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Shcherbakov-Wu W, Saris S, Sheehan TJ, Wong NN, Powers ER, Krieg F, Kovalenko MV, Willard AP, Tisdale WA. Persistent enhancement of exciton diffusivity in CsPbBr 3 nanocrystal solids. Sci Adv 2024; 10:eadj2630. [PMID: 38381813 PMCID: PMC10881049 DOI: 10.1126/sciadv.adj2630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 01/19/2024] [Indexed: 02/23/2024]
Abstract
In semiconductors, exciton or charge carrier diffusivity is typically described as an inherent material property. Here, we show that the transport of excitons among CsPbBr3 perovskite nanocrystals (NCs) depends markedly on how recently those NCs were occupied by a previous exciton. Using transient photoluminescence microscopy, we observe a striking dependence of the apparent exciton diffusivity on excitation laser power that does not arise from nonlinear exciton-exciton interactions or thermal heating. We interpret our observations with a model in which excitons cause NCs to transition to a long-lived metastable configuration that markedly increases exciton transport. The exciton diffusivity observed here (>0.15 square centimeters per second) is considerably higher than that observed in other NC systems, revealing unusually strong excitonic coupling between NCs. The finding of a persistent enhancement in excitonic coupling may help explain other photophysical behaviors observed in CsPbBr3 NCs, such as superfluorescence, and inform the design of optoelectronic devices.
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Affiliation(s)
- Wenbi Shcherbakov-Wu
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Chemistry, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Seryio Saris
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
- Laboratory of Nanochemistry for Energy (LNCE), Institute of Chemical Sciences and Engineering (ISIC), École Polytechnique Fédérale de Lausanne, CH-1950 Sion, Switzerland
| | - Thomas John Sheehan
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Narumi Nagaya Wong
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Eric R. Powers
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Franziska Krieg
- Department of Chemistry and Applied Bioscience, ETH Zürich, Zürich, Switzerland
- Laboratory for Thin Films and Photovoltaics and Laboratory for Transport at Nanoscale Interfaces, Empa – Swiss Federal Laboratories for Materials Science and Technology, Dübendorf, Switzerland
| | - Maksym V. Kovalenko
- Department of Chemistry and Applied Bioscience, ETH Zürich, Zürich, Switzerland
- Laboratory for Thin Films and Photovoltaics and Laboratory for Transport at Nanoscale Interfaces, Empa – Swiss Federal Laboratories for Materials Science and Technology, Dübendorf, Switzerland
| | - Adam P. Willard
- Department of Chemistry, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - William A. Tisdale
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
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2
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Lee WS, Cho Y, Powers ER, Paritmongkol W, Sakurada T, Kulik HJ, Tisdale WA. Light Emission in 2D Silver Phenylchalcogenolates. ACS Nano 2022; 16:20318-20328. [PMID: 36416726 DOI: 10.1021/acsnano.2c06204] [Citation(s) in RCA: 1] [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] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Silver phenylselenolate (AgSePh, also known as "mithrene") and silver phenyltellurolate (AgTePh, also known as "tethrene") are two-dimensional (2D) van der Waals semiconductors belonging to an emerging class of hybrid organic-inorganic materials called metal-organic chalcogenolates. Despite having the same crystal structure, AgSePh and AgTePh exhibit a strikingly different excitonic behavior. Whereas AgSePh exhibits narrow, fast luminescence with a minimal Stokes shift, AgTePh exhibits comparatively slow luminescence that is significantly broadened and red-shifted from its absorption minimum. Using time-resolved and temperature-dependent absorption and emission microspectroscopy, combined with subgap photoexcitation studies, we show that exciton dynamics in AgTePh films are dominated by an intrinsic self-trapping behavior, whereas dynamics in AgSePh films are dominated by the interaction of band-edge excitons with a finite number of extrinsic defect/trap states. Density functional theory calculations reveal that AgSePh has simple parabolic band edges with a direct gap at Γ, whereas AgTePh has a saddle point at Γ with a horizontal splitting along the Γ-N1 direction. The correlation between the unique band structure of AgTePh and exciton self-trapping behavior is unclear, prompting further exploration of excitonic phenomena in this emerging class of hybrid 2D semiconductors.
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Affiliation(s)
- Woo Seok Lee
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts02139, United States
- Department of Materials Science and Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts02139, United States
| | - Yeongsu Cho
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts02139, United States
| | - Eric R Powers
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts02139, United States
| | - Watcharaphol Paritmongkol
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts02139, United States
- Department of Chemistry, Massachusetts Institute of Technology, Cambridge, Massachusetts02139, United States
| | - Tomoaki Sakurada
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts02139, United States
| | - Heather J Kulik
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts02139, United States
| | - William A Tisdale
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts02139, United States
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3
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Ha SK, Shcherbakov-Wu W, Powers ER, Paritmongkol W, Tisdale WA. Power-Dependent Photoluminescence Efficiency in Manganese-Doped 2D Hybrid Perovskite Nanoplatelets. ACS Nano 2021; 15:20527-20538. [PMID: 34793677 DOI: 10.1021/acsnano.1c09103] [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] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Substitutional metal doping is a powerful strategy for manipulating the emission spectra and excited state dynamics of semiconductor nanomaterials. Here, we demonstrate the synthesis of colloidal manganese (Mn2+)-doped organic-inorganic hybrid perovskite nanoplatelets (chemical formula: L2[APb1-xMnxBr3]n-1Pb1-xMnxBr4; L, butylammonium; A, methylammonium or formamidinium; n (= 1 or 2), number of Pb1-xMnxBr64- octahedral layers in thickness) via a ligand-assisted reprecipitation method. Substitutional doping of manganese for lead introduces bright (approaching 100% efficiency) and long-lived (>500 μs) midgap Mn2+ atomic states, and the doped nanoplatelets exhibit dual emission from both the band edge and the dopant state. Photoluminescence quantum yields and band-edge-to-Mn intensity ratios exhibit strong excitation power dependence, even at a very low incident intensity (<100 μW/cm2). Surprisingly, we find that the saturation of long-lived Mn2+ dopant sites cannot explain our observation. Instead, we propose an alternative mechanism involving the cross-relaxation of long-lived Mn-site excitations by freely diffusing band-edge excitons. We formulate a kinetic model based on this cross-relaxation mechanism that quantitatively reproduces all of the experimental observations and validate the model using time-resolved absorption and emission spectroscopy. Finally, we extract a concentration-normalized microscopic rate constant for band edge-to-dopant excitation transfer that is ∼10× faster in methylammonium-containing nanoplatelets than in formamidinium-containing nanoplatelets. This work provides fundamental insight into the interaction of mobile band edge excitons with localized dopant sites in 2D semiconductors and expands the toolbox for manipulating light emission in perovskite nanomaterials.
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Affiliation(s)
- Seung Kyun Ha
- Department of Chemical Engineering, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02139, United States
| | - Wenbi Shcherbakov-Wu
- Department of Chemical Engineering, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02139, United States
- Department of Chemistry, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02139, United States
| | - Eric R Powers
- Department of Chemical Engineering, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02139, United States
| | - Watcharaphol Paritmongkol
- Department of Chemical Engineering, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02139, United States
- Department of Chemistry, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02139, United States
| | - William A Tisdale
- Department of Chemical Engineering, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02139, United States
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4
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Kuku KO, Garcia-Garcia HM, Doros G, Mintz GS, Ali ZA, Singh S, Cate TT, Powers ER, Wong SC, Wykrzykowska J, Shah PR, Sum ST, Torguson R, Di Mario C, Waksman R. Two-year plaque level outcomes involving the left anterior descending artery: insights from the Lipid-Rich Plaque study. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Coronary artery disease (CAD) is more frequently seen in the left anterior descending artery (LAD). LAD disease resulting in an acute anterior wall myocardial infarction (MI) is associated with a low left ventricular ejection fraction and invariably a worsened prognosis. The Lipid Rich Plaque (LRP) Study reported the strong association between NIRS-IVUS derived max4mmLCBI and future plaque events in non-culprit vessels.
Objective
To report the events involving the LAD versus the other major coronary vessels in the Lipid-Rich Plaque study.
Methods
The LRP Study was an international, multicenter, prospective cohort study conducted in patients with suspected CAD who underwent cardiac catheterization with possible ad hoc percutaneous coronary intervention (PCI) for an index event. Plaque level events within the subsequent 2 years were adjudicated. Plaque level events were defined as the composite of cardiac death, cardiac arrest, non-fatal MI, acute coronary syndrome (ACS), revascularization by coronary artery bypass grafting (CABG) or PCI, and rehospitalization for angina with >20% stenosis progression related and unrelated to the treatment at index procedure. All together these events were reported as Non-Culprit Lesion-related Major Adverse Cardiac Events (NC-MACE). Prespecified subgroups of segments were defined according to LAD (vs. non-LAD) with maxLCBI4mm ≤400 or >400.
Results
A total of 57 plaque events occurred through 2 years of follow-up. More than half occurred in the LAD, followed by the LCX and the RCA. There were more, albeit non-statistically significant, lipid-rich plaques in the LAD, compared to the LCX and RCA: 12.5% vs 10.4% and 11.3%, respectively, p=0.097. A minimum lumen area (MLA) ≤4mm2 within the maxLCBI4mm was observed more in the LAD and the LCX, compared to the RCA: 34.1% vs 25.9% vs 13.7%, respectively, p<0.001. Lipid rich plaque (maxLCBI4mm>400) was present in 20/57 (35.1%) of the plaque level events, a large PB (≥70%) was present in 6/57 (10.5%), and a small MLA (≤4mm2) was present in 26/57 (45.6%). Out of the 57 plaque level events, 4 (7%) had all three high risk plaque characteristics.
Presence of an elevated maxLCBI4mm (>400) was predictive of NC-MACE in all subgroups (for LAD >400 HR 4.32; 95% CI (1.93, 9.69; p 0.0004) and for the non-LAD >400 HR 2.56; 95% CI (1.06, 6.17; p 0.0354).
