. CONCLUSION This study has highlighted several areas of practice where large-scale prospective registries and clinical trials in the HF-CS population are urgently needed to reliably inform clinical practice and the synthesis of future societal HF-CS guidelines.
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Affiliation(s)
- Stefan Williams
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Antonis Kalakoutas
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Segun Olusanya
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Benedict Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Pavia, Italy
| | - Anthony P Carnicelli
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Santiago Montero
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Adriana Luk
- Division of Cardiology, Department of Medicine, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Hoong Sern Lim
- Department of Cardiology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Sai Bhagra
- Advanced Heart Failure and Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Sascha C Ott
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany
| | | | - Marc D Samsky
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jamie L W Kennedy
- Heart Failure / Transplant Program, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Richa Agrawal
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | | | - Amanda Coniglio
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Federico Pappalardo
- Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Christopher Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Alastair G Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK.
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
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Mehta A, Vavilin I, Nguyen AH, Batchelor WB, Blumer V, Cilia L, Dewanjee A, Desai M, Desai SS, Flanagan MC, Isseh IN, Kennedy JLW, Klein KM, Moukhachen H, Psotka MA, Raja A, Rosner CM, Shah P, Tang DG, Truesdell AG, Tehrani BN, Sinha SS. Contemporary approach to cardiogenic shock care: a state-of-the-art review. Front Cardiovasc Med 2024; 11:1354158. [PMID: 38545346 PMCID: PMC10965643 DOI: 10.3389/fcvm.2024.1354158] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/13/2024] [Indexed: 05/02/2024] Open
Abstract
Cardiogenic shock (CS) is a time-sensitive and hemodynamically complex syndrome with a broad spectrum of etiologies and clinical presentations. Despite contemporary therapies, CS continues to maintain high morbidity and mortality ranging from 35 to 50%. More recently, burgeoning observational research in this field aimed at enhancing the early recognition and characterization of the shock state through standardized team-based protocols, comprehensive hemodynamic profiling, and tailored and selective utilization of temporary mechanical circulatory support devices has been associated with improved outcomes. In this narrative review, we discuss the pathophysiology of CS, novel phenotypes, evolving definitions and staging systems, currently available pharmacologic and device-based therapies, standardized, team-based management protocols, and regionalized systems-of-care aimed at improving shock outcomes. We also explore opportunities for fertile investigation through randomized and non-randomized studies to address the prevailing knowledge gaps that will be critical to improving long-term outcomes.
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Affiliation(s)
- Aditya Mehta
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Ilan Vavilin
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Andrew H. Nguyen
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Wayne B. Batchelor
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Vanessa Blumer
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Lindsey Cilia
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
- Department of Cardiovascular Disease, Virginia Heart, Falls Church, VA, United States
| | - Aditya Dewanjee
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Mehul Desai
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Shashank S. Desai
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Michael C. Flanagan
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Iyad N. Isseh
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Jamie L. W. Kennedy
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Katherine M. Klein
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Hala Moukhachen
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Mitchell A. Psotka
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Anika Raja
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Carolyn M. Rosner
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Palak Shah
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Daniel G. Tang
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Alexander G. Truesdell
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
- Department of Cardiovascular Disease, Virginia Heart, Falls Church, VA, United States
| | - Behnam N. Tehrani
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Shashank S. Sinha
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
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Nguyen AH, Murrin E, Moyo A, Sharma G, Sullivan SA, Maxwell GL, Kennedy JLW, Saad AF. Ischemic heart disease in pregnancy: a practical approach to management. Am J Obstet Gynecol MFM 2024; 6:101295. [PMID: 38278176 DOI: 10.1016/j.ajogmf.2024.101295] [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: 12/08/2023] [Accepted: 01/03/2024] [Indexed: 01/28/2024]
Abstract
Ischemic heart disease is a crucial issue during pregnancy. The term is composed of both preexisting conditions and acute coronary syndrome in pregnancy, including pregnancy-associated myocardial infarction, which can have a significant effect on maternal and fetal outcomes. This review provides a complete guide to managing ischemic heart disease in pregnant women, emphasizing the importance of multidisciplinary care and individualized treatment strategies. Cardiovascular disease, particularly ischemic heart disease, is now the leading cause of maternal mortality worldwide. Pregnancy introduces unique physiological changes that increase the risk of acute myocardial infarction, with pregnancy-associated myocardial infarction cases often associated with factors, such as advanced maternal age, chronic hypertension, and preexisting cardiovascular conditions. This review distinguishes between preexisting ischemic heart disease and pregnancy-associated myocardial infarction. It will emphasize the various etiologies of pregnancy-associated myocardial infarction, including coronary atherosclerosis and plaque rupture presenting as ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, and other nonatherosclerotic causes, including spontaneous coronary artery dissection, vasospasm, and embolism. Our study discusses the practical management of ischemic heart disease in pregnancy, with a focus on preconception counseling, risk assessment, and tailored antenatal planning for women with preexisting ischemic heart disease. Moreover, this document focuses on the challenges of diagnosing cardiovascular disease, especially when presented with nonclassical risk factors and presentation. It provides insight into the appropriate diagnostic testing methods, such as electrocardiogram, cardiac biomarkers, and echocardiography. In addition, the review covers various treatment strategies, from medical management to more invasive procedures, including coronary angiography, percutaneous coronary intervention, and coronary artery bypass graft. Special attention is given to medication safety during pregnancy, including anticoagulation, beta-blockers, and antiplatelet agents. The complexities of delivery planning in women with ischemic heart disease are discussed, advocating for a multidisciplinary team-based approach and careful consideration of the timing and mode of delivery. Furthermore, the roles of breastfeeding and postpartum care are explored, emphasizing the long-term benefits and the suitability of various medications during lactation. Lastly, this review provides crucial insights into the management of ischemic heart disease in pregnancy, stressing the need for heightened awareness, prompt diagnosis, and tailored management to optimize maternal and fetal health outcomes.
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Affiliation(s)
- Andrew H Nguyen
- Department of Internal Medicine, Inova Fairfax Hospital, Falls Church, Virginia (Drs Nguyen and Moyo)
| | - Ellen Murrin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia (Drs Murrin, Sullivan, and Saad)
| | - Axucillia Moyo
- Department of Internal Medicine, Inova Fairfax Hospital, Falls Church, Virginia (Drs Nguyen and Moyo)
| | - Garima Sharma
- Department of Cardiology, Inova Schar Heart and Vascular Institute, Falls Church, Virginia (Drs Sharma and Kennedy)
| | - Scott A Sullivan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia (Drs Murrin, Sullivan, and Saad)
| | - George L Maxwell
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia (Dr Maxwell)
| | - Jamie L W Kennedy
- Department of Cardiology, Inova Schar Heart and Vascular Institute, Falls Church, Virginia (Drs Sharma and Kennedy)
| | - Antonio F Saad
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia (Drs Murrin, Sullivan, and Saad).
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Nguyen AH, Hurwitz M, Sullivan SA, Saad A, Kennedy JLW, Sharma G. Update on sex specific risk factors in cardiovascular disease. Front Cardiovasc Med 2024; 11:1352675. [PMID: 38380176 PMCID: PMC10876862 DOI: 10.3389/fcvm.2024.1352675] [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] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 01/17/2024] [Indexed: 02/22/2024] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of death worldwide and accounts for roughly 1 in 5 deaths in the United States. Women in particular face significant disparities in their cardiovascular care when compared to men, both in the diagnosis and treatment of CVD. Sex differences exist in the prevalence and effect of cardiovascular risk factors. For example, women with history of traditional cardiovascular risk factors including hypertension, tobacco use, and diabetes carry a higher risk of major cardiovascular events and mortality when compared to men. These discrepancies in terms of the relative risk of CVD when traditional risk factors are present appear to explain some, but not all, of the observed differences among men and women. Sex-specific cardiovascular disease research-from identification, risk stratification, and treatment-has received increasing recognition in recent years, highlighting the current underestimated association between CVD and a woman's obstetric and reproductive history. In this comprehensive review, sex-specific risk factors unique to women including adverse pregnancy outcomes (APO), such as hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus, preterm delivery, and newborn size for gestational age, as well as premature menarche, menopause and vasomotor symptoms, polycystic ovarian syndrome (PCOS), and infertility will be discussed in full detail and their association with CVD risk. Additional entities including spontaneous coronary artery dissection (SCAD), coronary microvascular disease (CMD), systemic autoimmune disorders, and mental and behavioral health will also be discussed in terms of their prevalence among women and their association with CVD. In this comprehensive review, we will also provide clinicians with a guide to address current knowledge gaps including implementation of a sex-specific patient questionnaire to allow for appropriate risk assessment, stratification, and prevention of CVD in women.
