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Shekhar S, Agrawal A, Isogai T, Vaidya P, Lak HM, Mahalwar G, Reed GW, Puri R, Krishnaswamy A, Yun J, Kapadia SR. OUTCOMES OF CANCER PATIENTS WITH MIXED AORTIC VALVE DISEASE: A NATIONWIDE ANALYSIS. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01543-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Abushouk A, Spilias N, Isogai T, Kansara T, Agrawal A, Hariri E, Abdelfattah O, Krishnaswamy A, Puri R, Yun J, Kapadia SR. MID-TERM OUTCOMES OF TRANSCATHETER AORTIC VALVE IMPLANTATION IN PATIENTS WITH SMALL AORTIC ANNULI. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01303-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Girard A, Gaillard E, Puri R, Capoulade R, Chan KL, Paulin A, Manikpurage HD, Dumesnil J, Tam JW, Teo KK, Couture C, Wareham NJ, Clavel MA, Stroes ESG, Mathieu P, Thériault S, Tsimikas S, Pibarot P, Boekholdt SM, Arsenault BJ. Impact of C-reactive protein levels on lipoprotein(a)-associated aortic stenosis incidence and progression. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead032. [PMID: 37077580 PMCID: PMC10108885 DOI: 10.1093/ehjopen/oead032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/14/2023] [Accepted: 03/22/2023] [Indexed: 04/01/2023]
Abstract
Aims Elevated lipoprotein(a) [Lp(a)] levels are associated with the risk of coronary artery disease (CAD) and calcific aortic valve stenosis (CAVS). Observational studies revealed that Lp(a) and C-reactive protein (CRP) levels, a biomarker of systemic inflammation, may jointly predict CAD risk. Whether Lp(a) and CRP levels also jointly predict CAVS incidence and progression is unknown. Methods and results We investigated the association of Lp(a) with CAVS according to CRP levels in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Norfolk study (n = 18 226, 406 incident cases) and the UK Biobank (n = 438 260, 4582 incident cases), as well as in the ASTRONOMER study (n = 220), which assessed the haemodynamic progression rate of pre-existing mild-to-moderate aortic stenosis. In EPIC-Norfolk, in comparison to individuals with low Lp(a) levels (<50 mg/dL) and low CRP levels (<2.0 mg/L), those with elevated Lp(a) (>50 mg/dL) and low CRP levels (<2.0 mg/L) and those with elevated Lp(a) (>50 mg/dL) and elevated CRP levels (>2.0 mg/L) had a higher CAVS risk [hazard ratio (HR) = 1.86 (95% confidence intervals, 1.30-2.67) and 2.08 (1.44-2.99), respectively]. A comparable predictive value of Lp(a) in patients with vs. without elevated CRP levels was also noted in the UK Biobank. In ASTRONOMER, CAVS progression was comparable in patients with elevated Lp(a) levels with or without elevated CRP levels. Conclusion Lp(a) predicts the incidence and possibly progression of CAVS regardless of plasma CRP levels. Lowering Lp(a) levels may warrant further investigation in the prevention and treatment of CAVS, regardless of systemic inflammation.
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Rosalia L, Ozturk C, Goswami D, Bonnemain J, Wang SX, Bonner B, Weaver JC, Puri R, Kapadia S, Nguyen CT, Roche ET. Soft robotic patient-specific hydrodynamic model of aortic stenosis and ventricular remodeling. Sci Robot 2023; 8:eade2184. [PMID: 36812335 PMCID: PMC10280738 DOI: 10.1126/scirobotics.ade2184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 01/30/2023] [Indexed: 02/24/2023]
Abstract
Aortic stenosis (AS) affects about 1.5 million people in the United States and is associated with a 5-year survival rate of 20% if untreated. In these patients, aortic valve replacement is performed to restore adequate hemodynamics and alleviate symptoms. The development of next-generation prosthetic aortic valves seeks to provide enhanced hemodynamic performance, durability, and long-term safety, emphasizing the need for high-fidelity testing platforms for these devices. We propose a soft robotic model that recapitulates patient-specific hemodynamics of AS and secondary ventricular remodeling which we validated against clinical data. The model leverages 3D-printed replicas of each patient's cardiac anatomy and patient-specific soft robotic sleeves to recreate the patients' hemodynamics. An aortic sleeve allows mimicry of AS lesions due to degenerative or congenital disease, whereas a left ventricular sleeve recapitulates loss of ventricular compliance and diastolic dysfunction (DD) associated with AS. Through a combination of echocardiographic and catheterization techniques, this system is shown to recreate clinical metrics of AS with greater controllability compared with methods based on image-guided aortic root reconstruction and parameters of cardiac function that rigid systems fail to mimic physiologically. Last, we leverage this model to evaluate the hemodynamic benefit of transcatheter aortic valves in a subset of patients with diverse anatomies, etiologies, and disease states. Through the development of a high-fidelity model of AS and DD, this work demonstrates the use of soft robotics to recreate cardiovascular disease, with potential applications in device development, procedural planning, and outcome prediction in industrial and clinical settings.