Conclusion
Non-culprit segments in the LAD with maxLCBI4mm values >400 were more frequently associated with plaque level events than in the lipid -rich segments in the other epicardial vessels. This sub-study results point to the unequivocal value of maxLCBI4mm>400 in predicting future plaque level events especially in the LAD.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Infraredx Plaque Events-Ware Segment Locations
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Affiliation(s)
- K O Kuku
- MedStar Health Research Institute, Cardiovascular Imaging, Washington DC, United States of America
| | - H M Garcia-Garcia
- Medstar Washington Hospital Centre, Interventional Cardiology, Washington, DC, United States of America
| | - G Doros
- Medstar Washington Hospital Centre, Interventional Cardiology, Washington, DC, United States of America
| | - G S Mintz
- Medstar Washington Hospital Centre, Interventional Cardiology, Washington, DC, United States of America
| | - Z A Ali
- Columbia University, Interventional Cardiology, New York, United States of America
| | - S Singh
- Long Island Jewish, Interventional Cardiology, New York, United States of America
| | - T T Cate
- University of Amsterdam, Cardiology, Amsterdam, Netherlands (The)
| | - E R Powers
- Medical University of South Carolina, Cardiology, Charleston, United States of America
| | - S C Wong
- Weill Cornell Medicine, Cardiology, New York, United States of America
| | - J Wykrzykowska
- University Medical Center Groningen, Cardiology, Groningen, Netherlands (The)
| | - P R Shah
- Infraredx, Boston, United States of America
| | - S T Sum
- Infraredx, Boston, United States of America
| | - R Torguson
- Icahn School of Medicine at Mount Sinai, Cardiology, New York, United States of America
| | - C Di Mario
- Royal Brompton Hospital, Cardiology, London, United Kingdom
| | - R Waksman
- Medstar Washington Hospital Centre, Interventional Cardiology, Washington, DC, United States of America
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5
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Viray MC, Bonno EL, Gabrielle ND, Maron BA, Atkins J, Amoroso NS, Fernandes VL, Maran A, Nielsen CD, Powers ER, Steinberg DH, Todoran TM, Di Salvo TG, Jackson GR, Houston BA, Tedford RJ. Role of Pulmonary Artery Wedge Pressure Saturation During Right Heart Catheterization: A Prospective Study. Circ Heart Fail 2020; 13:e007981. [PMID: 33016102 PMCID: PMC7674188 DOI: 10.1161/circheartfailure.120.007981] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michael C. Viray
- Division of Cardiology, Department of Medicine, Medical University of South Carolina; Charleston, SC
| | - Eric L. Bonno
- Division of Cardiology, Department of Medicine, Medical University of South Carolina; Charleston, SC
| | - Nicholas D. Gabrielle
- Division of Cardiology, Department of Medicine, Medical University of South Carolina; Charleston, SC
| | - Bradley A. Maron
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Jessica Atkins
- Division of Cardiology, Department of Medicine, Medical University of South Carolina; Charleston, SC
| | - Nicholas S. Amoroso
- Division of Cardiology, Department of Medicine, Medical University of South Carolina; Charleston, SC
| | - Valerian L.C. Fernandes
- Division of Cardiology, Department of Medicine, Medical University of South Carolina; Charleston, SC
| | - Anbukarasi Maran
- Division of Cardiology, Department of Medicine, Medical University of South Carolina; Charleston, SC
| | - Christopher D. Nielsen
- Division of Cardiology, Department of Medicine, Medical University of South Carolina; Charleston, SC
| | - Eric R. Powers
- Division of Cardiology, Department of Medicine, Medical University of South Carolina; Charleston, SC
| | - Daniel H. Steinberg
- Division of Cardiology, Department of Medicine, Medical University of South Carolina; Charleston, SC
| | - Thomas M. Todoran
- Division of Cardiology, Department of Medicine, Medical University of South Carolina; Charleston, SC
| | - Thomas G. Di Salvo
- Division of Cardiology, Department of Medicine, Medical University of South Carolina; Charleston, SC
| | - Gregory R. Jackson
- Division of Cardiology, Department of Medicine, Medical University of South Carolina; Charleston, SC
| | - Brian A. Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina; Charleston, SC
| | - Ryan J. Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina; Charleston, SC
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6
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Abstract
Broadband emission in lead iodide 2D perovskites has been alternately attributed to self-trapped excitons (STEs) or permanent structural defects and/or impurities. Here, we investigate six different multilayered (n > 1) 2D lead iodide perovskites as a function of sample temperature from 5 to 300 K. We distinguish shallow defect-associated emission from a broad near-infrared (NIR) spectral feature, which we assign to an STE through subgap photoexcitation experiments. When we varied the thickness (n = 2, 3, 4), A-site cation (methylammonium vs formamidinium), and organic spacer (butylammonium vs hexylammonium vs phenylethylammonium), we found that the temperature dependence of broad NIR emission was strongly correlated with both the strength of electron-phonon coupling and the extent of structural deformation of the ground-state lattice, strongly supporting the assignment of this spectral feature to an STE. However, the extent to which formation of these STEs is intrinsic versus defect-assisted remains open to debate.
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Affiliation(s)
- Watcharaphol Paritmongkol
- Department of Chemistry, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
| | - Eric R Powers
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
| | - Nabeel S Dahod
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
| | - William A Tisdale
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
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7
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Viray MC, Bonno EL, Gabrielle N, Atkins JL, Amoroso NS, Fernandez VL, Maran A, Nielsen CD, Powers ER, Steinberg DH, Todoran TM, Salvo TGD, Jackson GR, Houston BA, Tedford RJ. The Critical Role of Pulmonary Artery Wedge Pressure Saturation In The Standardization of Pulmonary Artery Wedge Pressure Measurement. J Card Fail 2020. [DOI: 10.1016/j.cardfail.2020.09.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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8
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Affiliation(s)
- Khaled M Ziada
- Division of Cardiovascular Medicine Gill Heart & Vascular Institute University of Kentucky Lexington KY
| | - Eric R Powers
- Division of Cardiovascular Medicine Medical University of South Carolina Charleston SC
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9
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Yamamoto MH, Maehara A, Stone GW, Kini AS, Brilakis ES, Rizik DG, Shunk K, Powers ER, Tobis JM, Maini BS, Dixon SR, Goldstein JA, Petersen JL, Généreux P, Shah PR, Crowley A, Nicholls SJ, Mintz GS, Muller JE, Weisz G. 2-Year Outcomes After Stenting of Lipid-Rich and Nonrich Coronary Plaques. J Am Coll Cardiol 2020; 75:1371-1382. [DOI: 10.1016/j.jacc.2020.01.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 12/24/2019] [Accepted: 01/20/2020] [Indexed: 12/28/2022]
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10
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Houston BA, Tedford RJ, Baxley RL, Sykes B, Powers ER, Nielsen CD, Steinberg DH, Maran A, Fernandes VLC, Todoran T, Jones JA, Zile MR. Relation of Lymphangiogenic Factor Vascular Endothelial Growth Factor-D to Elevated Pulmonary Artery Wedge Pressure. Am J Cardiol 2019; 124:756-762. [PMID: 31296367 DOI: 10.1016/j.amjcard.2019.05.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/17/2019] [Accepted: 05/20/2019] [Indexed: 01/30/2023]
Abstract
Lymphatic flow is augmented in states of chronic heart failure (cHF). However, the biological mechanism driving increased lymphatic flow capacity (lymphangiogenesis) in cHF is unknown. Recent studies have indicated that vascular endothelial growth factors (VEGF-A, -C, and -D) are involved in lymphangiogenesis. This study examined the association between VEGF-A, -C, and -D levels, invasively measured hemodynamics, and heart failure symptoms. Subjects who underwent clinically indicated right heart catheterization at Medical University of South Carolina between 12/2016 and 7/2018 were eligible for inclusion. These subjects underwent clinical assessment of cHF severity (including 6MWT and KCCQ), hemodynamic assessment with right heart catheterization, laboratory studies including B-type natriuretic peptide, and concomitant measurement of VEGF-A, -C, and -D. Fifty-six patients were included for analysis. Subjects with elevated pulmonary artery wedge pressure (PAWP) had significantly higher VEGF-D levels (263 ± 415 pg/ml vs 65 ± 101 pg/ml; p = 0.02). PAWP was not associated with VEGF-A or VEGF-C levels. When stratified by VEGF-D, subjects with elevated VEGF-D had clinical and hemodynamic characteristics associated with worse HF severity (lower ejection fraction, higher b-type natriuretic peptide, higher PAWP, lower cardiac output), but were not more symptomatic by Kansas City Cardiomyopathy Questionnaire scores and had similar 6-minute walk test distance compared with subjects with lower VEGF-D. Subjects with an elevated VEGF-D were more likely to have a diagnosis of heart failure for >3 years. In conclusion, VEGF-D is associated with elevated PAWP in cHF, and elevated VEGF-D may mitigate cHF symptoms.
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Affiliation(s)
- Brian A Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Renee L Baxley
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Brandon Sykes
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Eric R Powers
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Christopher D Nielsen
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Daniel H Steinberg
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Anbukarasi Maran
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Valerian L C Fernandes
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Thomas Todoran
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jeffrey A Jones
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Michael R Zile
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina; Research Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina
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11
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Powers ER. Aspiration Thrombectomy: The Possible Importance of Effective Thrombus Removal and Minimal Residual Thrombus Burden. JACC Cardiovasc Interv 2018; 9:2012-2013. [PMID: 27712736 DOI: 10.1016/j.jcin.2016.07.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 07/25/2016] [Accepted: 07/28/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Eric R Powers
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina.