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Affiliation(s)
- Andrew H. Nguyen
- Department of Medicine, Inova Fairfax Hospital, Falls Church, VA, United States
| | - Madelyn Hurwitz
- School of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Scott A. Sullivan
- Department of Maternal Fetal Medicine, Inova Fairfax Hospital, Falls Church, VA, United States
| | - Antonio Saad
- Department of Maternal Fetal Medicine, Inova Fairfax Hospital, Falls Church, VA, United States
| | - Jamie L. W. Kennedy
- Department of Cardiology, Inova Schar Heart and Vascular Institute, Falls Church, VA, United States
| | - Garima Sharma
- Department of Cardiology, Inova Schar Heart and Vascular Institute, Falls Church, VA, United States
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Cantres‐Fonseca O, Kennedy JLW. Where's the Easy Button? The Many Barriers to Care for Patients With Pulmonary Arterial Hypertension. J Am Heart Assoc 2022; 11:e027967. [DOI: 10.1161/jaha.122.027967] [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: 11/13/2022]
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Earasi K, Mihaltses J, Kennedy JLW, Rao S, Holsten L, Mazimba S, Doyle A, Mihalek AD. Intensive ultrafiltration strategy restores kidney transplant candidacy for patients with echocardiographic evidence of pulmonary hypertension. Clin Transplant 2022; 36:e14799. [PMID: 36029145 PMCID: PMC10078392 DOI: 10.1111/ctr.14799] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 05/12/2022] [Accepted: 08/10/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Pulmonary hypertension (PH) is prevalent in those with end-stage kidney disease (ESKD) and poses a barrier to kidney transplant due to its association with poor outcomes. Studies examining these adverse outcomes are limited and often utilize echocardiographic measurements of pulmonary artery systolic pressure (PASP) instead of the gold standard right heart catheterization (RHC). We hypothesized that in ESKD patients deemed ineligible for kidney transplant because of an echocardiographic diagnosis of PH the predominant cause of PH is hypervolemia and is potentially reversible. METHODS We conducted a prospective study of 16 patients with ESKD who were denied transplant candidacy. Prior echocardiograms and RHCs were reviewed for confirmation of PH. Patients were admitted for daily sessions of ultrafiltration for volume removal and repeat RHCs were performed following intervention. RHC parameters and body weight were compared before and after intervention. Statistical analysis was performed using PRISM GraphPad software. A p-value <.05 was considered statistically significant. RESULTS Following intervention, the mean pulmonary artery pressure (mPAP) and pulmonary arterial wedge pressure decreased from 45.0 ± 3.06 to 29.1 ± 7.77 mmHg (p < .0001) and 22.2 ± 5.06 to 13.1 ± 7.25 mmHg (p = .003), respectively. The pulmonary vascular resistance decreased from 4.73 ± 1.99 to 4.28 ± 2.07 WU (p = .30). Eleven patients from the initial cohort underwent successful kidney transplantation post-intervention with 100% survival at 1-year. CONCLUSIONS In ESKD patients, diagnoses of PH made by echocardiography may be largely due to hypervolemia and may be optimized using an intensive ultrafiltration strategy to restore transplant candidacy.
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Affiliation(s)
- Kranthikiran Earasi
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - John Mihaltses
- Eastern Nephrology Associates, Wilmington, North Carolina, USA
| | | | - Swati Rao
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA.,Division of Nephrology, University of Virginia, Charlottesville, Virginia, USA
| | - Laura Holsten
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA.,Division of Nephrology, University of Virginia, Charlottesville, Virginia, USA
| | - Sula Mazimba
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA.,Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Alden Doyle
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA.,Division of Nephrology, University of Virginia, Charlottesville, Virginia, USA
| | - Andrew D Mihalek
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA.,Division of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, Virginia, USA
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Kennedy JLW, Mihalek AD. Update in approaches to pulmonary hypertension because of left heart disease. Curr Opin Pulm Med 2022; 28:337-342. [PMID: 35838362 DOI: 10.1097/mcp.0000000000000891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Left heart disease is the most common cause of pulmonary hypertension. This review summarizes the current care of patients with pulmonary hypertension caused by left heart disease (PH-LHD) and discusses recent and active clinical trials in this patient population. RECENT FINDINGS The primary focus of interventions aimed at treating PH-LHD address the treatment of left heart disease. Significant advancements in the treatment of heart failure with preserved ejection fraction (HFpEF), a frequent cause of PH-LHD, are supported in the current literature. Patients with residual pulmonary hypertension despite optimal treatment of left heart disease have poor outcomes. Yet, interventions targeting the pulmonary vasculature in PH-LHD patients have not demonstrated significant benefits in studies to date. Current work focuses on differentiating isolated postcapillary pulmonary hypertension (IpcPH) from combined precapillary and postcapillary pulmonary hypertension (CpcPH) in a clinically consistent manner. It is hopeful that thorough phenotyping of PH-LHD patients will translate into effective treatment strategies addressing pulmonary vascular disease. SUMMARY Referral to centers of excellence, considerations for enrollment in clinical trials, and evaluation for transplant is recommended for patients with residual pulmonary hypertension despite optimal treatment of left heart disease, particularly those with CpcPH.
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Affiliation(s)
| | - Andrew D Mihalek
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
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Kaso ER, Pan JA, Salerno M, Kadl A, Aldridge C, Haskal ZJ, Kennedy JLW, Mazimba S, Mihalek AD, Teman NR, Giri J, Aronow HD, Sharma AM. Venoarterial Extracorporeal Membrane Oxygenation for Acute Massive Pulmonary Embolism: a Meta-Analysis and Call to Action. J Cardiovasc Transl Res 2021; 15:258-267. [PMID: 34282541 PMCID: PMC8288068 DOI: 10.1007/s12265-021-10158-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/09/2021] [Indexed: 01/08/2023]
Abstract
Venoarterial extracorporeal membrane oxygenation (ECMO) has been used to treat acute massive pulmonary embolism (PE) patients. However, the incremental benefit of ECMO to standard therapy remains unclear. Our meta-analysis objective is to compare in-hospital mortality in patients treated for acute massive PE with and without ECMO. The National Library of Medicine MEDLINE (USA), Web of Science, and PubMed databases from inception through October 2020 were searched. Screening identified 1002 published articles. Eleven eligible studies were identified, and 791 patients with acute massive PE were included, of whom 270 received ECMO and 521 did not. In-hospital mortality was not significantly different between patients treated with vs. without ECMO (OR = 1.24 [95% CI, 0.63–2.44], p = 0.54). However, these findings were limited by significant study heterogeneity. Additional research will be needed to clarify the role of ECMO in massive PE treatment.
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Affiliation(s)
- Elona Rrapo Kaso
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA
| | - Jonathan A Pan
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA
| | - Michael Salerno
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA.,Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA.,Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, USA
| | - Alexandra Kadl
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, VA, USA
| | - Chad Aldridge
- Department of Therapy Services, University of Virginia, Charlottesville, VA, USA
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - Jamie L W Kennedy
- Division of Cardiology, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Sula Mazimba
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA
| | - Andrew D Mihalek
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, VA, USA
| | - Nicholas R Teman
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA, USA
| | - Jay Giri
- Division of Cardiology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Herbert D Aronow
- Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Aditya M Sharma
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA.