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Johnston DR, Mahboubi R, Soltesz EG, Artis AS, Roselli EE, Blackstone EH, Svensson LG, Gillinov AM, Kapadia S, Desai MY, Burns D, Vargo PR, Unai S, Pettersson GB, Weiss A, Elgharably H, Puri R, Reed GW, Popovic ZB, Jaber W, Thomas SA, Bakaeen FG, Karamlou T, Najm H, Griffin B, Krishnaswamy A, McCurry KR, Rodriguez LL, Smedira NG, Zhen-Yu Tong M, Wierup P, Yun J. Redefining "low risk": Outcomes of surgical aortic valve replacement in low-risk patients in the transcatheter aortic valve replacement era. J Thorac Cardiovasc Surg 2023; 165:591-604.e3. [PMID: 36635021 DOI: 10.1016/j.jtcvs.2021.01.145] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 01/13/2021] [Accepted: 01/26/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Guidelines suggest aortic valve replacement (AVR) for low-risk asymptomatic patients. Indications for transcatheter AVR now include low-risk patients, making it imperative to understand state-of-the-art surgical AVR (SAVR) in this population. Therefore, we compared SAVR outcomes in low-risk patients with those expected from Society of Thoracic Surgeons (STS) models and assessed their intermediate-term survival. METHODS From January 2005 to January 2017, 3493 isolated SAVRs were performed in 3474 patients with STS predicted risk of mortality <4%. Observed operative mortality and composite major morbidity or mortality were compared with STS-expected outcomes according to calendar year of surgery. Logistic regression analysis was used to identify risk factors for these outcomes. Patients were followed for time-related mortality. RESULTS With 15 observed operative deaths (0.43%) compared with 55 expected (1.6%), the observed:expected ratio was 0.27 for mortality (95% confidence interval [CI], 0.14-0.42), stroke 0.65 (95% CI, 0.41-0.89), and reoperation 0.50 (95% CI, 0.42-0.60). Major morbidity or mortality steadily declined, with probabilities of 8.6%, 6.7%, and 5.2% in 2006, 2011, and 2016, respectively, while STS-expected risk remained at approximately 12%. Mitral valve regurgitation, ventricular hypertrophy, pulmonary, renal, and hepatic failure, coronary artery disease, and earlier surgery date were residual risk factors. Survival was 98%, 91%, and 82% at 1, 5, and 9 years, respectively, superior to that predicted for the US age-race-sex-matched population. CONCLUSIONS STS risk models overestimate contemporary SAVR risk at a high-volume center, supporting efforts to create a more agile quality assessment program. SAVR in low-risk patients provides durable survival benefit, supporting early surgery and providing a benchmark for transcatheter AVR.
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Taveras LR, Scrushy MG, Cripps MW, Kuhlenschmidt K, Crandall M, Puri R, Schroeppel TJ, Schuster KM, Dumas RP. From mild to gangrenous cholecystitis, laparoscopic cholecystectomy is safe 24 hours a day. Am J Surg 2023:S0002-9610(23)00045-4. [PMID: 36746709 DOI: 10.1016/j.amjsurg.2023.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/06/2022] [Accepted: 01/26/2023] [Indexed: 01/29/2023]
Abstract
OBJECTIVES Laparoscopic cholecystectomy (LC) at night remains controversial. Prior studies have not controlled for disease severity. We analyzed outcomes of LC performed day vs. night while controlling for the Parkland Grading Scale for Cholecystitis (PGS). METHODS Analysis of the AAST multicenter evaluation of cholecystitis database was performed. Exclusion criteria included non-operative cases, open operations, and missing PGS. Cases were divided based on operation start time. PGS was used to control for disease severity. Outcomes included operative time, use of bailout techniques and complications. RESULTS Of 759 procedures identified, 16% were nighttime LC. No differences in demographics, comorbidities, physiologic variables and PGS were noted. Operative time (108.6 min vs 105.6), bailout techniques (8.3% vs 7.4%) and complications (9.9% vs 11.3%) were similar between groups. CONCLUSION Regardless of severity, laparoscopic cholecystectomy is safe 24-h a day. Operations performed at night have a similar complication profile to those performed during the day.
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Sammour YM, Lak H, Chahine J, Abushouk A, Chawla S, Kadri A, Alkhalaileh F, Kumar S, Ghimire B, Svensson L, Popovic Z, Tarakji K, Wazni O, Reed GW, Yun J, Puri R, Krishnaswamy A, Kapadia SR. Clinical and echocardiographic outcomes with new-onset left bundle branch block after SAPIEN-3 transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2023; 101:187-196. [PMID: 36378620 DOI: 10.1002/ccd.30488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 10/13/2022] [Accepted: 10/30/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND New-onset left bundle branch block (LBBB) can develop after transcatheter aortic valve replacement (TAVR) resulting in worse outcomes. AIMS Describe clinical and echocardiographic outcomes with new-onset LBBB after TAVR. METHODS We included consecutive patients who underwent transfemoral-TAVR with SAPIEN-3 (S3) valve between April 2015 and December 2018. Exclusion criteria included pre-existing LBBB, right BBB, left anterior hemiblock, left posterior hemiblock, wide QRS ≥ 120ms, prior permanent pacemaker (PPM), and nontransfemoral access. RESULTS Among 612 patients, 11.4% developed new-onset LBBB upon discharge. The length of stay was longer with new-onset LBBB compared with no LBBB [3 (2-5) days versus 2 (1-3) days; p < 0.001]. New-onset LBBB was associated with higher rates of 30-day PPM requirement (18.6% vs. 5.4%; p < 0.001) and 1-year heart failure hospitalizations (10.7% vs. 4.4%; p = 0.033). There was no difference in 3-year mortality between both groups (30.9% vs. 30.6%; p = 0.829). Further, new-onset LBBB was associated with lower left ventricular ejection fraction (LVEF) at both 30 days (55.9 ± 11.4% vs. 59.3 ± 9%; p = 0.026) and 1 year (55 ± 12% vs. 60.1 ± 8.9%; p = 0.002). These changes were still present when we stratified patients according to baseline LVEF (≥50% or <50%). New-onset LBBBs were associated with a higher 1-year LV end-diastolic volume index (51.4 ± 18.6 vs. 46.4 ± 15.1 ml/m2 ; p = 0.036), and LV end-systolic volume index (23.2 ± 14.1 vs. 18.9 ± 9.7 ml/m2 ; p = 0.009). Compared with resolved new-onset LBBB, persistent new-onset LBBB was associated with worse LVEF and higher PPM at 1 year. CONCLUSIONS New-onset LBBB after S3 TAVR was associated with higher PPM requirement, worse LVEF, higher LV volumes, and increased heart failure hospitalizations, with no difference in mortality.