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12
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Floroff CK, Palm NM, Steinberg DH, Powers ER, Wiggins BS. Higher Maximum Doses and Infusion Rates Compared with Standard Unfractionated Heparin Therapy Are Associated with Adequate Anticoagulation without Increased Bleeding in Both Obese and Nonobese Patients with Cardiovascular Indications. Pharmacotherapy 2017; 37:393-400. [DOI: 10.1002/phar.1904] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | | | | | - Eric R. Powers
- Medical University of South Carolina; Charleston South Carolina
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13
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Rier JD, Schoepf UJ, Renker M, Baumann S, Powers ER. Aortocoronary saphenous vein graft aneurysm causing high-gradient right ventricular outflow tract obstruction. Eur Heart J Cardiovasc Imaging 2014; 16:117. [PMID: 25227269 DOI: 10.1093/ehjci/jeu178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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] Open
Affiliation(s)
- Jeremy D Rier
- Heart and Vascular Center, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Drive, Charleston, SC 29425-2260, USA
| | - U Joseph Schoepf
- Heart and Vascular Center, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Drive, Charleston, SC 29425-2260, USA
| | - Matthias Renker
- Heart and Vascular Center, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Drive, Charleston, SC 29425-2260, USA Department of Internal Medicine I, Giessen University, Giessen, Germany
| | - Stefan Baumann
- Heart and Vascular Center, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Drive, Charleston, SC 29425-2260, USA First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany
| | - Eric R Powers
- Heart and Vascular Center, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Drive, Charleston, SC 29425-2260, USA
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14
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Steinberg DH, Richardson S, Patel CA, Machado R, Castillo-Sang M, Powers ER, Crawford FA, Gregg DM, Abernathy JH, Finley A, Ikonomidis JS. Transcatheter aortic valve replacement--the initial MUSC experience. J S C Med Assoc 2013; 109:121-125. [PMID: 24908911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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15
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Dohi T, Weisz G, Powers ER, Steinberg DH, Goldstein J, Shah PR, Muller JE, Mintz GS, Stone G, Maehara A. TCT-583 The Extent of Lipid-Rich Plaque Assessed by Near-Infrared Spectroscopy May Predict DES Failure: A COLOR Registry Analysis. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.08.1330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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16
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Affiliation(s)
- Thomas M. Todoran
- Division of Cardiology, Medical University of South Carolina, Charleston, SC (T.M.T., E.R.P.)
- Correspondence to: Thomas M. Todoran, MD, MSc, 25 Courtenay Drive MSC 592, Charleston, SC 29425. E‐mail:
| | - Eric R. Powers
- Division of Cardiology, Medical University of South Carolina, Charleston, SC (T.M.T., E.R.P.)
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17
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Leonardi RA, Townsend JC, Patel CA, Wolf BJ, Todoran TM, Powers ER, Steinberg DH, Fernandes VL, Nielsen CD. Alcohol septal ablation for obstructive hypertrophic cardiomyopathy: outcomes in young, middle-aged, and elderly patients. Catheter Cardiovasc Interv 2013; 82:838-45. [PMID: 22936613 DOI: 10.1002/ccd.24643] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Accepted: 08/27/2012] [Indexed: 11/09/2022]
Abstract
OBJECTIVES We compared the efficacy and safety of alcohol septal ablation (ASA) for obstructive hypertrophic cardiomyopathy (HCM) in young, middle-aged, and elderly patients. BACKGROUND Intersociety guidelines suggest based on limited evidence that young patients with medically refractory symptoms of obstructive HCM should undergo surgical myectomy while elderly patients may be more appropriate for ASA. METHODS Data for 360 patients undergoing 389 ASAs were prospectively collected and retrospectively analyzed according to age. RESULTS Young (<45 years), middle-aged (45-64 years), and elderly (≥65 years) patients comprised 28, 40, and 32% of the study population, respectively. Young patients had thicker left ventricular septal walls at baseline, and elderly patients had more comorbidity and dyspnea. Resting, mean left ventricular outflow tract gradients (LVOTGs) were similar across the age groups at baseline (62, 66, and 68 mm Hg, respectively; P = NS for all comparisons). LVOTGs and dyspnea were significantly and similarly improved in all age groups immediately after ASA and through 12 months of follow-up (P < 0.001 for before and after comparisons; P = NS for intergroup comparisons). Complication rates were similar for young and middle-aged patients but higher for elderly patients (9.1 and 6.3% vs. 20.8%, respectively; P ≤ 0.016 for elderly vs. others). Mortality rates for young and middle-aged patients were lower than for elderly patients, but the differences were not statistically significant. CONCLUSIONS Patients undergoing ASA had significant and similar improvements in LVOTGs and symptoms regardless of age. Procedural complications were increased in elderly patients, who had numerically but not statistically significantly higher mortality rates.
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Affiliation(s)
- Robert A Leonardi
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
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Townsend JC, Heard R, Powers ER, Reuben A. Usefulness of international normalized ratio to predict bleeding complications in patients with end-stage liver disease who undergo cardiac catheterization. Am J Cardiol 2012; 110:1062-5. [PMID: 22728001 DOI: 10.1016/j.amjcard.2012.05.043] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Revised: 05/09/2012] [Accepted: 05/09/2012] [Indexed: 12/28/2022]
Abstract
Patients with end-stage liver disease frequently require invasive cardiac procedures in preparation for liver transplantation. Because of the impaired hepatic function, these patients often have a prolonged prothrombin time and elevated international normalized ratio (INR). To determine whether an abnormal prothrombin time/INR is predictive of bleeding complications from invasive cardiac procedures, we retrospectively reviewed, for bleeding complications, the databases and case records of our series of patients with advanced cirrhosis who underwent cardiac catheterization. A total of 157 patients underwent isolated right-sided heart catheterization, and 83 underwent left-sided heart catheterization or combined left- and right-sided heart catheterization. The INR ranged from 0.93 to 2.35. No major procedure-related complications occurred. Several patients in each group required a blood transfusion for gastrointestinal bleeding but not for procedure-related bleeding. No significant change was found in the hemoglobin after right-sided or left-sided heart catheterization, and no correlation was found between the preprocedure INR and the change in postprocedure hemoglobin. When comparing patients with a normal (≤1.5) and elevated (>1.5) INR, no significant difference in hemoglobin after the procedure was found in either group. In conclusion, despite an elevated INR, patients with end-stage liver disease can safely undergo invasive cardiac procedures. An elevated INR does not predict catheterization-related bleeding complications in this patient population.
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Affiliation(s)
- Jacob C Townsend
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA.
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Leonardi RA, Townsend JC, Bonnema DD, Patel CA, Gibbons MT, Todoran TM, Nielsen CD, Powers ER, Steinberg DH. Comparison of percutaneous coronary intervention safety before and during the establishment of a transradial program at a teaching hospital. Am J Cardiol 2012; 109:1154-9. [PMID: 22245405 DOI: 10.1016/j.amjcard.2011.11.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 11/30/2011] [Accepted: 11/30/2011] [Indexed: 01/08/2023]
Abstract
This study sought to examine the safety of percutaneous coronary intervention (PCI) before and during de novo establishment of a transradial (TR) program at a teaching hospital. TR access remains underused in the United States, where cardiology fellowship programs continue to produce cardiologists with little TR experience. Establishment of TR programs at teaching hospitals may affect PCI safety. Starting in July 2009 a TR program was established at a teaching hospital. PCI-related data for academic years 2008 to 2009 (Y1) and 2009 to 2010 (Y2) were prospectively collected and retrospectively analyzed. Of 1,366 PCIs performed over 2 years, 0.1% in Y1 and 28.7% in Y2 were performed by TR access. No major complications were identified in 194 consecutive patients undergoing TR PCI, and combined bleeding and vascular complication rates were lower in Y2 versus Y1 (0.7% vs 2.0%, p = 0.05). Patients treated in Y2 versus Y1 and by TR versus transfemoral approach required slightly more fluoroscopy but similar contrast volumes and had similar procedural durations, lengths of stay, and predischarge mortality rates. PCI success rates were 97% in Y1, 97% in Y2, and 98% in TR cases. TR PCIs were performed by 13 cardiology fellows and 9 attending physicians, none of whom routinely performed TR PCI previously. In conclusion, de novo establishment of a TR program improved PCI safety at a teaching hospital. TR programs are likely to improve PCI safety at other teaching hospitals and should be established in all cardiology fellowship training programs.
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Goldstein JA, Maini B, Dixon SR, Brilakis ES, Grines CL, Rizik DG, Powers ER, Steinberg DH, Shunk KA, Weisz G, Moreno PR, Kini A, Sharma SK, Hendricks MJ, Sum ST, Madden SP, Muller JE, Stone GW, Kern MJ. Detection of Lipid-Core Plaques by Intracoronary Near-Infrared Spectroscopy Identifies High Risk of Periprocedural Myocardial Infarction. Circ Cardiovasc Interv 2011; 4:429-37. [DOI: 10.1161/circinterventions.111.963264] [Citation(s) in RCA: 172] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- James A. Goldstein
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Brijeshwar Maini
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Simon R. Dixon
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Emmanouil S. Brilakis
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Cindy L. Grines
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - David G. Rizik
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Eric R. Powers
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Daniel H. Steinberg
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Kendrick A. Shunk
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Giora Weisz
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Pedro R. Moreno
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Annapoorna Kini
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Samin K. Sharma
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Michael J. Hendricks
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Steve T. Sum
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Sean P. Madden
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - James E. Muller
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Gregg W. Stone
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Morton J. Kern
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
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Townsend J, Heard R, Steinberg DH, Powers ER, Reuben A. ELEVATED INTERNATIONAL NORMALIZED RATIO (INR) IS NOT ASSOCIATED WITH INCREASED BLEEDING IN PATIENTS WITH END-STAGE LIVER DISEASE UNDERGOING INVASIVE CARDIAC PROCEDURES. J Am Coll Cardiol 2011. [DOI: 10.1016/s0735-1097(11)61984-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Townsend J, Steinberg DH, Nielsen CD, Todoran TM, Zwerner PL, McCarty CP, McManus WJ, Sneed JD, Patel CP, Leonardi RA, Brilakis ES, Shunk KA, Goldstein JA, Kern MJ, Maini B, Powers ER. INTRACORONARY LIPID BURDEN AT BIFURCATIONS: RESULTS FROM THE COLOR REGISTRY. J Am Coll Cardiol 2011. [DOI: 10.1016/s0735-1097(11)61472-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Pallares MJ, Powers ER, Zwerner PL, Fowler A, Reeves R, Nappi JM. Barriers to clopidogrel adherence following placement of drug-eluting stents. Ann Pharmacother 2009; 43:259-67. [PMID: 19193589 DOI: 10.1345/aph.1l286] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Nonadherence to clopidogrel after drug-eluting stent (DES) placement is associated with in-stent thrombosis and adverse cardiac events. OBJECTIVE To identify the incidence of and barriers associated with nonadherence to clopidogrel in patients receiving DES. METHODS Patients who received a DES between March 1, 2004, and August 31, 2005, from a single academic medical center were eligible. Telephone interviews were conducted 6 or more months following discharge. Nonadherence was defined as premature discontinuation of or less than 80% adherence to clopidogrel. Patients were asked to identify barriers to adherence. Differences between adherent and nonadherent patients were analyzed using chi(2) and t-test analysis. RESULTS Of the 674 patients identified, 257 (38%) participated. The nonadherence rate was 20%. The majority (58%) of nonadherent patients discontinued therapy prematurely. Patients identified the main reason for discontinuation as medical barriers (18.56%), including perceived adverse effects (9.28%). The incidence of rash was higher in patients who were nonadherent (12% vs 4%; p = 0.049). Overall, 49% of patients recalled receiving discharge counseling regarding adverse effects. A financial barrier was identified by 22 (42%) patients in the nonadherent and 73 (36%) in the adherent group, of whom 64% and 52%, respectively, reported having insurance coverage for medications. Adherent patients reported higher copays ($29.69 vs $18.14; p = 0.01). CONCLUSIONS Prospective studies should be conducted to aid in identifying patients at risk for nonadherence and possible in-stent thrombosis in order to identify interventions to improve adherence.