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Mazimba S, Ginn G, Mwansa H, Laja O, Jeukeng C, Elumogo C, Patterson B, Kennedy JLW, Mehta N, Hossack JA, Parker AM, Mihalek A, Tallaj J, Sodhi N, Kwon Y, Pamboukian SV, Adamson PB, Bilchick KC. Pulmonary Artery Proportional Pulse Pressure (PAPP) Index Identifies Patients With Improved Survival From the CardioMEMS Implantable Pulmonary Artery Pressure Monitor. Heart Lung Circ 2021; 30:1389-1396. [PMID: 33863665 DOI: 10.1016/j.hlc.2021.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 07/17/2020] [Revised: 12/29/2020] [Accepted: 03/07/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND Pulmonary artery proportional pulse pressure (PAPP) was recently shown to have prognostic value in heart failure (HF) with reduced ejection fraction (HFrEF) and pulmonary hypertension. We tested the hypothesis that PAPP would be predictive of adverse outcomes in patients with implantable pulmonary artery pressure monitor (CardioMEMS™ HF System, St. Jude Medical [now Abbott], Atlanta, GA, USA). METHODS Survival analysis with Cox proportional hazards regression was used to evaluate all-cause deaths and HF hospitalisation (HFH) in CHAMPION trial1 patients who received treatment with the CardioMEMS device based on the PAPP. RESULTS Among 550 randomised patients, 274 had PAPP ≤ the median value of 0.583 while 276 had PAPP>0.583. Patients with PAPP≤0.583 (versus PAPP>0.583) had an increased risk of HFH (HR 1.40, 95% CI 1.16-1.68, p=0.0004) and experienced a significant 46% reduction in annualised risk of death with CardioMEMS treatment (HR 0.54, 95% CI 0.31-0.92) during 2-3 years of follow-up. This survival benefit was attributable to the treatment benefit in patients with HFrEF and PAPP≤0.583 (HR 0.50, 95% CI 0.28-0.90, p<0.05). Patients with PAPP>0.583 or HF with preserved EF (HFpEF) had no significant survival benefit with treatment (p>0.05). CONCLUSION Lower PAPP in HFrEF patients with CardioMEMS constitutes a higher mortality risk status. More studies are needed to understand clinical applications of PAPP in implantable pulmonary artery pressure monitors.
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Affiliation(s)
- Sula Mazimba
- University of Virginia Health System, Charlottesville, VA, USA.
| | - Greg Ginn
- Global Research and Development, St. Jude Medical, Sylmar, CA, USA
| | - Hunter Mwansa
- Case Western Reserve University/St Vincent Charity Medical Center, Cleveland, OH, USA
| | - Olusola Laja
- University of Virginia Health System, Charlottesville, VA, USA
| | | | - Comfort Elumogo
- University of Virginia Health System, Charlottesville, VA, USA
| | | | | | - Nishaki Mehta
- University of Virginia Health System, Charlottesville, VA, USA
| | - John A Hossack
- Department of Biomedical, Electrical and Computer Engineering, University of Virginia Health System, Charlottesville, VA, USA
| | - Alex M Parker
- University of Virginia Health System, Charlottesville, VA, USA
| | - Andrew Mihalek
- University of Virginia Health System, Charlottesville, VA, USA
| | - Jose Tallaj
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nishtha Sodhi
- University of Virginia Health System, Charlottesville, VA, USA
| | - Younghoon Kwon
- University of Washington Medical Center, Seattle, WA, USA
| | | | - Philip B Adamson
- Global Research and Development, St. Jude Medical, Sylmar, CA, USA
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11
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Abstract
BACKGROUND As the population becomes increasingly obese, so does the pool of potential organ donors. We sought to investigate the impact of donors with body mass index ≥40 (severe obesity) on heart transplant outcomes. METHODS Single-organ first-time adult heart transplants from 2003 to 2017 were evaluated from the United Network for Organ Sharing database and stratified by donor severe obesity status (body mass index ≥40). Demographics were compared, and univariate and risk-adjusted analyses evaluated the relationship between severe obesity and short-term outcomes and long-term mortality. Further analysis evaluated the prevalence of severe obesity within the pool of organ donation candidates. RESULTS A total of 26 532 transplants were evaluated, of which 939 (3.5%) had donors with body mass index ≥40, with prevalence increasing over time (2.2% in 2003, 5.3% in 2017). Severely obese donors more likely had diabetes mellitus (10.4% versus 3.1%, P<0.01) and hypertension (33.3% versus 14.8%, P<0.01), and 67.4% were size mismatched (donor weight >130% of recipient). Short-term outcomes were similar, including 1-year survival (10.6% versus 10.7%), with no significant difference in unadjusted and risk-adjusted long-term survival (log-rank P=0.67, hazard ratio, 0.928, P=0.30). Organ donation candidates also exhibited an increase in severe obesity over time, from 3.5% to 6.8%, with a lower proportion of hearts from severely obese donors being transplanted (19.5% versus 31.6%, P<0.01). CONCLUSIONS Donor severe obesity was not associated with adverse post-transplant outcomes. Increased evaluation of hearts from obese donors, even those with body mass index ≥40, has the potential to expand the critically low donor pool.
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Affiliation(s)
- Elizabeth D Krebs
- Department of Surgery, University of Virginia Health System, Charlottesville, VA (E.D.K., J.P.B., J.H.M., M.R.T., G.A., L.T.Y.)
| | - Jared P Beller
- Department of Surgery, University of Virginia Health System, Charlottesville, VA (E.D.K., J.P.B., J.H.M., M.R.T., G.A., L.T.Y.)
| | - J Hunter Mehaffey
- Department of Surgery, University of Virginia Health System, Charlottesville, VA (E.D.K., J.P.B., J.H.M., M.R.T., G.A., L.T.Y.)
| | - Nicholas R Teman
- Department of Surgery, University of Virginia Health System, Charlottesville, VA (E.D.K., J.P.B., J.H.M., M.R.T., G.A., L.T.Y.)
| | - Jamie L W Kennedy
- Department of Cardiology, University of California San Francisco Health System, San Francisco, CA (J.L.W.K.)
| | - Gorav Ailawadi
- Department of Surgery, University of Virginia Health System, Charlottesville, VA (E.D.K., J.P.B., J.H.M., M.R.T., G.A., L.T.Y.)
| | - Leora T Yarboro
- Department of Surgery, University of Virginia Health System, Charlottesville, VA (E.D.K., J.P.B., J.H.M., M.R.T., G.A., L.T.Y.)
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12
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Myc LA, Solanki JN, Barros AJ, Nuradin N, Nevulis MG, Earasi K, Richardson ED, Tsutsui SC, Enfield KB, Teman NR, Haskal ZJ, Mazimba S, Kennedy JLW, Mihalek AD, Sharma AM, Kadl A. Adoption of a dedicated multidisciplinary team is associated with improved survival in acute pulmonary embolism. Respir Res 2020; 21:159. [PMID: 32571318 PMCID: PMC7310489 DOI: 10.1186/s12931-020-01422-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [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: 01/09/2020] [Accepted: 06/14/2020] [Indexed: 12/31/2022] Open
Abstract
Background Acute pulmonary embolism remains a significant cause of mortality and morbidity worldwide. Benefit of recently developed multidisciplinary PE response teams (PERT) with higher utilization of advanced therapies has not been established. Methods To evaluate patient-centered outcomes and cost-effectiveness of a multidisciplinary PERT we performed a retrospective analysis of 554 patients with acute PE at the university of Virginia between July 2014 and June 2015 (pre-PERT era) and between April 2017 through October 2018 (PERT era). Six-month survival, hospital length-of-stay (LOS), type of PE therapy, and in-hospital bleeding were assessed upon collected data. Results 317 consecutive patients were treated for acute PE during an 18-month period following institution of a multidisciplinary PE program; for 120 patients PERT was activated (PA), the remaining 197 patients with acute PE were considered as a separate, contemporary group (NPA). The historical, comparator cohort (PP) was composed of 237 patients. These 3 groups were similar in terms of baseline demographics, comorbidities and risk, as assessed by the Pulmonary Embolism Severity Index (PESI). Patients in the historical cohort demonstrated worsened survival when compared with patients treated during the PERT era. During the PERT era no statistically significant difference in survival was observed in the PA group when compared to the NPA group despite significantly higher severity of illness among PA patients. Hospital LOS was not different in the PA group when compared to either the NPA or PP group. Hospital costs did not differ among the 3 cohorts. 30-day re-admission rates were significantly lower during the PERT era. Rates of advanced therapies were significantly higher during the PERT era (9.1% vs. 2%) and were concentrated in the PA group (21.7% vs. 1.5%) without any significant rise in in-hospital bleeding complications. Conclusions At our institution, all-cause mortality in patients with acute PE has significantly and durably decreased with the adoption of a PERT program without incurring additional hospital costs or protracting hospital LOS. Our data suggest that the adoption of a multidisciplinary approach at some institutions may provide benefit to select patients with acute PE.