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Nicholls SJ, Kataoka Y, Nissen SE, Prati F, Windecker S, Puri R, Hucko T, Aradi D, Herrman JPR, Hermanides RS, Wang B, Wang H, Butters J, Giovanni GD, Jones S, Pompili G, Wolski K, Psaltis PJ. Coronary Atheroma Regression With Evolocumab in Stable and Unstable Coronary Syndromes. JACC Cardiovasc Imaging 2023; 16:130-132. [PMID: 36599559 DOI: 10.1016/j.jcmg.2022.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 11/17/2022]
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Isogai T, Agrawal A, Shekhar S, Spilias N, Hodges K, Yun JJ, Puri R, Reed GW, Krishnaswamy A, Kapadia SR. One-year clinical and echocardiographic outcomes of transcatheter aortic valve replacement with SAPIEN 3 Ultra versus SAPIEN 3. Catheter Cardiovasc Interv 2022; 101:417-430. [PMID: 36511393 DOI: 10.1002/ccd.30515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 11/24/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The newest-generation balloon-expandable valve, SAPIEN 3 Ultra (S3U), is expected to function well with the enhanced sealing skirt compared with SAPIEN 3 (S3). However, current literature on the comparison between these two valves is limited to short-term follow-ups. Therefore, we aimed to evaluate the 1-year outcomes and echocardiographic changes of S3U compared with S3. METHODS We retrospectively identified patients who underwent transfemoral-transcatheter aortic valve replacement with S3U or S3 (20/23/26 mm) at our institution in 2018-2020. Outcomes were 1-year clinical events and echocardiographic parameters, and were compared between S3U and S3 after adjustment with inverse probability of treatment weighting. RESULTS The S3U and S3 groups included 297 (25.7%) and 858 (74.3%) patients, respectively. There were no significant differences between the two groups in clinical events (death 5.8% vs. 5.5%, hazard ratio [HR] 1.07, 95% confidence interval [CI] 0.81-1.90; death or heart failure hospitalization 10.3% vs. 10.1%, HR 1.04, 95% CI 0.67-1.62). The S3U group had a lower prevalence of mild paravalvular leakage (PVL) (13.7% vs. 22.3%, p = 0.044), with similar moderate PVL (0.7% vs. 1.2%, p > 0.99). No significant differences were observed in aortic valve mean gradient and Doppler velocity index at 1 year. However, the S3U group had a larger increase in mean gradient from implantation to 1 year (median +4.70 vs. +1.63 mmHg, p < 0.001). CONCLUSIONS S3U and S3 carried similarly favorable clinical event risks. Nonetheless, S3U was associated with less frequent mild PVL but a larger increase in transprosthetic gradient. Further studies are needed to determine the prognostic impact of these hemodynamic differences.
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Abushouk A, Agrawal A, Hariri E, Dykun I, Kansara T, Saad A, Abdelfattah O, Badwan O, Jaggi C, Farwati M, Harb SC, Puri R, Reed GW, Krishnaswamy A, Yun J, Kapadia S. Association between haematological parameters and outcomes following transcatheter aortic valve implantation at mid-term follow-up. Open Heart 2022; 9:openhrt-2022-002108. [PMID: 36600647 PMCID: PMC9748985 DOI: 10.1136/openhrt-2022-002108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 11/14/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Patients undergoing transcatheter aortic valve implantation (TAVI) often have multiple comorbidities, such as anaemia and chronic inflammatory disorders. We sought to investigate the association between preoperative and postoperative haematological parameters and clinical outcomes in TAVI patients at mid-term follow-up. METHODS In the present study, consecutive patients (N=908) who underwent TAVI at the Cleveland Clinic between 2017 and 2019 with available complete blood counts were studied. Data were collected on preoperative and postoperative anaemia and elevations in neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR). Survival analysis was used to study the association of haematologic parameters with all-cause mortality and major adverse cardiac and cerebrovascular events (MACCE). RESULTS We found that preoperative anaemia and elevated NLR were significantly associated with a higher risk of all-cause mortality (aHR=1.6 (95% CI: 1.1 to 2.0) and 1.4 (95% CI: 1.1 to 1.6), respectively) and MACCE (aHR=1.9 (95% CI: 1.3 to 2.8) and 1.6 (95% CI: 1.1 to 2.4), respectively). While an elevated preoperative PLR was not associated with increased mortality risk, it had a significant association with MACCE risk (aHR: 1.6 (95% CI: 1.1 to 2.4)). Further, postoperative anaemia, elevated NLR and PLR were associated with increased risks of all-cause mortality and MACCE. CONCLUSION Pathological alterations in haematological parameters were associated with higher risks of post-TAVI mortality and MACCE at mid-term follow-up. Our findings advocate for further incorporating haematological parameters in the preoperative evaluation of TAVI candidates.