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Affiliation(s)
- Maria José Pallares
- South Carolina College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA.
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Affiliation(s)
- Balazs Ruzsics
- Department of Radiology (B.R., H.L., P.C., U.J.S.) and Division of Cardiology (E.R.P., U.J.S.), Medical University of South Carolina, Charleston; Department of Radiology, Seoul Medical Center, Seoul, Republic of Korea (H.L.); and Department of Radiology, University of Tuebingen, Germany (T.G.F.)
| | - Heon Lee
- Department of Radiology (B.R., H.L., P.C., U.J.S.) and Division of Cardiology (E.R.P., U.J.S.), Medical University of South Carolina, Charleston; Department of Radiology, Seoul Medical Center, Seoul, Republic of Korea (H.L.); and Department of Radiology, University of Tuebingen, Germany (T.G.F.)
| | - Eric R. Powers
- Department of Radiology (B.R., H.L., P.C., U.J.S.) and Division of Cardiology (E.R.P., U.J.S.), Medical University of South Carolina, Charleston; Department of Radiology, Seoul Medical Center, Seoul, Republic of Korea (H.L.); and Department of Radiology, University of Tuebingen, Germany (T.G.F.)
| | - Thomas G. Flohr
- Department of Radiology (B.R., H.L., P.C., U.J.S.) and Division of Cardiology (E.R.P., U.J.S.), Medical University of South Carolina, Charleston; Department of Radiology, Seoul Medical Center, Seoul, Republic of Korea (H.L.); and Department of Radiology, University of Tuebingen, Germany (T.G.F.)
| | - Philip Costello
- Department of Radiology (B.R., H.L., P.C., U.J.S.) and Division of Cardiology (E.R.P., U.J.S.), Medical University of South Carolina, Charleston; Department of Radiology, Seoul Medical Center, Seoul, Republic of Korea (H.L.); and Department of Radiology, University of Tuebingen, Germany (T.G.F.)
| | - U. Joseph Schoepf
- Department of Radiology (B.R., H.L., P.C., U.J.S.) and Division of Cardiology (E.R.P., U.J.S.), Medical University of South Carolina, Charleston; Department of Radiology, Seoul Medical Center, Seoul, Republic of Korea (H.L.); and Department of Radiology, University of Tuebingen, Germany (T.G.F.)
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Le DE, Powers ER, Bin JP, Leong-Poi H, Goodman NC, Kaul S. Transmyocardial revascularization ameliorates ischemia by attenuating paradoxical catecholamine-induced vasoconstriction. J Nucl Cardiol 2007; 14:207-14. [PMID: 17386383 PMCID: PMC1865521 DOI: 10.1016/j.nuclcard.2006.12.328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2006] [Revised: 12/22/2006] [Accepted: 12/22/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND The mechanism by which transmyocardial revascularization (TMR) offers clinical benefit is controversial. We hypothesized that TMR ameliorates ischemia by reversing paradoxical catecholamine-induced vasoconstriction. METHODS AND RESULTS Chronic ischemic cardiomyopathy was created in 11 dogs by placing ameroid constrictors on the proximal coronary arteries and their major branches. Six weeks later, 35 channels were created percutaneously in the left circumflex artery region, with the left anterior descending artery region serving as control. At rest, wall thickening and myocardial blood flow did not change in the treated region, whereas they deteriorated in the control bed. Contractile and myocardial blood flow reserve increased in the treated region but deteriorated in the control region. There was diminished iodine 123 metaiodobenzylguanidine uptake and a significant reduction in noradrenergic nerves in the treated region compared with the control region, with a corresponding reduction in tissue tyrosine hydroxylase activity. CONCLUSIONS We conclude that the absence of a catecholamine-induced reduction in MBF reserve and contractile reserve in the TMR-treated region with associated evidence of neuronal injury indicates that the relief of exercise-induced ischemia after TMR most likely results from reversal of paradoxical catecholamine-induced vasoconstriction. These findings may have implications in selecting patients who would benefit from TMR.
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Ragosta M, Bishop AH, Lipson LC, Watson DD, Gimple LW, Sarembock IJ, Powers ER. Comparison between angiography and fractional flow reserve versus single-photon emission computed tomographic myocardial perfusion imaging for determining lesion significance in patients with multivessel coronary disease. Am J Cardiol 2007; 99:896-902. [PMID: 17398179 DOI: 10.1016/j.amjcard.2006.11.035] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2006] [Revised: 11/07/2006] [Accepted: 11/07/2006] [Indexed: 01/29/2023]
Abstract
We hypothesized that myocardial perfusion imaging (MPI) would fail to identify all vascular zones with the potential for myocardial ischemia in patients with multivessel coronary disease (MVD). MPI is based on the concept of relative flow reserve. The ability of these techniques to determine the significance of a particular stenosis in the setting of MVD is questionable. Fractional flow reserve (FFR) can determine the significance of individual stenoses. Thirty-six patients with disease involving 88 arteries underwent angiography, FFR, and MPI. FFR was performed using a pressure wire with hyperemia from intracoronary adenosine. Myocardial perfusion images were analyzed quantitatively and segments assigned to a specific coronary artery. The relation between FFR and perfusion was determined for each vascular zone. Of the 88 vessels, the artery was occluded (n=20) or had an abnormal FFR<or=0.75 (n=34) in 54 of 88 (61%). MPI showed no defect in 51 zones (58%). Concordance between angiography, FFR, and MPI was seen in 61 of 88 zones (69%). Discordance was seen in the remaining 27 zones (31%) and was predominantly from the finding of a FFR<0.75 or total occlusion despite no defect on MPI. In conclusion, many patients with MVD show no perfusion defect in zones supplied by arteries with total occlusion or a FFR<0.75. Thus, MPI underestimates ischemic burden and FFR may be better at guiding revascularization decisions than perfusion imaging in patients with MVD.
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Affiliation(s)
- Michael Ragosta
- Cardiovascular Division, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA.
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Fischer JJ, Wang XQ, Samady H, Sarembock IJ, Powers ER, Gimple LW, Ragosta M. Outcome of patients with acute coronary syndromes and moderate coronary lesions undergoing deferral of revascularization based on fractional flow reserve assessment. Catheter Cardiovasc Interv 2006; 68:544-8. [PMID: 16969847 DOI: 10.1002/ccd.20748] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To determine the outcome of consecutive patients with and without acute coronary syndromes (ACS) in whom revascularization was deferred on the basis of fractional flow reserve (FFR). BACKGROUND FFR < 0.75 correlates with ischemia on noninvasive tests and deferral of treatment on the basis of FFR is associated with low event rates in selected populations. Whether these low event rates apply to patients undergoing assessment of moderate stenoses in association with an ACS is not known and is an important clinical question. METHODS Retrospective analysis and 12 month follow-up of consecutive, moderate (50-70%) de novo coronary lesions assessed with FFR. RESULTS Revascularization was deferred in 120 lesions (111 patients) with FFR > or = 0.75. ACS was present in 35 patients (40 lesions). The clinical, angiographic and coronary hemodynamic characteristics of patients with and without ACS were similar. Among the 35 patients with ACS, there were 3 deaths, 1 MI, and 6 target vessel revascularizations (TVRs) (15% of lesions). Among the 76 patients without ACS, there were 5 deaths, 1 MI, and 7 TVR's (9% of lesions). CONCLUSIONS Deferral of revascularization based on FFR in patients with ACS and moderate coronary stenoses is associated with acceptable and low event rates at 1 year.