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Affiliation(s)
- Lukasz A Myc
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, USA
| | - Jigna N Solanki
- Department of Medicine, University of Virginia, Charlottesville, USA
| | - Andrew J Barros
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, USA
| | - Nebil Nuradin
- Department of Medicine, University of Virginia, Charlottesville, USA
| | - Matthew G Nevulis
- Department of Medicine, University of Virginia, Charlottesville, USA
| | | | | | - Shawn C Tsutsui
- Department of Medicine, University of Virginia, Charlottesville, USA
| | - Kyle B Enfield
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, USA
| | - Nicholas R Teman
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, USA
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging, Division of Vascular and Interventional Radiology, University of Virginia, Charlottesville, USA
| | - Sula Mazimba
- Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, USA
| | - Jamie L W Kennedy
- Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, USA
| | - Andrew D Mihalek
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, USA
| | - Aditya M Sharma
- Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, USA
| | - Alexandra Kadl
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, USA. .,Department of Pharmacology, University of Virginia, Charlottesville, VA, USA.
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13
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Fallon JM, Parker AM, Dunn SP, Kennedy JLW. A giant mystery in giant cell myocarditis: navigating diagnosis, immunosuppression, and mechanical circulatory support. ESC Heart Fail 2019; 7:315-319. [PMID: 31872976 PMCID: PMC7083393 DOI: 10.1002/ehf2.12564] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 07/16/2019] [Revised: 10/02/2019] [Accepted: 11/04/2019] [Indexed: 12/04/2022] Open
Abstract
Giant cell myocarditis is a rare but often devastating diagnosis. Advances in cardiac imaging and mechanical circulatory support have led to earlier and more frequent diagnoses and successful management. This disease state has wide variation in acuity of presentation, and consequently, optimal treatment ranging from intensity and type of immunosuppression to mechanical circulatory support is not well defined. The following case describes the management of a patient with an unusual presentation of giant cell myocarditis over a 10 year course of advanced heart failure therapies and immunomodulatory support. This case highlights emerging concepts in the management of giant cell myocarditis including sub‐acute presentations, challenges in diagnosis, and treatment modalities in the modern era.
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Affiliation(s)
| | - Alex M Parker
- Division of Cardiology, University of Florida Health, Gainesville, FL, USA
| | - Steven P Dunn
- Department of Pharmacy, University of Virginia Health System, Charlottesville, VA, USA
| | - Jamie L W Kennedy
- Division of Cardiology, University of California San Francisco, San Francisco, CA, USA
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14
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Peters AE, Smith LA, Ababio P, Breathett K, McMurry TL, Kennedy JLW, Abuannadi M, Bergin J, Mazimba S. Comparative Analysis of Established Risk Scores and Novel Hemodynamic Metrics in Predicting Right Ventricular Failure in Left Ventricular Assist Device Patients. J Card Fail 2019; 25:620-628. [PMID: 30790625 PMCID: PMC6945118 DOI: 10.1016/j.cardfail.2019.02.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 04/13/2018] [Revised: 01/15/2019] [Accepted: 02/12/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND Right ventricular failure (RVF) portends poor outcomes after left ventricular assist device (LVAD) implantation. Although numerous RVF predictive models have been developed, there are few independent comparative analyses of these risk models. METHODS AND RESULTS RVF was defined as use of inotropes for >14 days, inhaled pulmonary vasodilators for >48 hours or unplanned right ventricular mechanical support postoperatively during the index hospitalization. Risk models were evaluated for the primary outcome of RVF by means of logistic regression and receiver operating characteristic curves. Among 93 LVAD patients with complete data from 2011 to 2016, the Michigan RVF score (C = 0.74 [95% CI 0.61-0.87]; P = .0004) was the only risk model to demonstrate significant discrimination for RVF, compared with newer risk scores (Utah, Pitt, EuroMACS). Among individual hemodynamic/echocardiographic metrics, preoperative right ventricular dysfunction (C = 0.72 [95% CI 0.58-0.85]; P = .0022) also demonstrated significant discrimination of RVF. The Michigan RVF score was also the best predictor of in-hospital mortality (C = 0.67 [95% CI 0.52-0.83]; P = .0319) and 3-year survival (Kaplan-Meier log-rank 0.0135). CONCLUSIONS In external validation analysis, the more established Michigan RVF score-which emphasizes preoperative hemodynamic instability and target end-organ dysfunction-performed best, albeit modestly, in predicting RVF and demonstrated association with in-hospital and long-term mortality.
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Affiliation(s)
- Anthony E Peters
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - LaVone A Smith
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Priscilla Ababio
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson, Arizona
| | - Timothy L McMurry
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Jamie L W Kennedy
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Mohammad Abuannadi
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - James Bergin
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia.
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15
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Mysore MM, Bilchick KC, Ababio P, Ruth BK, Harding WC, Breathett K, Chadwell K, Patterson B, Mwansa H, Jeukeng CM, Kwon Y, Kennedy JLW, Mihalek AD, Mazimba S. Right atrial to left atrial volume index ratio is associated with increased mortality in patients with pulmonary hypertension. Echocardiography 2018; 35:1729-1735. [PMID: 30315607 DOI: 10.1111/echo.14149] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 08/19/2018] [Accepted: 09/09/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is characterized by increased pulmonary vascular resistance leading to right heart failure. Elevated right atrial (RA) pressure reflects right ventricular (RV) pressure overload and is an established risk factor for mortality in PH. We hypothesized that PH patients with an increased ratio of RA to LA volume index (RAVI/LAVI), would have increased mortality. METHODS We evaluated the association of RAVI/LAVI with mortality in 124 patients seen at a single academic center's PH clinic after adjusting for the REVEAL risk score, an established risk score in PH. LA and RA volume indices were measured in the four-and two-chamber views by two independent researchers. Multivariable logistic regression was used to model the independent association of RAVI/LAVI with survival. RESULTS Among 124 patients (mean age 62 ± 12.7 years, 68.6% female), each unit increase in RAVI/LAVI was associated with a nearly twofold increase in mortality (OR: 1.91, 95% CI: 1.20-3.04). In a multivariable logistic regression, each unit increase in RAVI/LAVI was associated with a nearly twofold increase in mortality (OR: 1.73, 95% CI: 1.003-2.998). Furthermore, RAVI/LAVI in the highest quartile (>1.42) was significantly associated with elevated right atrial pressure (RAP) to pulmonary artery wedge pressure ratio (RAP/PAWP) (0.76 ± 0.41, P = 0.02) compared with the lowest quartile (<0.77), suggesting an interaction between invasive hemodynamic data, atrial structural changes, and mortality in PH. CONCLUSIONS Increased RAVI/LAVI in PH is associated with decreased survival and accounts for atrial structural remodeling related to invasive hemodynamics. These findings support further study of this index in predicting outcomes in PH.