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Bansal A, Kumar A, Garg C, Kalra A, Puri R, Kapadia SR, Reed GW. Use of Machine Learning to Develop Prediction Models for Mortality and Stroke in Patients Undergoing Balloon Aortic Valvuloplasty. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 45:26-34. [PMID: 35931638 DOI: 10.1016/j.carrev.2022.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 06/23/2022] [Accepted: 07/27/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To develop an artificial intelligence, machine learning prediction model for estimating in-hospital mortality and stroke in patients undergoing balloon aortic valvuloplasty (BAV). METHODS The National Inpatient Sample (NIS) database was used to identify patients who underwent BAV from 2005 to 2017. Outcomes analyzed were in-hospital all-cause mortality and stroke after BAV. Predictors of mortality and stroke were selected using LASSO regularization. A conventional logistic regression and a random forest machine learning algorithm were used to train the models for predicting outcomes. The performance of all the modeling algorithms for predicting in-hospital mortality and stroke was compared between models using c-statistic, F1 score, brier score loss, diagnostic accuracy, and Kolmogorov-Smirnov plots. RESULTS A total of 6962 patients with severe aortic stenosis who underwent BAV were identified. The performance of random forest classifier was comparable with logistic regression for predicting in-hospital mortality for all measures of performance (F1 score 0.422 vs 0.409, ROC-AUC 0.822 [95 % CI 0.787-0.855] vs 0.815 [95 % CI 0.779-0.849], diagnostic accuracy 70.42 % vs 70.93 %, KS-statistic 0.513 vs 0.494 and brier score loss 0.295 vs 0.291). The random forest algorithm significantly outperformed logistic regression in predicting in-hospital stroke with respect to all performance metrics: F1 score 0.225 vs 0.095, AUC 0.767 [0.662-0.858] vs 0.637 [0.499-0.754], brier score loss [0.399 vs 0.407], and KS-statistic [0.465 vs 0.254]. CONCLUSIONS The good discrimination of machine learning models reveal the potential of artificial intelligence to improve patient risk stratification for BAV.
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Kumar A, Ogunnowo GO, Khot UN, Raphael CE, Ghobrial J, Rampersad P, Puri R, Khatri JJ, Reed GW, Krishnaswamy A, Cho L, Lincoff AM, Ziada KM, Kapadia SR, Ellis SG. Interaction Between Race and Income on Cardiac Outcomes After Percutaneous Coronary Intervention. J Am Heart Assoc 2022; 11:e026676. [DOI: 10.1161/jaha.122.026676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background
Compared with White Americans, Black Americans have a greater prevalence of cardiac events following percutaneous coronary intervention. We evaluated the association between race and neighborhood income on post–percutaneous coronary intervention cardiac events and assessed whether income modifies the effect of race on this relationship.
Methods and Results
Consecutive patients (n=23 822) treated with percutaneous coronary intervention from January 1, 2000, to December 31, 2016, were included. All‐cause mortality and major adverse cardiac event were assessed at 3 years. Extended 10‐year follow‐up was performed for those residing locally (n=1285). Neighborhood income was derived using median adjusted annual gross household income reported within the patient's zip code. We compared differences in treatment and outcomes, adjusting for race, income, and their interaction. In total, 3173 (13.3%) patients self‐identified as Black Americans, and 20 649 (86.7%) self‐identified as White Americans. Black Americans had a worse baseline cardiac risk profile and lower neighborhood income compared with White Americans. Although risk profile improved with increasing income in White Americans, no difference was observed across incomes among Black Americans. Despite similar long‐term outpatient cardiology follow‐up and medication prescription, risk profiles among Black Americans remained worse. At 3 years, unadjusted all‐cause mortality (18.0% versus 15.2%;
P
<0.001) and major adverse cardiac event (37.3% versus 34.6%;
P
<0.001) were greater among Black Americans and with lower income (both
P
<0.001); race, income, and their interaction were not significant predictors in multivariable models. At 10‐year follow‐up, increasing income was associated with improved outcomes only in White Americans but not Black Americans. In multivariable models for major adverse cardiac event, income (hazard ratio [HR], 0.97 [95% CI, 0.96–0.98];
P
=0.005), Black race (HR, 1.77 [95% CI, 1.58–1.96];
P
=0.006), and their interaction (HR, 0.98 [95% CI, 0.97–0.99];
P
=0.003) were significant predictors. Similar findings were observed for cardiac death.
Conclusions
Early 3‐year post–percutaneous coronary intervention outcomes were driven by worse risk factor profiles in both Black Americans and those with lower neighborhood income. However, late 10‐year outcomes showed an independent effect of race and income, with improving outcomes with greater income limited to White Americans. These findings illustrate the importance of developing novel care strategies that address both risk factor modification and social determinants of health to mitigate disparities in cardiac outcomes.