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Affiliation(s)
- Joshua J Fischer
- The Cardiovascular Division, Department of Medicine, University of Virginia Health Systems, Charlottesville, Virginia 22908, USA
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Chhatriwalla AK, Ragosta M, Powers ER, Sarembock IJ, Gimple LW, Fischer JJ, Barringhaus KG, Kramer CM, Samady H. High left ventricular mass index does not limit the utility of fractional flow reserve for the physiologic assessment of lesion severity. J Invasive Cardiol 2006; 18:544-9. [PMID: 17090819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVES To demonstrate that fractional flow reserve (FFR) of vessels in patients with high left ventricular mass index (LVMI) should be similar to that of matched vessels in patients with normal LVMI. BACKGROUND FFR is a physiologic index of coronary lesion severity. It is not known whether FFR remains useful in the setting of increased LVMI, when microvascular abnormalities may be present. METHODS LVMI was calculated in 84 patients using contrast left ventriculography after validation with cardiac magnetic resonance imaging. Cardiac risk factors, LV ejection fraction (LVEF), minimal lumen diameter (MLD), percent diameter stenosis (%DS), lesion length and FFR were compared in 22 patients with high LVMI to 62 patients with normal LVMI and angiographically-matched vessels. RESULTS LVMI was 126 +/- 21 g/m2 in the high LVMI group and 84 +/- 21 g/m2 in the normal LVMI group. There were no differences in age, LVEF, diabetes, hypertension or dyslipidemia between groups. Angiographic lesion characteristics were well matched in patients with high versus normal LVMI (MLD 1.3 +/- 0.6 mm vs. 1.3 +/- 0.6 mm, %DS 61 +/- 13% vs. 62 +/- 13%, and lesion length 14.2 +/- 7.0 mm vs. 14.3 +/- 7.0 mm; p = NS for all). Importantly, no difference in FFR was observed (0.79 +/- 0.12 vs. 0.78 +/- 0.16; p = NS) between the groups, and LVMI did not correlate with FFR in a multivariate analysis. CONCLUSIONS FFR of coronary lesions in patients with high LVMI is no different than FFR of angiographically-matched lesions in patients with normal LVMI, suggesting that high LV mass should not limit the utility of FFR as an index of coronary lesion severity.
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Affiliation(s)
- Adnan K Chhatriwalla
- Cardiovascular Division, Department of Medicine, University of Virginia Health Systems, Charlottesville, Virginia, USA
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Samady H, Lepper W, Powers ER, Wei K, Ragosta M, Bishop GG, Sarembock IJ, Gimple L, Watson DD, Beller GA, Barringhaus KG. Fractional Flow Reserve of Infarct-Related Arteries Identifies Reversible Defects on Noninvasive Myocardial Perfusion Imaging Early After Myocardial Infarction. J Am Coll Cardiol 2006; 47:2187-93. [PMID: 16750683 DOI: 10.1016/j.jacc.2006.01.065] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2005] [Revised: 01/05/2006] [Accepted: 01/09/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES We hypothesized that fractional flow reserve (FFR) of an infarct-related artery (IRA) early after myocardial infarction (MI) identifies inducible ischemia on noninvasive imaging. BACKGROUND Early after MI, IRAs frequently have angiographically indeterminant lesions. Whether FFR can detect reversible perfusion defects early after MI when dynamic microvascular abnormalities are present is not known. METHODS Rest and dipyridamole (DP)-stress 99mTc sestamibi single-photon emission computed tomography (SPECT) were performed in 48 patients 3.7 +/- 1.3 days after MI, with 23 patients undergoing concurrent myocardial contrast echocardiography (MCE). Angiography, FFR, and percutaneous coronary intervention (PCI) of the IRA (as necessary) were subsequently performed. Follow-up SPECT was performed 11 weeks after PCI to identify true reversibility on baseline SPECT. RESULTS The sensitivity, specificity, positive and negative predictive value, and concordance of FFR < or =0.75 for detecting reversibility on SPECT were 88%, 50%, 68%, 89%, and 71% (chi-square <0.001), respectively; which improved to 88%, 93%, 88%, 93%, and 91% (chi-square <0.001), respectively, for the detection of true reversibility. The corresponding values of FFR < or =0.75 for detecting reversibility on DP-MCE were 90%, 100%, 100%, 75%, and 93% (chi-square <0.001), respectively, and on either SPECT or MCE were 88%, 93%, 91%, 91%, and 91% (chi-square <0.001), respectively. The optimal FFR value for discriminating inducible ischemia on noninvasive imaging was 0.78. CONCLUSIONS Fractional flow reserve of the IRA accurately identifies reversibility on noninvasive imaging early after MI. These findings support the utility of FFR early after MI.
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Affiliation(s)
- Habib Samady
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
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Ragosta M, Dee S, Sarembock IJ, Lipson LC, Gimple LW, Powers ER. Prevalence of unfavorable angiographic characteristics for percutaneous intervention in patients with unprotected left main coronary artery disease. Catheter Cardiovasc Interv 2006; 68:357-62. [PMID: 16892431 DOI: 10.1002/ccd.20709] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES The goal of this study was to determine the proportion of patients with left main coronary disease (LMCD) with unfavorable characteristics for percutaneous coronary intervention (PCI). BACKGROUND Published series suggest that LMCD can be treated percutaneously, however, the proportion of patients in whom PCI is an option based on angiographic criteria is unknown. METHODS In 13,228 consecutive coronary angiograms, 476 (3.6%) patients had < or =60% stenosis of the left main. In 232 patients with unprotected LMCD, the clinical characteristics and angiograms were reviewed with six features chosen as "unfavorable" for PCI: (1) Bifurcation LMCD, (2) occlusion of a major coronary, (3) ejection fraction <30%, (4) occlusion of a dominant RCA, (5) left dominant circulation, and (6) coexisting three-vessel disease. Treatment modality and 1 year mortality were determined. RESULTS The mean age was 69 years and 68% were male. Unfavorable characteristics were common with at least one unfavorable characteristic seen in 80%. Bifurcation disease was the most common unfavorable characteristic observed (53%) and coexisting three-vessel disease was seen in 38%. Treatment consisted of CABG in 205 (88%), medical therapy in 24 (10%) and PCI in 3 (1%). Among patients referred for CABG, 1 year survival was 88% with similar rates of survival for those with favorable characteristics (86%) compared to those with at least one unfavorable characteristic (88%). CONCLUSIONS Most patients with LMCD have at least one unfavorable characteristic for PCI suggesting that PCI may be a technically difficult option for most patients with LMCD.
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Affiliation(s)
- Michael Ragosta
- Cardiovascular Division, Department of Internal Medicine, University of Virginia Health System, Charlottesville, Virginia 22908, USA.
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Samady H, Choi CJ, Ragosta M, Powers ER, Beller GA, Kramer CM. Electromechanical mapping identifies improvement in function and retention of contractile reserve after revascularization in ischemic cardiomyopathy. Circulation 2004; 110:2410-6. [PMID: 15477418 DOI: 10.1161/01.cir.0000145119.94542.ae] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We hypothesized that (1) a significant proportion of ischemic dysfunctional segments that do not improve function will demonstrate postrevascularization contractile reserve and (2) electromechanical mapping (EMM) can identify segments that improve function as well as those with postrevascularization contractile reserve, a potential indicator of delayed functional improvement. METHODS AND RESULTS Eighteen patients with severe ischemic left ventricular dysfunction underwent EMM and dobutamine (D) cardiac magnetic resonance imaging (CMR) followed by revascularization. Four months after revascularization, all patients underwent a repeated D-CMR, and at 35 months, a subgroup (n=6) underwent a third CMR. Of 120 dysfunctional segments, 60 segments had improved rest function (IRF) and 60 did not. Twenty-eight of 60 segments (47%) that did not improve RF demonstrated postrevascularization contractile reserve (CR), and 32 of 60 segments (53%) that demonstrated neither IRF nor CR were persistently dysfunctional (PD). CR segments recovered significantly greater late function compared with IRF or PD: 14+/-12% vs 2+/-5% and 4+/-7%, respectively; P<0.05. EMM ratio, defined as the unipolar voltage divided by linear shortening, was significantly higher in IRF segments compared with segments that did not improve RF: 2.4+/-4.5 vs 0.7+/-3.5, P<0.05. Unipolar voltage was stepwise lower in normal, IRF, CR, and PD segments (10.5+/-4.7, 9.3+/-3.9, 8.8+/-3.2, and 7.4+/-2.3 mV, respectively; P<0.01 for trend). CONCLUSIONS Almost half of dysfunctional myocardial segments in chronic ischemic heart disease that do not improve RF early after revascularization demonstrate early CR and delayed functional recovery. EMM parameters can identify segments that improve RF and retain CR early after revascularization.
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Affiliation(s)
- Habib Samady
- Division of Cardiology, Eastern Virginia Medical School, Sentara Norfolk General Hospital, Norfolk, VA 23505, USA.
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Ragosta M, Samady H, Isaacs RB, Gimple LW, Sarembock IJ, Powers ER. Coronary flow reserve abnormalities in patients with diabetes mellitus who have end-stage renal disease and normal epicardial coronary arteries. Am Heart J 2004; 147:1017-23. [PMID: 15199350 DOI: 10.1016/j.ahj.2003.07.029] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Diabetic nephropathy is associated with increased cardiovascular events. Coronary atherosclerosis is responsible for many of these events, but other mechanisms such as impaired flow reserve may be involved. The purpose of this study was to define the prevalence and mechanism of abnormal coronary velocity reserve (CVR) in patients with diabetes mellitus who have nephropathy and a normal coronary artery. METHODS Patients undergoing catheterization for clinical purposes were enrolled. CVR was measured with a Doppler ultrasound scanning wire in a normal coronary in 32 patients without diabetes mellitus, 11 patients with diabetes mellitus who did not have renal failure, and 21 patients with diabetes mellitus who had nephropathy. A CVR <2.0 was considered to be abnormal. RESULTS Patients with diabetes mellitus who had renal failure had a higher incidence of hypertension and left ventricular hypertrophy. The average peak velocity (APV) at baseline was higher in patients with diabetes mellitus who had renal failure. At peak hyperemia, APV increased in all 3 groups, with no difference between groups. The mean CVR for patients without diabetes was 2.8 +/- 0.8 and was not different from that in patients with diabetes mellitus who did not have renal failure (2.7 +/- 0.7), but was lower than that in patients with diabetes mellitus who had renal failure (1.6 +/- 0.5; P < 0.001). Abnormal CVR was observed in 9% of patients without diabetes mellitus, 18% of patients with diabetes mellitus who did not have renal failure, and 57% of patients with diabetes mellitus who had renal failure, and abnormal CVR was caused by an elevation of baseline APV in 66% of these cases. The baseline heart rate and the presence of diabetes mellitus with renal failure were independent predictors of abnormal CVR by multivariable analysis. CONCLUSIONS Patients with diabetic nephropathy have abnormalities in CVR in the absence of angiographically evident coronary disease.