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Affiliation(s)
- Manu M Mysore
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Kenneth C Bilchick
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Priscilla Ababio
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Benjamin K Ruth
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - William C Harding
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson, Arizona
| | - Kimberley Chadwell
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Brandy Patterson
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Hunter Mwansa
- St Vincent Charity Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Christiana M Jeukeng
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Younghoon Kwon
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Jamie L W Kennedy
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Andrew D Mihalek
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
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16
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Schubert SA, Mehaffey JH, Booth A, Yarboro LT, Kern JA, Kennedy JLW, Ailawadi G, Mazimba S. Pulmonary-Systemic Pressure Ratio Correlates with Morbidity in Cardiac Valve Surgery. J Cardiothorac Vasc Anesth 2018; 33:677-682. [PMID: 30243869 DOI: 10.1053/j.jvca.2018.08.190] [Citation(s) in RCA: 5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Pulmonary hypertension portends worse outcomes in cardiac valve surgery; however, isolated pulmonary artery pressures may not reflect patients' global cardiac function accurately. To better account for the interventricular relationship, the authors hypothesized that patients with greater pulmonary-systemic ratios (mean pulmonary arterial pressure)/(mean systemic arterial pressure) would correlate with worse outcomes after valve surgery. DESIGN Retrospective cohort study. SETTING Single academic hospital. PARTICIPANTS The study comprised 314 patients undergoing valve surgery with or without coronary artery bypass grafting (2004-2016) with Society of Thoracic Surgeons predicted risk scores and preoperative right heart catheterization. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The pulmonary-systemic ratio was calculated as follows: mean pulmonary arterial pressure/mean systemic arterial pressure. Patients were stratified by pulmonary-systemic ratio quartile. Logistic regression was used to assess the risk-adjusted association between pulmonary-systemic ratio or mean pulmonary arterial pressure. Median pulmonary-systemic ratio was 0.33 (Q1-Q3: 0.23-0.65); median pulmonary arterial pressure was 29 (21-30) mmHg. Patients with the highest pulmonary-systemic ratio had the highest rates of morbidity and mortality (p < 0.0001). A high pulmonary-systemic ratio was associated with longer duration in the intensive care unit (p < 0.0001) and hospital (p < 0.0001). After risk-adjustment, pulmonary-systemic ratio and pulmonary arterial pressure were independently associated with morbidity and mortality, but the pulmonary-systemic ratio (odds ratio 23.88, p = 0.008, Wald 7.1) was more strongly associated than the pulmonary arterial pressure (odds ratio 1.035, p = 0.011, Wald 6.5). CONCLUSIONS The pulmonary-systemic ratio is more strongly associated with risk-adjusted morbidity and mortality in valve surgery than pulmonary arterial pressure. By integrating ventricular interactions, this metric may better characterize the risk of valve surgery.
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Affiliation(s)
- Sarah A Schubert
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA.
| | - J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA
| | - Alexander Booth
- University of Virginia School of Medicine, Charlottesville, VA
| | - Leora T Yarboro
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA
| | - John A Kern
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA
| | - Jamie L W Kennedy
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia, Charlottesville, VA
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA
| | - Sula Mazimba
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia, Charlottesville, VA
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17
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Saji M, Katz MR, Ailawadi G, Welch TS, Fowler DE, Kennedy JLW, Bergin JD, Kuntjoro I, Dent JM, Ragosta M, Lim DS. 6-Minute walk test predicts prolonged hospitalization in patients undergoing transcatheter mitral valve repair by MitraClip. Catheter Cardiovasc Interv 2018; 92:566-573. [PMID: 29656614 DOI: 10.1002/ccd.27600] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 02/08/2017] [Revised: 01/29/2018] [Accepted: 02/23/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND The 6-minute walk test (6MWT) is a simple functional test that can predict exercise capacity and is widely employed to assess treatment outcomes. Although mortality with transcatheter mitral valve repair (TMVr) using the MitraClip (Abbott Vascular, Menlo Park, CA) is significantly less than for open mitral valve surgery in high-risk patients, identifying which patient will benefit the most from TMVr remains a concern. There are limited prognostic metrics guiding patient selection and, no studies have reported relationship between prolonged hospitalization and 6MWT. This study aimed to determine if the 6MWT can predict prolonged hospitalization in patients undergoing TMVr by MitraClip. METHODS We retrospectively reviewed 162 patients undergoing 6MWT before TMVr. Patients were divided into three groups according to the 6MWT distance (6MWTD) using the median (6MWTD ≥219 m, 6MWTD <219 m, and Unable to Walk). Multivariate logistic regression model was applied to select the demographic characteristics that were associated with the prolonged hospitalization defined as total length of stay ≥4 days in the study. RESULTS We found that 6MWT (odds ratio 3.64, 95% confidence interval 2.03-6.52, P < 0.001) was independently associated with prolonged hospitalization after adjustment in multivariate analysis. Area under the curve of 6MWT for predicting prolonged hospitalization was 0.79 (95% confidence interval 0.72-0.85). CONCLUSIONS Our study demonstrates that 6MWT was independently associated with prolonged hospitalization in patients with TMVr, and has a good discriminatory performance for predicting prolonged hospitalization.
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Affiliation(s)
- Mike Saji
- Advanced Cardiac Valve Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia.,Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Marc R Katz
- Department of Surgery, Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Gorav Ailawadi
- Advanced Cardiac Valve Center, Department of Surgery, Division of Cardiothoracic Surgery, University of Virginia, Charlottesville, Virginia
| | - Timothy S Welch
- Heart and Vascular Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia
| | - Dale E Fowler
- Heart and Vascular Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia
| | - Jamie L W Kennedy
- Heart and Vascular Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia
| | - James D Bergin
- Heart and Vascular Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia
| | - Ivandito Kuntjoro
- Advanced Cardiac Valve Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia.,Department of Cardiology, National University Heart Center of Singapore, Singapore, Singapore
| | - John M Dent
- Advanced Cardiac Valve Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia
| | - Michael Ragosta
- Advanced Cardiac Valve Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia
| | - D Scott Lim
- Advanced Cardiac Valve Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia
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18
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Bilchick K, Moss T, Welch T, Levy W, Stukenborg G, Lawlor BT, Reigle J, Thomas SC, Brady C, Bergin JD, Kennedy JLW, Abuannadi M, Scully K, Mazimba S. Improving Heart Failure Readmission Costs and Outcomes With a Hospital-to-Home Readmission Intervention Program. Am J Med Qual 2018; 34:127-135. [PMID: 30024279 DOI: 10.1177/1062860618788436] [Citation(s) in RCA: 5] [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] [Indexed: 12/22/2022]
Abstract
A retrospective cohort study was performed of the Hospital-to-Home (H2H) program, a rapid clinic follow-up program for patients with recent heart failure (HF) admissions at the University of Virginia Health System. There were 6761 hospitalizations among 4685 patients (age 67.5 ± 14.2 years, 43.9% female), and 759 had H2H follow-up. Thirty day mortality after the initial HF hospitalization was lower in H2H patients (1.84% vs 3.13%; P = .049), and this difference remained significant after adjustment in a multivariable logistic regression model (odds ratio = 0.56 [95% CI = 0.31-099]; P = .046). There also was a 24% reduction in readmission days within the first 30 days after the index admission ( P < .0001), and readmission cost savings were found to be greater than the costs of staffing the H2H clinic. In summary, the H2H program is cost-effective, with significant improvements in survival, readmission days, and readmission costs over 30 days.