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Isogai T, Vanguru HR, Krishnaswamy A, Agrawal A, Spilias N, Shekhar S, Saad AM, Verma BR, Puri R, Reed GW, Popović ZB, Unai S, Yun JJ, Uchino K, Kapadia SR. Cerebral embolic protection and severity of stroke following transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2022; 100:810-820. [PMID: 35916117 PMCID: PMC9805232 DOI: 10.1002/ccd.30340] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 07/04/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND The cerebral embolic protection (CEP) device captures embolic debris during transcatheter aortic valve replacement (TAVR). However, the impact of CEP on stroke severity following TAVR remains unclear. Therefore, we aimed to examine whether CEP was associated with reduced severity of stroke following TAVR. METHODS This was a retrospective cohort study of 2839 consecutive patients (mean age: 79.2 ± 9.5 years, females: 41.5%) who underwent transfemoral TAVR at our institution between 2013 and 2020. We categorized patients into Sentinel CEP users and nonusers. Neuroimaging data were reviewed and the final diagnosis of a cerebrovascular event was adjudicated by a neurologist blinded to the CEP use or nonuse. We compared the incidence and severity (assessed by the National Institutes of Health Stroke Scale [NIHSS]) of stroke through 72 h post-TAVR or discharge between the two groups using stabilized inverse probability of treatment weighting (IPTW) of propensity scores. RESULTS Of the eligible patients, 1802 (63.5%) received CEP during TAVR and 1037 (36.5%) did not. After adjustment for patient characteristics by stabilized IPTW, the rate of overall stroke was numerically lower in CEP users than in CEP nonusers, but the difference did not reach statistical significance (0.49% vs. 1.18%, p = 0.064). However, CEP users had significantly lower rates of moderate-or-severe stroke (NIHSS ≥ 6: 0.11% vs. 0.69%, p = 0.013) and severe stroke (NIHSS ≥ 15: 0% vs. 0.29%, p = 0.046). Stroke following CEP use (n = 8), compared with stroke following CEP nonuse (n = 15), tended to carry a lower NIHSS (median [IQR], 4.0 [2.0-7.0] vs. 7.0 [4.5-19.0], p = 0.087). Four (26.7%) out of 15 patients with stroke following CEP nonuse died within 30 days, with no death after stroke following CEP use. CONCLUSIONS CEP use may be associated with attenuated severity of stroke despite no significant difference in overall stroke incidence compared with CEP nonuse. This finding is considered hypothesis-generating and needs to be confirmed in large prospective studies.
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Puri R, Gandhi A, Rastogi M, Khurana R, Hadi R, Srivastava A, Bharati A, Mishra S. Impact of Induction Chemotherapy Antecedent to Long Course Neoadjuvant Concurrent Chemo-Radiotherapy on Clinical Outcomes of Patients with Carcinoma Rectum: Retrospective Audit from a Tertiary Cancer Center. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Abadie B, Held M, Puri R, Krishnaswamy A, Yun J, Hanna M, Reed G, Kapadia S, Jaber W. Incidence and predictors of transthyretin cardiac amyloidosis in patients with degenerative aortic stenosis. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The approval of new therapies for treating transthyretin (TTR) cardiac amyloidosis has led to significant interest in identifying patients at high risk for this disease. Investigators have identified a correlation between severe degenerative aortic stenosis (AS) and TTR cardiac amyloidosis in older patients, with several studies finding up to 20% of patients who undergo transcatheter aortic valve replacement (TAVR) having TTR cardiac amyloidosis. These initial TAVR studies were conducted when TAVR was performed almost exclusively in high surgical risk populations. Therefore, the true incidence of TTR cardiac amyloidosis in an all-comers with severe degenerative AS referred for TAVR is unknown.
Purpose
To identify the true burden of TTR cardiac amyloidosis in a contemporary population of severe degenerative AS undergoing TAVR screening.
Methods
All patients ≥70 years with severe native valve degenerative AS seen in a multidisciplinary valve clinic were referred for technetium-99m pyrophosphate cardiac scintigraphy (PYP scan) for evaluation of cardiac amyloidosis. Diagnosis was made via combination of planar grade and heart to contralateral lung ratio, confirmed on single positron emission computed tomography/computed tomography (SPECT/CT). Patients with a positive PYP scan were referred to a heart failure clinic where they underwent testing for AL amyloidosis.
Results
Over a 10 month period, 247 patients seen in valve clinic underwent a PYP scan. Of this cohort, 203 patients ultimately underwent TAVR, 15 surgical aortic valve replacement, and 2 balloon valvuloplasty with 27 patients having not yet undergone a procedure. The positivity rate was 4% (10/247) with 1 patient having an equivocal result. The patients with a positive PYP scan had higher rate of low-flow low-gradient (LFLG) AS (64% vs 29%, p=0.006) and classical LFLG AS (27% vs 8%, p=0.02). Echocardiographic measures associated with a positive PYP scan include a lower global longitudinal strain (−10.0% vs −16.1%, p=0.008), lower average e' (4.5 vs 6.5, p=0.003), and an increased E/A ratio (1.8 vs 1.1, p=0.018).
Conclusions
The incidence of TTR amyloidosis in a contemporary, severe AS population ≥70 years undergoing TAVR screening appears much lower than previously described in the literature. Echocardiographic traits may be able to predict which patients with severe AS should undergo evaluation for TTR cardiac amyloidosis.