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Affiliation(s)
- Michael Ragosta
- Cardiovascular Division, University of Virginia Health Systems, Charlottesville, Va 22908-0158, USA.
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McClish JC, Ragosta M, Powers ER, Barringhaus KG, Gimple LW, Fischer J, Garnett J, Siadaty M, Sarembock IJ, Samady H. Effect of acute myocardial infarction on the utility of fractional flow reserve for the physiologic assessment of the severity of coronary artery narrowing. Am J Cardiol 2004; 93:1102-6. [PMID: 15110200 DOI: 10.1016/j.amjcard.2004.01.035] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2003] [Revised: 01/15/2004] [Accepted: 01/15/2004] [Indexed: 11/25/2022]
Abstract
Fractional flow reserve (FFR) has been shown to be a useful physiologic index of coronary lesion severity in myocardial beds of patients without prior infarction and in those with remote infarction. Acute myocardial infarction (AMI) causes myocardial necrosis and microvascular stunning, embolization, and damage. Whether FFR remains a useful index of epicardial flow in the setting of recent myocardial infarction is not established. Cardiac risk factors, serum troponin I, angiographic minimal lumen diameter (MLD), percent diameter stenosis (DS), lesion length, vessel reference diameter, hyperemic central aortic pressure, hyperemic pressure distal to stenosis, and FFR were compared in 43 vessels subtending recent AMI beds to 25 control vessels, matched by lesion length and MLD, in patients without AMI. There were no differences in DS, MLD, lesion length, or reference diameter between AMI and non-AMI groups. Patients with AMI had mean troponin I levels of 91.8 +/- 162 ng/ml. Left ventricular ejection fraction was significantly lower in patients with than without AMI (55 +/- 9% vs 62 +/- 8%, p <0.05). There were no significant differences in hyperemic central aortic pressure (92 +/- 13 vs 99 +/- 15 mm Hg, p = NS), hyperemic pressure distal to the stenosis (62 +/- 17 vs 66 +/- 19 mm Hg, p = NS), or FFR (0.67 +/- 17 vs 0.68 +/- 17, p = NS) between recent AMI and non-AMI control patients. There was a significant correlation between DS and FFR for both patients with (p <0.001) and without (p = 0.003) infarctions. Thus, FFR and the relation between FFR and DS of lesions subtending AMI was not significantly different from FFR of angiographically matched lesions in patients without AMI.
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Affiliation(s)
- J Christopher McClish
- Cardiovascular Division, Department of Medicine, University of Virginia Health Systems, Charlottesville, Virginia, USA
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Chhatriwalla AK, Barringhaus KG, Ragosta M, Powers ER, McClish J, Fischer J, Bishop AH, Gimple LW, Saremocck IJ, Choi C, Kramer CM, Samady H. 1120-64 High left ventricular mass does not limit the utility of fractional flow reserve for the physiologic assessment of lesion severity. J Am Coll Cardiol 2004. [DOI: 10.1016/s0735-1097(04)90315-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Ragosta M, Samady H, Gimple LW, Sarembock IJ, Fenster M, Powers ER. Percutaneous treatment of focal vs. diffuse in-stent restenosis: A prospective randomized comparison of conventional therapies. Catheter Cardiovasc Interv 2004; 61:344-9. [PMID: 14988893 DOI: 10.1002/ccd.10779] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Few randomized studies compare outcomes for focal vs. diffuse in-stent restenosis (ISR) using conventional treatments. The purpose of this study was to compare the rates of major adverse cardiac events (MACEs) for focal vs. diffuse ISR using conventional techniques. One hundred thirteen patients with ISR were prospectively classified as focal (< 10 mm) or diffuse (> 10 mm). Focal ISR was randomized to balloon angioplasty (n = 29) or restenting (n = 29) and diffuse ISR randomized to rotational atherectomy (n = 30) or restenting (n = 25). At 9 months, patients with focal ISR had higher survival free of MACEs than patients with diffuse ISR (86% vs. 63%; P < 0.005), with no difference between techniques. Only the presence of diffuse ISR was an independent predictor of MACE at 9 months. Thus, focal ISR has a low rate of MACE compared to diffuse ISR, which carries a high event rate regardless of treatment employed.
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Affiliation(s)
- Michael Ragosta
- Cardiovascular Division, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia 22908, USA.
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Whitlow PL, DeMaio SJ, Perin EC, O'Neill WW, Lasala JM, Schneider JE, McKeever LS, Ezratty AM, Knopf WD, Powers ER, Shawl FA. One-year results of percutaneous myocardial revascularization for refractory angina pectoris. Am J Cardiol 2003; 91:1342-6. [PMID: 12767430 DOI: 10.1016/s0002-9149(03)00326-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Patrick L Whitlow
- Department of Cardiology, F25, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Samady H, Liu YH, Choi CJ, Ragosta M, Pfau SE, Cleman MW, Powers ER, Kramer CM, Wackers FJT, Beller GA, Watson DD. Electromechanical mapping for detecting myocardial viability and ischemia in patients with severe ischemic cardiomyopathy. Am J Cardiol 2003; 91:807-11. [PMID: 12667565 DOI: 10.1016/s0002-9149(03)00013-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This study was designed to evaluate several electromechanical mapping parameters for assessment of myocardial viability and inducible ischemia as defined by dipyridamole single-photon emission computed tomographic (SPECT) imaging at rest in patients with severe ischemic cardiomyopathy. Unipolar voltage, normalized unipolar voltage, bipolar voltage, and fragmentation were compared with tracer uptake at rest and reversibility on stress or rest quantitative technetium-99m sestamibi SPECT imaging in 32 patients with severe ischemic cardiomyopathy (left ventricular ejection fraction 0.24 +/- 0.08). In dysfunctional myocardial segments, logistic regression showed unipolar voltage, normalized unipolar voltage, and bipolar voltage to be predictive of viable myocardium (> or = 60% tracer uptake at rest) and was significantly higher in viable than in nonviable segments (p <0.01). A unipolar voltage of > or = 7.1 mV was the best predictor of viable myocardium. In dysfunctional viable segments, unipolar voltage was significantly higher in reversible than in fixed segments (p <0.001), and a unipolar voltage of > or = 8.5 mV had optimal power for identifying reversibility on dipyridamole SPECT imaging. We conclude that in patients with severe ischemic cardiomyopathy, unipolar voltage can identify viable from nonviable myocardium and reversible from fixed viable defects as defined by dipyridamole technetium-99m sestamibi SPECT imaging.
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Affiliation(s)
- Habib Samady
- Cardiovascular Division, Department of Medicine, University of Virginia Health System, Charlottesville 22908-0158, USA.
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Balcells E, Powers ER, Lepper W, Belcik T, Wei K, Ragosta M, Samady H, Lindner JR. Detection of myocardial viability by contrast echocardiography in acute infarction predicts recovery of resting function and contractile reserve. J Am Coll Cardiol 2003; 41:827-33. [PMID: 12628729 DOI: 10.1016/s0735-1097(02)02962-5] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES We sought to determine whether myocardial contrast echocardiography (MCE) performed before and early after primary coronary stenting (PCS) in patients with acute myocardial infarction (AMI) could predict recovery of resting left ventricular systolic function and contractile reserve. BACKGROUND Myocardial contrast echocardiography can be used to assess perfusion within the risk area before PCS and the extent of necrosis soon after PCS. METHODS In 30 patients with AMI, MCE and two-dimensional echocardiography were performed before PCS and 3 to 5 days and 4 weeks after PCS. Contractile reserve was assessed by dobutamine echocardiography at four weeks in patients with persistent severe wall-motion abnormalities. RESULTS Of segments without perfusion at 3 to 5 days, 95% had severe hypokinesis to akinesis at 4 weeks. Of segments with normal perfusion at 3 to 5 days, 90% had normal wall motion or mild hypokinesis at 4 weeks, whereas those with partial perfusion at 3 to 5 days were evenly divided between normal wall motion, hypokinesis, and akinesis. In segments with persistent severe wall-motion abnormalities at four weeks, contractile reserve was found in >80% of segments with perfusion, compared with only 10% of segments without detectable perfusion (p < 0.01). The presence of myocardial perfusion by MCE before PCS was associated with maintained or improved perfusion at 3 to 5 days and eventual recovery of resting wall motion. CONCLUSIONS Myocardial contrast echocardiography performed early after PCS provides information on the extent of infarction, and hence the likelihood for recovery of resting systolic function or contractile reserve. The presence of perfusion before PCS, from either collateral or antegrade flow, predicts the maintenance of perfusion and recovery of systolic function.
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Affiliation(s)
- Eduardo Balcells
- Cardiovascular Division, University of Virginia, Charlottesville, Virginia 22908, USA
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McClish JC, Ragosta M, Powers ER, Bishop GA, Fischer J, Barringhaus KG, Garnett J, Gimple LW, Sarembock IJ, Samady H. Recent myocardial infarction does not limit the utility of fractional flow reserve for the physiologic assessment of lesion severity. J Am Coll Cardiol 2003. [DOI: 10.1016/s0735-1097(03)80876-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Mehrdad Sadeghi H, Grines CL, Moliterno DJ, White J, Herrmann H, Powers ER, Cohen DJ, Bertrand ME, Neumann FJ, DiBattiste PM, Stone GW, Topol EJ. Timing and risk factors for enzymatic myocardial infarctions in patients undergoing percutaneous intervention: Insights from TARGET. J Am Coll Cardiol 2003. [DOI: 10.1016/s0735-1097(03)80112-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fischer JJ, Samady H, McPherson JA, Sarembock IJ, Powers ER, Gimple LW, Ragosta M. Comparison between visual assessment and quantitative angiography versus fractional flow reserve for native coronary narrowings of moderate severity. Am J Cardiol 2002; 90:210-5. [PMID: 12127605 DOI: 10.1016/s0002-9149(02)02456-6] [Citation(s) in RCA: 164] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We tested the hypothesis that experienced interventional cardiologists can identify patients with fractional flow reserve (FFR) <0.75 either by visual assessment of the angiogram or by quantitative coronary angiography (QCA). Estimation of the significance of moderate lesions is difficult. FFR can determine the physiologic significance of a stenosis. Data comparing visual assessment and QCA of moderate lesions with FFR are limited. FFR was measured in 83 moderate lesions defined as having a 40% to 70% stenosis by visual inspection. An FFR <0.75 was considered "significant." Lesions were visually assessed by 3 experienced interventional cardiologists and their significance estimated. QCA was performed. Both analyses were compared with FFR. FFR averaged 0.82 +/- 0.11 and was <0.75 in 15 of 83 lesions (18%). The reviewers' classification was concordant with the FFR in about half the lesions. Concordance between reviewers was poor (Spearman's rho = 0.36). Visual assessment resulted in good sensitivity (80%) and negative predictive value (91%), but poor specificity (47%) and positive predictive value (25%) compared with FFR. By QCA, no patient with stenosis <60% or minimal luminal diameter >1.4 mm had FFR <0.75. QCA did not discriminate the significance of lesions outside of these parameters. Thus, neither visual assessment of an angiogram by experienced interventional cardiologists nor QCA can accurately predict the significance of most moderate narrowings.