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Affiliation(s)
- Kenneth Bilchick
- 1 University of Virginia Health System, Charlottesville, Virginia
| | - Travis Moss
- 1 University of Virginia Health System, Charlottesville, Virginia
| | - Timothy Welch
- 1 University of Virginia Health System, Charlottesville, Virginia
| | - Wayne Levy
- 2 University of Washington, Seattle, Washington
| | - George Stukenborg
- 3 University of Virginia School of Medicine, Charlottesville, Virginia
| | - Bryan T Lawlor
- 1 University of Virginia Health System, Charlottesville, Virginia
| | - Juanita Reigle
- 1 University of Virginia Health System, Charlottesville, Virginia
| | - S Craig Thomas
- 1 University of Virginia Health System, Charlottesville, Virginia
| | - Carolyn Brady
- 1 University of Virginia Health System, Charlottesville, Virginia
| | - James D Bergin
- 1 University of Virginia Health System, Charlottesville, Virginia
| | | | | | - Kenneth Scully
- 1 University of Virginia Health System, Charlottesville, Virginia
| | - Sula Mazimba
- 1 University of Virginia Health System, Charlottesville, Virginia
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19
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Ruth BK, Bilchick KC, Mysore MM, Mwansa H, Harding WC, Kwon Y, Kennedy JLW, Mazurek JA, Mihalek AD, Smith LA, Mejia-Lopez E, Parker AM, Welch TS, Mazimba S. Increased Pulmonary-Systemic Pulse Pressure Ratio Is Associated With Increased Mortality in Group 1 Pulmonary Hypertension. Heart Lung Circ 2018; 28:1059-1066. [PMID: 30006114 DOI: 10.1016/j.hlc.2018.05.199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 03/14/2018] [Accepted: 05/29/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is characterised by remodelling of the pulmonary vasculature leading to right ventricular (RV) failure. The failing RV, through interventricular uncoupling, deleteriously impacts the left ventricle and overall cardiac efficiency. We hypothesised that the ratio of the pulmonary artery pulse pressure to the systemic pulse pressure ("pulmonary-systemic pulse pressure ratio", or PS-PPR) would be associated with mortality in PAH. METHODS We conducted a retrospective analysis of 262 patients in the National Institute of Health Primary Pulmonary Hypertension Registry (NIH-PPH). We evaluated the association between the PS-PPR and mortality after adjustment for the Pulmonary Hypertension Connection (PHC) risk equation. RESULTS Among 262 patients (mean age 37.5±15.8years, 62.2% female), median PS-PPR was 1.04 (IQR 0.79-1.30). In the Cox proportional hazards regression model, each one unit increase in the PS-PPR was associated with more than a two-fold increase in mortality during follow-up (HR 2.06, 95% CI 1.40-3.02, p=0.0002), and this association of PS-PPR with mortality remained significant in the multivariable Cox model adjusted for the PHC risk equation, mean pulmonary artery pressure, and body mass index (BMI) (adjusted HR 1.81, 95% CI 1.13-2.88, p=0.01). Furthermore, PS-PPR in the upper quartile (>1.30) versus quartiles 1-3 was associated with a 68% increase in mortality after adjustment for these same covariates (adjusted HR 1.68, 95% CI 1.13-2.50, p=0.01). CONCLUSIONS Pulmonary-systemic pulse pressure ratio, a marker of biventricular efficiency, is associated with survival in PAH even after adjustment for the PHC risk equation. Further studies are needed on the wider applications of PS-PPR in PAH patients.
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Affiliation(s)
- Benjamin K Ruth
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Kenneth C Bilchick
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Manu M Mysore
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Hunter Mwansa
- St Vincent Charity Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - William C Harding
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Younghoon Kwon
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Jamie L W Kennedy
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Jeremy A Mazurek
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew D Mihalek
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - LaVone A Smith
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Eliany Mejia-Lopez
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Alex M Parker
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Timothy S Welch
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA; Cardiology Service Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA.
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Mazimba S, Welch TS, Mwansa H, Breathett KK, Kennedy JLW, Mihalek AD, Harding WC, Mysore MM, Zhuo DX, Bilchick KC. Haemodynamically Derived Pulmonary Artery Pulsatility Index Predicts Mortality in Pulmonary Arterial Hypertension. Heart Lung Circ 2018; 28:752-760. [PMID: 29748060 DOI: 10.1016/j.hlc.2018.04.280] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 02/21/2018] [Accepted: 04/02/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Pulmonary artery (PA) pulsitility index (PAPi) is a novel haemodynamic index shown to predict right ventricular failure in acute inferior myocardial infarction and post left ventricular assist device surgery. We hypothesised that PAPi calculated as [PA systolic pressure - PA diastolic pressure]/right atrial pressure (RAP) would be associated with mortality in the National Institutes of Health Registry for Primary Pulmonary Hypertension (NIH-RPPH). METHODS The impact of PAPi, the Pulmonary Hypertension Connection (PHC) risk score, right ventricular stroke work, pulmonary artery capacitance (PAC), other haemodynamic indices, and demographic characteristics was evaluated in 272 NIH-RPPH patients using multivariable Cox proportional hazards (CPH) regression and receiver operating characteristic (ROC) analysis. RESULTS In the 272 patients (median age 37.7+/-15.9years, 63% female), the median PAPi was 5.8 (IQR 3.7-9.2). During 5years of follow-up, 51.8% of the patients died. Survival was markedly lower (32.8% during the first 3years) in PAPi quartile 1 compared with the remaining patients (58.5% over 3years in quartiles 2-4; p<0.0001). The best multivariable CPH survival model included PAPi, the PHC-Risk score, PAC, and body mass index (BMI). In this model, the adjusted hazard ratio for death with increasing PAPi was 0.946 (95% CI 0.905-0.989). The independent ROC areas for 5-year survival based on bivariable logistic regression for PAPi, BMI, PHC Risk, and PAC were 0.63, 0.62, 0.64, and 0.65, respectively (p<0.01). The ROC area for 5-year survival for the multivariable logistic model with all four covariates was 0.77 (p<0.0001). CONCLUSIONS Pulmonary artery pulsatility index was independently associated with survival in PAH, highlighting the utility of PAPi in combination with other key measures for risk stratification in this population.
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Affiliation(s)
- Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA.
| | - Timothy S Welch
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Hunter Mwansa
- St Vincent Charity Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | | | - Jamie L W Kennedy
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Andrew D Mihalek
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - William C Harding
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Manu M Mysore
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - David X Zhuo
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Kenneth C Bilchick
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
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Mwansa H, Bilchick KC, Parker AM, Harding W, Ruth B, Kennedy JLW, Mysore M, Kwon Y, Mihalek A, Mazimba S. Decreased pulmonary arterial proportional pulse pressure is associated with increased mortality in group 1 pulmonary hypertension. Clin Cardiol 2017; 40:988-992. [PMID: 28692753 DOI: 10.1002/clc.22752] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 03/28/2017] [Revised: 05/31/2017] [Accepted: 06/05/2017] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND This study evaluated the utility of a novel index, pulmonary arterial (PA) proportional pulse pressure (PAPP; range 0-1, defined as [PA systolic pressure - PA diastolic pressure] / PA systolic pressure), in predicting mortality in patients with World Health Organization group 1 pulmonary hypertension (PH). HYPOTHESIS Low PAPP is associated with increased 5-year mortality independent of a validated contemporary risk-prediction equation (Pulmonary Hypertension Connection [PHC] equation). METHODS In a group of 262 patients in the National Institutes of Health Primary Pulmonary Hypertension (NIH-PPH) Registry, PAPP and the PHC risk equation were used to predict mortality during 5 years of follow-up using Cox proportional hazards models. Kaplan-Meier survival curves were used to compare mortality among PAPP quartiles, and significance was tested using the log-rank test. RESULTS Patients in the lowest quartile (PAPP ≤0.47) had a significantly higher 5-year mortality than did patients in higher quartiles (log-rank P = 0.016). In a Cox model adjusted for the PHC equation, PAPP remained significantly associated with 5-year mortality (hazard ratio: 0.74 per 0.10 increase in PAPP, 95% confidence interval: 0.61-0.90). The χ2 statistic for the single PAPP covariate in this model was 8.8 (P = 0.003), which compared favorably with the χ2 statistic of 15.2 (P < 0.0001) for the multivariable PHC equation. CONCLUSIONS PAPP, an index of ventricular-arterial coupling, is independently associated with survival in World Health Organization group 1 PH. The use of this easily measurable index for guiding risk stratification needs further investigation.