Funding Acknowledgement
Type of funding sources: None.
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Isogai T, Vanguru HR, Krishnaswamy A, Agrawal A, Spilias N, Shekhar S, Saad AM, Verma BR, Puri R, Reed GW, Popović ZB, Unai S, Yun JJ, Uchino K, Kapadia SR. Feasibility of Sentinel Cerebral Embolic Protection Device Deployment During Transfemoral Transcatheter Aortic Valve Replacement. Am J Cardiol 2022; 184:157-159. [PMID: 36192198 DOI: 10.1016/j.amjcard.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 08/17/2022] [Accepted: 09/02/2022] [Indexed: 11/19/2022]
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Abushouk AI, Abdelfattah O, Gad MM, Saad A, Hariri E, Isogai T, Shekhar S, Reed GW, Puri R, Yun J, Vargo PR, Weiss AJ, Burns D, Unai S, Popovic Z, Harb SC, Krishnaswamy A, Svensson LG, Johnston DR, Kapadia SR. Two-year outcomes after transcatheter aortic valve-in-valve implantation in degenerated surgical valves. Catheter Cardiovasc Interv 2022; 100:860-867. [PMID: 36116028 DOI: 10.1002/ccd.30388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Transcatheter aortic valve-in-valve implantation (ViV-TAVI) has emerged in recent years as a safe alternative to redo surgery in high-risk patients. Although early results are encouraging, data beyond short-term outcomes are lacking. Herein, we aimed to assess the 2-year outcomes after ViV-TAVI. METHODS Patients undergoing ViV-TAVI for degenerated surgical valves between 2013 and 2019 at the Cleveland Clinic were reviewed. The coprimary endpoints were all-cause mortality and congestive heart failure (CHF) hospitalizations. We used time-to-event analyses to assess the primary outcomes. Further, we measured the changes in transvalvular gradients and the incidence of structural valve deterioration (SVD). RESULTS One hundred and eighty-eight patients were studied (mean age = 76 years; 65% males). At 2 years of follow-up, all-cause mortality and CHF hospitalizations occurred in 15 (8%) and 28 (14.9%) patients, respectively. On multivariable analysis, the postprocedural length of stay was a significant predictor for both all-cause mortality (hazard ratio [HR] = 1.1; 95% confidence interval [CI]: 1.01, 1.19) and CHF hospitalization (HR = 1.16; 95% CI: 1.07, 1.27). However, the internal diameter of the surgical valve was not associated with significant differences in both primary endpoints. For hemodynamic outcomes, nine patients (4.8%) developed SVD. The mean and peak transvalvular pressure gradients remained stable over the follow-up period. CONCLUSION ViV-TAVI for degenerated surgical valves was associated with favorable 2-year clinical and hemodynamic outcomes. Further studies are needed to better understand the role of ViV-TAVI as a treatment option in the life management of aortic valve disease.
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Wassif H, Saad M, Desai R, Hajj‐Ali RA, Menon V, Chaudhury P, Nakhla M, Puri R, Prasada S, Reed GW, Ziada K, Kapadia S, Desai M, Mentias A. Outcomes Following Acute Coronary Syndrome in Patients With and Without Rheumatic Immune‐Mediated Inflammatory Diseases. J Am Heart Assoc 2022; 11:e026411. [DOI: 10.1161/jaha.122.026411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Rheumatic immune mediated inflammatory diseases (IMIDs) are associated with high risk of acute coronary syndrome. The long‐term prognosis of acute coronary syndrome in patients with rheumatic IMIDs is not well studied.
Methods and Results
We identified Medicare beneficiaries admitted with a primary diagnosis of myocardial infarction (MI) from 2014 to 2019. Outcomes of patients with MI and concomitant rheumatic IMIDs including systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, dermatomyositis, or psoriasis were compared with propensity matched control patients without rheumatic IMIDs. One‐to‐three propensity‐score matching was done for exact age, sex, race, ST‐segment–elevation MI, and non–ST‐segment–elevation MI variables and greedy approach on other comorbidities. The study primary outcome was all‐cause mortality. The study cohort included 1 654 862 patients with 3.6% prevalence of rheumatic IMIDs, the most common of which was rheumatoid arthritis, followed by systemic lupus erythematosus. Patients with rheumatic IMIDs were younger, more likely to be women, and more likely to present with non–ST‐segment–elevation MI. Patients with rheumatic IMIDs were less likely to undergo coronary angiography, percutaneous coronary intervention or coronary artery bypass grafting. After propensity‐score matching, at median follow up of 24 months (interquartile range 9–45), the risk of mortality (adjusted hazard ratio [HR], 1.15 [95% CI, 1.14–1.17]), heart failure (HR, 1.12 [95% CI 1.09–1.14]), recurrent MI (HR, 1.08 [95% CI 1.06–1.11]), and coronary reintervention (HR, 1.06 [95% CI, 1.01–1.13]) (
P
<0.05 for all) was higher in patients with versus without rheumatic IMIDs.
Conclusions
Patients with MI and rheumatic IMIDs have higher risk of mortality, heart failure, recurrent MI, and need for coronary reintervention during follow‐up compared with patients without rheumatic IMIDs.