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Affiliation(s)
- Joshua J Fischer
- Cardiovascular Division, Department of Medicine, University of Virginia Health Systems, Charlottesville 22908, USA
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Roffi M, Moliterno DJ, Meier B, Powers ER, Grines CL, DiBattiste PM, Herrmann HC, Bertrand M, Harris KE, Demopoulos LA, Topol EJ. Impact of different platelet glycoprotein IIb/IIIa receptor inhibitors among diabetic patients undergoing percutaneous coronary intervention: : Do Tirofiban and ReoPro Give Similar Efficacy Outcomes Trial (TARGET) 1-year follow-up. Circulation 2002; 105:2730-6. [PMID: 12057986 DOI: 10.1161/01.cir.0000018123.02672.c7] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The platelet glycoprotein IIb/IIIa receptor inhibitor abciximab, a monoclonal antibody, has been shown to improve early and late outcomes among diabetic patients undergoing percutaneous coronary intervention (PCI). It is unknown whether small-molecule agents confer similar benefits. METHODS AND RESULTS In 18 countries, 4809 patients undergoing PCI with stent implantation were randomized to tirofiban or abciximab. At the time of enrollment, patients were stratified according to diabetes status. As compared with non-diabetic patients, patients with diabetes (n=1117) showed similar 30-day ischemic outcomes, an increased incidence of any target vessel revascularization (TVR) at 6 months (10.3% versus 7.8%; P= 0.008), and a trend toward higher 1-year mortality (2.5% versus 1.6%; P=0.056). Among diabetic patients randomized to tirofiban (n=560), the incidence of death, myocardial infarction (MI), or urgent TVR at 30 days was 6.2%, and among those randomized to abciximab (n=557) it was 5.4% (hazard ratio [HR] 1.16; P=0.540). At 6 months, the composite of death, MI, or any TVR occurred in 15.7% and in 16.9% of tirofiban and abciximab patients, respectively (HR 0.93; P=0.610). Any TVR occurred in 9.5% and 11.1%, respectively (HR 0.84; P= 0.366). The 1-year mortality was 2.1% in the tirofiban group and 2.9% in the abciximab group (HR 0.74; P= 0.436). CONCLUSIONS Among diabetic patients undergoing PCI, tirofiban and abciximab were associated with comparable event rates, including similar rates of 6-month TVR and 1-year mortality. These findings suggest that the non-glycoprotein IIb/IIIa properties of abciximab do not translate into a discernible long-term clinical benefit among diabetic patients.
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Affiliation(s)
- Marco Roffi
- Division of Cardiology, University Hospital, Zurich, Switzerland
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Stone GW, Moliterno DJ, Bertrand M, Neumann FJ, Herrmann HC, Powers ER, Grines CL, Moses JW, Cohen DJ, Cohen EA, Cohen M, Wolski K, DiBattiste PM, Topol EJ. Impact of clinical syndrome acuity on the differential response to 2 glycoprotein IIb/IIIa inhibitors in patients undergoing coronary stenting: the TARGET Trial. Circulation 2002; 105:2347-54. [PMID: 12021219 DOI: 10.1161/01.cir.0000017635.82128.8c] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although glycoprotein IIb/IIIa inhibitors have been shown to reduce periprocedural and late ischemic events in patients undergoing stent implantation, the relative safety and efficacy of different agents in this class is less established. Also unknown is whether the acuity of the presenting clinical syndrome, which may affect the degree of platelet inhibition required or achieved, influences the response to different antiplatelet agents. METHODS AND RESULTS A prospective, multicenter, double-blind, randomized trial was performed in which 4809 patients undergoing planned stenting were randomized to receive abciximab or tirofiban. In patients with acute coronary syndromes (ACS; n=3025), abciximab resulted in lower rates of myocardial infarction at 30 days (5.8% versus 8.5%; P=0.004) and 6 months (7.2% versus 9.8%; P=0.013), although 6-month mortality rates were identical (1.39% in both groups; P=0.99). Conversely, in patients without ACS (n=1784), myocardial infarction rates were not significantly lower with tirofiban, survival was similar, and target vessel revascularization was reduced, which translated into a trend toward enhanced 6-month event-free survival with tirofiban (89.7% versus 86.6%; P=0.056). CONCLUSIONS In patients with ACS undergoing stent implantation, abciximab use compared with tirofiban results in greater suppression of periprocedural myonecrosis, although a survival benefit has not been demonstrated. Patients with stable coronary syndromes may have equivalent or better outcomes with tirofiban relative to abciximab, with fewer adverse hematologic and hemorrhagic events. These data raise important issues regarding the relative pharmacodynamic inhibition of platelet function required in varying clinical scenarios and have important implications for the cost-effective utilization of glycoprotein IIb/IIIa inhibitors.
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Affiliation(s)
- Gregg W Stone
- Cardiovascular Research Foundation, Lenox Hill Heart and Vascular Institute, New York, NY 10022, USA.
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Stone GW, Moliterno DJ, Bertrand M, Neumann FJ, Herrmann HC, Powers ER, Grines CL, Cohen DJ, Cohen EA, Cohen M, Piedmonte M, DiBattiste PM. Impact of clinical syndrome acuity on the differential response to two glycoprotein IIb/IIIa inhibitors in patients undergoing coronary stenting: the TARGET trial. J Am Coll Cardiol 2002. [DOI: 10.1016/s0735-1097(02)80091-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Fearon WF, Luna J, Samady H, Powers ER, Feldman T, Dib N, Tuzcu EM, Cleman MW, Chou TM, Cohen DJ, Ragosta M, Takagi A, Jeremias A, Fitzgerald PJ, Yeung AC, Kern MJ, Yock PG. Fractional flow reserve compared with intravascular ultrasound guidance for optimizing stent deployment. Circulation 2001; 104:1917-22. [PMID: 11602494 DOI: 10.1161/hc4101.097539] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Determination of fractional flow reserve (FFR) has been proposed as a means to assess stent deployment. In this prospective, multicenter trial, we evaluate the use of FFR to optimize stenting by comparing it with standard intravascular ultrasound (IVUS) criteria. METHODS AND RESULTS Eighty-four stable patients with isolated coronary lesions underwent coronary stent deployment starting at 10 atm and increased serially by 2 atm until the FFR was >/=0.94 or 16 atm was achieved. IVUS was then performed. FFR was measured with a coronary pressure wire with intracoronary adenosine to induce hyperemia. The diagnostic characteristics of an FFR <0.94 to predict suboptimal stent expansion by IVUS, defined in both absolute and relative terms, were calculated. Over a range of IVUS criteria, the highest sensitivity, specificity, and predictive accuracy of FFR were 80%, 30%, and 42%, respectively. Receiver operator characteristic analysis defined an optimal FFR cut point at >/=0.96; at this threshold, the sensitivity, specificity, and predictive accuracy of FFR were 75%, 58%, and 62%, respectively (P=0.03 for comparison of predictive accuracy, P=0.01 for concordance between FFR and IVUS). The negative predictive value was 88%. Significantly better diagnostic performance was achieved in a subgroup that received higher doses (>30 microgram) of intracoronary adenosine during pressure measurements, suggesting that FFR might be overestimated in the other group. CONCLUSIONS A fractional flow reserve <0.96, measured after stent deployment, predicts a suboptimal result based on validated intravascular ultrasound criteria; however, an FFR >/=0.96 does not reliably predict an optimal stent result. Higher doses of intracoronary adenosine than previously used to measure FFR improve these results.
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Affiliation(s)
- W F Fearon
- Stanford University Medical Center, Stanford, CA, USA.
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McPherson JA, Barringhaus KG, Bishop GG, Sanders JM, Rieger JM, Hesselbacher SE, Gimple LW, Powers ER, Macdonald T, Sullivan G, Linden J, Sarembock IJ. Adenosine A(2A) receptor stimulation reduces inflammation and neointimal growth in a murine carotid ligation model. Arterioscler Thromb Vasc Biol 2001; 21:791-6. [PMID: 11348876 DOI: 10.1161/01.atv.21.5.791] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.8] [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: 12/31/2022]
Abstract
Endothelial activation and leukocyte recruitment are early events in atherosclerosis and the vascular response to injury. Adenosine has anti-inflammatory effects on leukocytes and endothelial cells mediated through its A(2A) receptor. We tested the hypothesis that A(2A) activation would reduce inflammation and neointimal formation in a murine carotid ligation model. Before injury, mice were randomized to a 7-day subcutaneous infusion of a specific A(2A) receptor agonist (ATL-146e, 0.004 microg/kg per minute), vehicle control, ATL-146e plus ZM241385 (a selective A(2A) antagonist), or ZM241385 alone. Leukocyte recruitment and adhesion molecule expression were assessed at early time points, and the neointimal area was measured at 14 and 28 days after injury. Compared with control mice, ATL-146e-treated mice had significantly less neutrophil and macrophage recruitment and vascular cell adhesion molecule-1, intercellular adhesion molecule-1, and P-selectin expression in the first 7 days after injury. Neointimal area was markedly and persistently reduced by 80% at 14 and 28 days, despite termination of ATL infusion at 7 days. ATL-146e+ZM241385-treated and ZM241385-treated animals had neointimal areas similar to those of control animals, confirming that the observed effects of ATL-146e were mediated specifically by the A(2A) receptor. These data demonstrate that novel stimulation of adenosine A(2A) receptors can inhibit early inflammatory processes that are important in neointimal formation after vascular injury.