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Affiliation(s)
- Hunter Mwansa
- Department of Internal Medicine, St. Vincent Charity Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Kenneth C Bilchick
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Alex M Parker
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - William Harding
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Benjamin Ruth
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Jamie L W Kennedy
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Manu Mysore
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Younghoon Kwon
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Andrew Mihalek
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia
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Mazimba S, Holland E, Nagarajan V, Mihalek AD, Kennedy JLW, Bilchick KC. Obesity paradox in group 1 pulmonary hypertension: analysis of the NIH-Pulmonary Hypertension registry. Int J Obes (Lond) 2017; 41:1164-1168. [PMID: 28209971 DOI: 10.1038/ijo.2017.45] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [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: 12/09/2016] [Revised: 02/02/2017] [Accepted: 02/09/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND The 'obesity paradox' refers to the fact that obese patients have better outcomes than normal weight patients. This has been observed in multiple cardiovascular conditions, but evidence for obesity paradox in pulmonary hypertension (PH) remains sparse. METHODS We categorized 267 patients from the National Institute of Health-PH registry into five groups based on body mass index (BMI): underweight, normal weight, overweight, obese and morbidly obese. Mortality was compared in BMI groups using the χ2 statistic. Five-year probability of death using the PH connection (PHC) risk equation was calculated, and the model was compared with BMI groups using Cox proportional hazards regression and Kaplan-Meier (KM) survival curves. RESULTS Patients had a median age of 39 years (interquartile range 30-50 years), a median BMI of 23.4 kg m-2 (21.0-26.8 kg m-2) and an overall mortality at 5 years of 50.2%. We found a U-shaped relationship between survival and 1-year mortality with the best 1-year survival in overweight patients. KM curves showed the best survival in the overweight, followed by obese and morbidly obese patients, and the worst survival in normal weight and underweight patients (log-rank P=0.0008). In a Cox proportional hazards analysis, increasing BMI was a highly significant predictor of improved survival even after adjustment for the PHC risk equation with a hazard ratio for death of 0.921 per kg m-2 (95% confidence interval: 0.886-0.954) (P<0.0001). CONCLUSION We observed that the best survival was in the overweight patients, making this more of an 'overweight paradox' than an 'obesity paradox'. This has implications for risk stratification and prognosis in group 1 PH patients.
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Affiliation(s)
- S Mazimba
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - E Holland
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - V Nagarajan
- Department of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - A D Mihalek
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - J L W Kennedy
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - K C Bilchick
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
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Bose-Basu B, Zhang W, Kennedy JLW, Hadad MJ, Carmichael I, Serianni AS. 13C-Labeled Idohexopyranosyl Rings: Effects of Methyl Glycosidation and C6 Oxidation on Ring Conformational Equilibria. J Org Chem 2017; 82:1356-1370. [DOI: 10.1021/acs.joc.6b02399] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Bidisha Bose-Basu
- Department
of Chemistry and Physics, Fayetteville State University, Fayetteville, North Carolina 28301, United States
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Murphy M, Welch T, Shaw PW, Kennedy JLW, Bilchick KC. Inhibition of pacing in a dependent patient with an implantable cardioverter-defibrillator and a left ventricular assist device. HeartRhythm Case Rep 2016; 2:473-477. [PMID: 28491740 PMCID: PMC5419973 DOI: 10.1016/j.hrcr.2016.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- Michele Murphy
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Timothy Welch
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Peter W Shaw
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Jamie L W Kennedy
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Kenneth C Bilchick
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
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Mehta BB, Auger DA, Gonzalez JA, Workman V, Chen X, Chow K, Stump CJ, Mazimba S, Kennedy JLW, Gay E, Salerno M, Kramer CM, Epstein FH, Bilchick KC. Detection of elevated right ventricular extracellular volume in pulmonary hypertension using Accelerated and Navigator-Gated Look-Locker Imaging for Cardiac T1 Estimation (ANGIE) cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2015; 17:110. [PMID: 26692265 PMCID: PMC4687111 DOI: 10.1186/s12968-015-0209-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [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: 07/05/2015] [Accepted: 11/19/2015] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Assessment of diffuse right ventricular (RV) fibrosis is of particular interest in pulmonary hypertension (PH) and heart failure (HF). Current cardiovascular magnetic resonance (CMR) T1 mapping techniques such as Modified Look-Locker inversion recovery (MOLLI) imaging have limited resolution, but accelerated and navigator-gated Look-Locker imaging for cardiac T1 estimation (ANGIE) is a novel CMR sequence with spatial resolution suitable for T1 mapping of the RV. We tested the hypothesis that patients with PH would have significantly more RV fibrosis detected with MRI ANGIE compared with normal volunteers and patients having HF with reduced (LV) ejection fraction (HFrEF) without co-existing PH, independent of RV dilitation and dysfunction. METHODS Patients with World Health Organization group 1 or group 4 PH, patients with HFrEF without PH, and normal volunteers were recruited to undergo contrast-enhanced CMR. RV and LV extracellular volume fractions (RV-ECV and LV-ECV) were determined using pre-contrast and post-contrast T1 mapping using ANGIE (RV and LV) and MOLLI (LV only). RESULTS Thirty-two participants (53.1% female, median age 52 years, IQR 26-65 years) were enrolled, including n = 12 with PH, n = 10 having HFrEF without co-existing PH, and n = 10 normal volunteers. ANGIE ECV imaging was of high quality, and ANGIE measurements of LV-ECV were highly correlated with those of MOLLI (r = 0.91; p < 0.001). The RV-ECV in PH patients was 27.2% greater than the RV-ECV in normal volunteers (0.341 v. 0.268; p < 0.0001) and 18.9% greater than the RV-ECV in HFrEF patients without PH (0.341 v. 0.287; p < 0.0001). RV-ECV was greater than LV-ECV in PH (RV-LV difference = 0.04), but RV-ECV was nearly equivalent to LV-ECV in normal volunteers (RV-LV difference = 0.002) (p < 0.0001 for RV-LV difference in PH versus normal volunteers). RV-ECV was linearly associated with both increasing RVEDVI (p = 0.049) and decreasing RVEF (p = 0.04) in a multivariable linear model, but PH was still associated with greater RV-ECV even after adjustment for RVEDVI and RVEF. CONCLUSIONS Pre- and post-contrast ANGIE imaging provides high-resolution ECV determination for the RV. PH is independently associated with increased RV-ECV even after adjustment for RV dilatation and dysfunction, consistent with an independent effect of PH on fibrosis. ANGIE RV imaging merits further clinical evaluation in PH.
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Affiliation(s)
- Bhairav B Mehta
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, VA, USA.
| | - Daniel A Auger
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, VA, USA.
| | - Jorge A Gonzalez
- Department of Medicine, University of Virginia Health System, P.O. Box 800158, Charlottesville, VA, 22908, USA.
| | - Virginia Workman
- Department of Medicine, University of Virginia Health System, P.O. Box 800158, Charlottesville, VA, 22908, USA.
| | - Xiao Chen
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, VA, USA.
| | - Kelvin Chow
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, VA, USA.
| | - Claire J Stump
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, VA, USA.
| | - Sula Mazimba
- Department of Medicine, University of Virginia Health System, P.O. Box 800158, Charlottesville, VA, 22908, USA.
| | - Jamie L W Kennedy
- Department of Medicine, University of Virginia Health System, P.O. Box 800158, Charlottesville, VA, 22908, USA.
| | - Elizabeth Gay
- Department of Medicine, University of Virginia Health System, P.O. Box 800158, Charlottesville, VA, 22908, USA.
| | - Michael Salerno
- Department of Medicine, University of Virginia Health System, P.O. Box 800158, Charlottesville, VA, 22908, USA.
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, VA, USA.
- Department of Radiology, University of Virginia Health System, Charlottesville, VA, USA.
| | - Christopher M Kramer
- Department of Medicine, University of Virginia Health System, P.O. Box 800158, Charlottesville, VA, 22908, USA.