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Guo R, Liang JH, Zhang Y, Lutchenkov M, Li Z, Wang Y, Trujillo-Alonso V, Puri R, Giulino-Roth L, Gewurz BE. Methionine metabolism controls the B cell EBV epigenome and viral latency. Cell Metab 2022; 34:1280-1297.e9. [PMID: 36070681 PMCID: PMC9482757 DOI: 10.1016/j.cmet.2022.08.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 08/13/2022] [Accepted: 08/15/2022] [Indexed: 12/12/2022]
Abstract
Epstein-Barr virus (EBV) subverts host epigenetic pathways to switch between viral latency programs, colonize the B cell compartment, and reactivate. Within memory B cells, the reservoir for lifelong infection, EBV genomic DNA and histone methylation marks restrict gene expression. But this epigenetic strategy also enables EBV-infected tumors, including Burkitt lymphomas, to evade immune detection. Little is known about host cell metabolic pathways that support EBV epigenome landscapes. We therefore used amino acid restriction, metabolomic, and CRISPR approaches to identify that an abundant methionine supply and interconnecting methionine and folate cycles maintain Burkitt EBV gene silencing. Methionine restriction, or methionine cycle perturbation, hypomethylated EBV genomes and de-repressed latent membrane protein and lytic gene expression. Methionine metabolism also shaped EBV latency gene regulation required for B cell immortalization. Dietary methionine restriction altered murine Burkitt xenograft metabolomes and de-repressed EBV immunogens in vivo. These results highlight epigenetic/immunometabolism crosstalk supporting the EBV B cell life cycle and suggest therapeutic approaches.
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Amat-Santos I, Loureiro RE, Gonzalez IC, Pascual I, Mascherbauer J, Abdul-Jawad Altisent O, Nombela-Franco L, Nouche RT, Moreno R, Puri R, Gomez-Herrero J, Blasco-Turrion S. TCT-530 Short-Term Structural Remodeling Following Bicaval TricValve Implantation for Treating Severe Tricuspid Regurgitation. J Am Coll Cardiol 2022. [DOI: 10.1016/j.jacc.2022.08.625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Isogai T, Agrawal A, Shekhar S, Spilias N, Puri R, Krishnaswamy A, Yun J, Kapadia S, Reed G. TCT-449 Outcomes of Transfemoral Transcatheter Aortic Valve Replacement Requiring Concomitant Peripheral Vascular Intervention. J Am Coll Cardiol 2022. [DOI: 10.1016/j.jacc.2022.08.528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Puri R, Spencer J, Tchetche D, Forrest J, Reardon M, Sanchez JZ, Popma J, Tang G. TCT-494 The Evolut Supra-Annular, Self-Expanding Transcatheter Aortic Bioprosthesis Provides Symmetric Scaffolding for Leaflet Coaptation Despite Variable Annular Morphology. J Am Coll Cardiol 2022. [DOI: 10.1016/j.jacc.2022.08.583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Ramchand J, Iskandar JP, Layoun H, Puri R, Chetrit M, Burrell LM, Krishnaswamy A, Griffin BP, Yun JJ, Flamm SD, Kapadia SR, Kwon DH, Harb SC. Effect of Myocardial Tissue Characterization Using Native T1 to Predict the Occurrence of Adverse Events in Patients With Chronic Kidney Disease and Severe Aortic Stenosis. Am J Cardiol 2022; 183:85-92. [PMID: 36031412 DOI: 10.1016/j.amjcard.2022.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 11/28/2022]
Abstract
Among patients with chronic kidney disease (CKD), aortic stenosis (AS) is associated with a significantly higher rate of mortality. We aimed to evaluate whether diffuse myocardial fibrosis, determined using native T1 mapping, has prognostic utility in predicting major adverse cardiovascular events (MACEs), including all-cause mortality or heart failure hospitalization, in patients with CKD and severe AS who are evaluated for transcatheter aortic valve implantation. Cardiac magnetic resonance with T1 mapping using the modified Look-Locker inversion recovery technique was performed in 117 consecutive patients with severe AS and CKD (stage ≥3). Patients were followed up to determine the occurrence of MACE. The mean age of the 117 patients in the cohort was 82 ± 8 years. Native T1 was 1,055 ms (25th- to 75th percentiles 1,031 to 1,078 ms), which is higher than previously reported in healthy controls. Patients with higher T1 times were more likely to have higher N-terminal pro-B-type natriuretic peptide levels (4,122 [IQR 1,578 to 7,980] pg/ml vs 1,678 [IQR 493 to 2,851] pg/ml, p = 0.005) and a history of heart failure (33% vs 9%, p = 0.034). After median follow-up of 3.4 years, MACE occurred in 71 patients (61%). The Society of Thoracic Surgeons predicted risk of mortality score (hazard ratio [HR] 1.07, 95% confidence interval [CI] 1.02 to 1.12, p = 0.006), native T1 >1,024 ms (HR 2.10, 95% CI 1.09 to 4.06, p = 0.028), and New York Heart Association class (HR 1.56, 95% 1.09 to 2.34, p = 0.016) were independent predictors of MACE. Longer native T1 was associated with MACE occurrence in patients with CKD and severe AS.