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Affiliation(s)
- J A McPherson
- Cardiovascular Division, Department of Medicine, University of Virginia Health System, Charlottesville 22908, USA
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Topol EJ, Moliterno DJ, Herrmann HC, Powers ER, Grines CL, Cohen DJ, Cohen EA, Bertrand M, Neumann FJ, Stone GW, DiBattiste PM, Demopoulos L. Comparison of two platelet glycoprotein IIb/IIIa inhibitors, tirofiban and abciximab, for the prevention of ischemic events with percutaneous coronary revascularization. N Engl J Med 2001; 344:1888-94. [PMID: 11419425 DOI: 10.1056/nejm200106213442502] [Citation(s) in RCA: 498] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In the setting of percutaneous coronary revascularization, agents in the class known as platelet glycoprotein IIb/IIIa inhibitors have significantly reduced the incidence of death or nonfatal myocardial infarction at 30 days. We assessed whether there are differences in safety or efficacy between two such inhibitors, tirofiban and abciximab. METHODS Using a double-blind, double-dummy design at 149 hospitals in 18 countries, we randomly assigned patients to receive either tirofiban or abciximab before undergoing percutaneous coronary revascularization with the intent to perform stenting. The primary end point was a composite of death, nonfatal myocardial infarction, or urgent target-vessel revascularization at 30 days. The trial was designed and statistically powered to demonstrate the noninferiority of tirofiban as compared with abciximab. RESULTS The primary end point occurred more frequently among the 2398 patients in the tirofiban group than among the 2411 patients in the abciximab group (7.6 percent vs. 6.0 percent; hazard ratio, 1.26; one-sided 95 percent confidence interval of 1.51, demonstrating lack of equivalence, and two-sided 95 percent confidence interval of 1.01 to 1.57, demonstrating the superiority of abciximab over tirofiban; P=0.038). The magnitude and the direction of the effect were similar for each component of the composite end point (hazard ratio for death, 1.21; hazard ratio for myocardial infarction, 1.27; and hazard ratio for urgent target-vessel revascularization, 1.26), and the difference in the incidence of myocardial infarction between the tirofiban group and the abciximab group was significant (6.9 percent and 5.4 percent, respectively; P=0.04). The relative benefit of abciximab was consistent regardless of age, sex, the presence or absence of diabetes, or the presence or absence of pretreatment with clopidogrel. There were no significant differences in the rates of major bleeding complications or transfusions, but tirofiban was associated with a lower rate of minor bleeding episodes and thrombocytopenia. CONCLUSIONS Although the trial was intended to assess the noninferiority of tirofiban as compared with abciximab, the findings demonstrated that tirofiban offered less protection from major ischemic events than did abciximab.
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Affiliation(s)
- E J Topol
- Department of Cardiology, Cleveland Clinic Foundation, OH 44195, USA.
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Bishop GG, McPherson JA, Sanders JM, Hesselbacher SE, Feldman MJ, McNamara CA, Gimple LW, Powers ER, Mousa SA, Sarembock IJ. Selective alpha(v)beta(3)-receptor blockade reduces macrophage infiltration and restenosis after balloon angioplasty in the atherosclerotic rabbit. Circulation 2001; 103:1906-11. [PMID: 11294811 DOI: 10.1161/01.cir.103.14.1906] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND alpha(v)beta(3)-Integrin receptors are upregulated in atherosclerotic arteries and play a key role in smooth muscle cell and possibly inflammatory cell migration. We hypothesized that after balloon angioplasty (BA) of atherosclerotic arteries, selective inhibition of the alpha(v)beta(3)-receptor by XT199, a small-molecule, non-peptide-selective alpha(v)beta(3)-receptor antagonist, would reduce restenosis. METHODS AND RESULTS After induction of focal atherosclerosis, rabbits underwent femoral BA and received XT199 (2.5 mg/kg IV bolus plus 2.5 mg. kg(-1). d(-1) IV; n=19) or vehicle (n=20) for 14 days. At 28 days after BA, the XT199 group had a larger lumen (0.75+/-0.26 versus 0.57+/-0.20 mm(2), P=0.03) and a smaller neointimal area (0.49+/-0.18 versus 0.68+/-0.25 mm(2), P=0.01) than the vehicle group. Angiographic analysis confirmed a 30% to 40% reduction in restenosis. Arteries harvested at 28 days after BA did not show a reduction in intima plus media smooth muscle cell content but did show a 50% reduction in macrophage cell density in the XT199 group (716+/-452 versus 1458+/-989 cells/mm(2), P<0.006). Neovessel density at 28 days was also reduced (23+/-42 versus 58+/-46 vessel cross sections/mm(2), P<0.02). Early after BA (ie, 3 to 7 days), there was a decrease in intracellular adhesion molecule-1 and vascular cell adhesion molecule-1 expression, indicative of a reduction in vascular cell activation. CONCLUSIONS Selective alpha(v)beta(3)-receptor blockade for 14 days after BA in the focally atherosclerotic rabbit significantly reduced restenosis and limited macrophage infiltration and neovascularization in the vessel wall.
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MESH Headings
- Actins/analysis
- Angioplasty, Balloon
- Animals
- Arterial Occlusive Diseases/pathology
- Arterial Occlusive Diseases/prevention & control
- Arteriosclerosis/pathology
- Arteriosclerosis/therapy
- Cell Adhesion/drug effects
- Cells, Cultured
- Chemokine CCL2/metabolism
- Cholesterol/blood
- Dose-Response Relationship, Drug
- Femoral Artery/drug effects
- Femoral Artery/metabolism
- Femoral Artery/pathology
- Imidazoles/pharmacology
- Immunohistochemistry
- Intercellular Adhesion Molecule-1/drug effects
- Intercellular Adhesion Molecule-1/metabolism
- Macrophages/drug effects
- Macrophages/pathology
- Male
- Muscle, Smooth, Vascular/cytology
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/metabolism
- Rabbits
- Receptors, Vitronectin/antagonists & inhibitors
- Receptors, Vitronectin/metabolism
- Recurrence
- Time Factors
- Tunica Intima/drug effects
- Tunica Intima/metabolism
- Tunica Intima/pathology
- Tunica Media/drug effects
- Tunica Media/metabolism
- Tunica Media/pathology
- Vascular Cell Adhesion Molecule-1/drug effects
- Vascular Cell Adhesion Molecule-1/metabolism
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Affiliation(s)
- G G Bishop
- University of Virginia, Charlottesville, VA, USA
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Ragosta M, Powers ER, Samady H, Gimple LW, Sarembock IJ, Beller GA. Relationship between extent of residual myocardial viability and coronary flow reserve in patients with recent myocardial infarction. Am Heart J 2001; 141:456-62. [PMID: 11231445 DOI: 10.1067/mhj.2001.113074] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The presence of viability in an infarct zone implies an intact microvasculature. We hypothesized that coronary flow reserve (CFR), which assesses the microcirculation, would correlate with the extent of viability in infarction zones. METHODS CFR was measured after stenting in 17 patients with single vessel disease >48 hours from infarction. Viability was determined with use of single-photon emission computed tomography sestamibi imaging. RESULTS Sestamibi uptake in the infarct zone correlated with CFR in the infarct artery (r = 0.62, P =.008) and sestamibi uptake in the infarct zone was greater in patients with normal CFR than in patients with abnormal CFR (61.9 +/- 9.1% vs 46.3 +/- 9.6%, P =.004). In addition, CFR was greater in patients with viability compared with patients without viability (2.4 +/- 1.3 vs 1.4 +/- 0.4, P =.015). CONCLUSIONS CFR correlates with the extent of viability after infarction. Preserved CFR in an infarct-related artery implies preserved viability.
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Affiliation(s)
- M Ragosta
- Cardiovascular Division, Department of Medicine, University of Virginia Health Sciences Center, Charlottesville, VA 22098, USA.
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Buckley RS, Kaul S, Jayaweera AR, Gimple LW, Powers ER, Dent JM. Quantification of mitral regurgitation in the cardiac catheterization laboratory with contrast echocardiography. Am Heart J 2000; 139:1109-13. [PMID: 10827395 DOI: 10.1067/mhj.2000.106167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND There is no method of quantifying the severity of mitral regurgitation (MR) from injection of tracer directly into the left ventricular (LV) cavity, a method commonly used in the cardiac catheterization laboratory. METHODS AND RESULTS We used a previously validated mathematical model that derives regurgitant fraction (RF) from the relative tracer washout from the left atrial (LA) and LV cavities. Thirty-nine patients referred for diagnostic cardiac catheterization with clinical evidence of possible MR were included in the study. Five milliliters of a microbubble mixture was power-injected into the LV during simultaneously performed contrast echocardiography. Relative changes in background-subtracted video intensity were measured from the LV and LA, and the resultant model-derived RF was correlated with the severity of MR on cineangiography. The severity of MR ranged from 0 to 4+ on cineangiography with corresponding model-derived RF of 0 to 0.69 on contrast echocardiography. A close linear relation was noted between angiographic severity of MR and model-derived RF on contrast echocardiography (y = 0.1x + 0.03, r = 0.89, P <.001). Contrast echocardiography was more sensitive than cineangiography for detecting mild MR. CONCLUSIONS We describe a new method of measuring the severity of MR in the cardiac catheterization laboratory. Apart from being quantitative, this method can be safely used during cardiac catheterization in patients in whom iodinated contrast agents may be potentially harmful.
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Affiliation(s)
- R S Buckley
- Cardiovascular Division, University of Virginia Medical Center, Charlottesville 22908, USA
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