- Department of Radiology, University of Virginia Health System, Charlottesville, VA, USA.
| | - Frederick H Epstein
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, VA, USA.
- Department of Radiology, University of Virginia Health System, Charlottesville, VA, USA.
| | - Kenneth C Bilchick
- Department of Medicine, University of Virginia Health System, P.O. Box 800158, Charlottesville, VA, 22908, USA.
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Smith LA, Yarboro LT, Kennedy JLW. Left ventricular assist device implantation strategies and outcomes. J Thorac Dis 2015; 7:2088-96. [PMID: 26793328 PMCID: PMC4703687 DOI: 10.3978/j.issn.2072-1439.2015.08.13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 07/30/2015] [Indexed: 11/14/2022]
Abstract
Over the past 15 years, the field of mechanical circulatory support has developed significantly. Currently, there are a multitude of options for both short and long term cardiac support. Choosing the appropriate device for each patient depends on the amount of support needed and the goals of care. This article focuses on long term, implantable devices for both bridge to transplantation and destination therapy indications. Implantation strategies, including the appropriate concomitant surgeries are discussed as well as expected long term outcomes. As device technology continues to improve, long term mechanical circulatory support may become a viable alternative to transplantation.
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Andritsos MJ, Kowzower BD, Kennedy JLW, Bergin JD, Blank RS. Perioperative considerations for a patient with severe biventricular dysfunction undergoing thoracoscopic lobectomy. J Cardiothorac Vasc Anesth 2015; 29:e21-2. [PMID: 25622972 DOI: 10.1053/j.jvca.2014.10.020] [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] [Received: 10/09/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Michael J Andritsos
- Department of AnesthesiologyThe Ohio State University Wexner Medical Center Columbus, OH
| | | | | | | | - Randal S Blank
- Anesthesiology University of Virginia Health System Charlottesville, VA
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Yarboro LT, Bergin JD, Kennedy JLW, Ballew CC, Benton EM, Ailawadi G, Kern JA. Technique for minimizing and treating driveline infections. Ann Cardiothorac Surg 2014; 3:557-62. [PMID: 25512894 DOI: 10.3978/j.issn.2225-319x.2014.09.08] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 07/22/2014] [Indexed: 01/07/2023]
Abstract
Left ventricular assist devices (LVADs) are increasingly utilized in the management of advanced heart failure. A transcutaneous driveline is necessary to power the LVAD, and although this technology has improved over the years in terms of smaller size and increased durability, driveline complications continue to develop in up to 20% of all devices implanted. Driveline infections are associated with significant morbidity and mortality. As more patients live longer with ventricular assist devices, minimizing driveline infections is paramount. A systematic, multidisciplinary approach can be used to develop a strategy to prevent, recognize and treat driveline infections. In this paper, we describe our approach to driveline management which has resulted in zero driveline infections between January 2012 and March 2014.
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Affiliation(s)
- Leora T Yarboro
- 1 Department of Surgery, 2 Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - James D Bergin
- 1 Department of Surgery, 2 Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Jamie L W Kennedy
- 1 Department of Surgery, 2 Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Carole C Ballew
- 1 Department of Surgery, 2 Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Emily M Benton
- 1 Department of Surgery, 2 Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Gorav Ailawadi
- 1 Department of Surgery, 2 Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - John A Kern
- 1 Department of Surgery, 2 Department of Medicine, University of Virginia, Charlottesville, VA, USA
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Shrode CW, Draper KV, Huang RJ, Kennedy JLW, Godsey AC, Morrison CC, Shami VM, Wang AY, Kern JA, Bergin JD, Ailawadi G, Banerjee D, Gerson LB, Sauer BG. Significantly higher rates of gastrointestinal bleeding and thromboembolic events with left ventricular assist devices. Clin Gastroenterol Hepatol 2014; 12:1461-7. [PMID: 24480675 DOI: 10.1016/j.cgh.2014.01.027] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [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: 08/27/2013] [Revised: 12/20/2013] [Accepted: 01/11/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The risk of gastrointestinal (GI) bleeding (GIB) and thromboembolic events may increase with continuous-flow left ventricular assist devices (CF-LVADs). We aimed to characterize GIB and thromboembolic events that occurred in patients with CF-LVADs and compare them with patients receiving anticoagulation therapy. METHODS We performed a retrospective analysis of 159 patients who underwent CF-LVAD placement at 2 large academic medical centers (mean age, 55 ± 13 y). We identified and characterized episodes of GIB and thromboembolic events through chart review; data were collected from a time period of 292 ± 281 days. We compared the rates of GIB and thromboembolic events between patients who underwent CF-LVAD placement and a control group of 159 patients (mean age, 64 ± 15 y) who received a cardiac valve replacement and were discharged with anticoagulation therapy. RESULTS Bleeding events occurred in 29 patients on CF-LVAD support (18%; 45 events total). Sixteen rebleeding events were identified among 10 patients (range, 1-3 rebleeding episodes/patient). There were 34 thrombotic events among 27 patients (17%). The most common source of bleeding was GI angiodysplastic lesions (n = 20; 44%). GIB and thromboembolic events were more common in patients on CF-LVAD support than controls; these included initial GIB (18% vs 4%, P < .001), rebleeding (6% vs none, P = .001), and thromboembolic events (17% vs 8%, P = .01). CONCLUSIONS Patients with CF-LVADS receiving anticoagulants have a significantly higher risk of GIB and thromboembolic events than patients receiving anticoagulants after cardiac valve replacement surgery. GI angiodysplastic lesions are the most common source of bleeding.
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Affiliation(s)
- Charles W Shrode
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia
| | - Karen V Draper
- Department of Medicine, Stanford University, Stanford, California
| | - Robert J Huang
- Department of Medicine, Stanford University, Stanford, California
| | - Jamie L W Kennedy
- Division of Cardiology, University of Virginia, Charlottesville, Virginia
| | - Adam C Godsey
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Christine C Morrison
- Division of Cardiothoracic Surgery, University of Virginia, Charlottesville, Virginia
| | - Vanessa M Shami
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia
| | - John A Kern
- Division of Cardiothoracic Surgery, University of Virginia, Charlottesville, Virginia
| | - James D Bergin
- Division of Cardiology, University of Virginia, Charlottesville, Virginia
| | - Gorav Ailawadi
- Division of Cardiothoracic Surgery, University of Virginia, Charlottesville, Virginia
| | | | - Lauren B Gerson
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California.
| | - Bryan G Sauer
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia.
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Andritsos MJ, Kozower BD, Kennedy JLW, Bergin JD, Blank RS. CASE 6-2014: anesthetic management of thoracoscopic lobectomy in a patient with severe biventricular dysfunction. J Cardiothorac Vasc Anesth 2013; 28:826-35. [PMID: 23992651 DOI: 10.1053/j.jvca.2013.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | | | - Randal S Blank
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA.
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Grubb KJ, Kennedy JLW, Bergin JD, Groves DS, Kern JA. Reply to the editor. J Thorac Cardiovasc Surg 2013; 145:898-9. [PMID: 23415008 DOI: 10.1016/j.jtcvs.2012.12.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 12/11/2012] [Indexed: 11/29/2022]
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Kennedy JLW, Barnard JJ, Prahlow JA. Syphilitic Coronary Artery Ostial Stenosis Resulting in Acute Myocardial Infarction and Death. Cardiology 2005; 105:25-9. [PMID: 16179782 DOI: 10.1159/000088337] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [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] [Received: 06/02/2005] [Accepted: 06/28/2005] [Indexed: 11/19/2022]
Abstract
Cardiovascular abnormalities are well-known manifestations of tertiary syphilis infections. Most notable in this regard is syphilitic aortitis, which tends to result in aortic root dilatation and its associated complications. A less common manifestation of syphilitic aortitis is coronary artery ostial narrowing related to aortic wall thickening. Herein, we present the case of a 32-year-old female who died of a myocardial infarct due to coronary artery ostial stenosis secondary to syphilitic aortitis.
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