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Dykun I, Clark D, Carlo J, Lincoff AM, Menon V, Nissen SE, Nicholls SJ, Puri R. Longitudinal High-Sensitivity C-Reactive Protein and Longer-Term Cardiovascular Outcomes in Optimally-Treated Patients With High-Risk Vascular Disease. Am J Cardiol 2022; 181:1-8. [PMID: 35970631 DOI: 10.1016/j.amjcard.2022.06.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/22/2022] [Accepted: 06/28/2022] [Indexed: 11/01/2022]
Abstract
The relation between serial high-sensitivity C-reactive protein (hsCRP) and long-term major cardiovascular events (MACEs; cardiovascular death, myocardial infarction, stroke, coronary revascularization, hospitalization for unstable angina) has not been explored in optimally-treated patients with atherosclerotic cardiovascular disease. We tested the hypothesis that longitudinal follow-up hsCRP (repeated measures over time) would associate with 30-month MACE rates. We performed a post hoc analysis of ACCELERATE (Assessment of Clinical Effects of Cholesteryl Ester Transfer Protein Inhibitor with Evacetrapib in Patients with High-Risk for Vascular Outcomes), involving optimally-treated patients with high-risk vascular disease, with available baseline and at least 1 follow-up hsCRP level. Using multivariable Cox proportional hazard models, we determined the association of longitudinal follow-up hsCRP with MACE at 30 months among 8,563 patients (aged 64.6 ± 9 years, 22% women). Patients with incident MACE (n = 961) had higher baseline hsCRP levels (1.77 vs 1.46 mg/L, p <0.0001 for patients with and without MACE, respectively) and showed an upward trajectory during follow-up, whereas median hsCRP levels remained <2 mg/L at all time points (1.83 vs 1.53 mg/L, 1.91 vs 1.53 mg/L, 1.76 vs 1.37 mg/L, at 3, 12, and 24 months, respectively). In a multivariable analysis, higher longitudinal hsCRP levels were independently associated with MACE (hazard ratio [95% confidence interval] per SD 1.19 [1.10 to 1.29], p <0.001), the majority of its individual components and all-cause death. Multivariable models containing longitudinal hsCRP provided improved predictive ability of MACE over baseline hsCRP. In the setting of established medical therapies, longitudinal follow-up hsCRP was independently associated with long-term MACE. In conclusion, these findings suggest that longitudinal hsCRP represents a novel approach of residual cardiovascular risk even when on-treatment hsCRP levels remain <2 mg/L.
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Majmundar M, Patel KN, Doshi R, Anantha-Narayanan M, Kumar A, Reed GW, Puri R, Kapadia SR, Jaradat ZA, Bhatt DL, Kalra A. Comparison of 6-Month Outcomes of Endovascular vs Surgical Revascularization for Patients With Critical Limb Ischemia. JAMA Netw Open 2022; 5:e2227746. [PMID: 35984655 PMCID: PMC9391961 DOI: 10.1001/jamanetworkopen.2022.27746] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE The Bypass Versus Angioplasty for Severe Ischemia of the Leg randomized controlled trial showed comparable outcomes between endovascular revascularization (ER) and surgical revascularization (SR) for patients with critical limb ischemia (CLI). However, several observational studies showed mixed results. Most of these studies were conducted before advanced endovascular technologies were available. OBJECTIVE To compare ER and SR treatment strategies for 6-month outcomes among patients with CLI. DESIGN, SETTING, AND PARTICIPANTS This retrospective, population-based cohort study used the Nationwide Readmissions Database to identify 66 277 patients with CLI who underwent ER or SR from January 1, 2016, to December 31, 2018. Data analyses were conducted from January 1, 2022, to February 8, 2022. A propensity score with 1:1 matching was applied. Patients with CLI who underwent ER or SR were identified, and those with missing information on the length of stay and/or younger than 18 years were excluded. EXPOSURES Endovascular or surgical revascularization. MAIN OUTCOMES AND MEASURES The primary outcome was a major amputation at 6 months. Significant secondary outcomes were in-hospital and 6-month mortality and an in-hospital safety composite of acute kidney injury, major bleeding, and vascular complication. Subgroup analysis was conducted for major amputation in high-volume centers. RESULTS A total of 66 277 patients were identified between 2016 and 2018 who underwent ER or SR for CLI. The Nationwide Readmissions Database does not provide racial and ethnic categories. The mean (SD) age of the cohort was 69.3 (12) years, and 62.5% of patients were male. A total of 54 546 patients (82.3%) underwent ER and 11 731 (17.7%) underwent SR. After propensity score matching, 11 106 matched pairs were found. Endovascular revascularization was associated with an 18% higher risk of major amputation compared with SR (997 of 10 090 [9.9%] vs 869 of 10 318 [8.4%]; hazard ratio, 1.18; 95% CI, 1.08-1.29; P = .001). However, no difference was observed in major amputation risk when both procedures were performed in high-volume centers. Endovascular revascularization and SR had similar mortality rates (517 of 11 106 [4.7%] vs 490 of 11 106 [4.4%]; hazard ratio, 1.06; 95% CI, 0.93-1.20; P = .39). However, the ER group had a 17% lower risk of in-hospital safety outcomes compared with the SR group (2584 of 11 106 [23.3%] vs 2979 of 11 106 [26.8%]; odds ratio, 0.83; 95% CI, 0.78-0.88; P < .001). CONCLUSIONS AND RELEVANCE The results of this study suggest that ER was safer, without any difference in mortality, but ER was associated with an increased risk of major amputation compared with SR. However, the risk of major amputation was similar when both procedures were performed at high-volume centers.
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