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Walker AJ, Zhu J, Thoma F, Marroquin O, Makani A, Gulati M, Gianos E, Virani SS, Rodriguez F, Reis SE, Ballantyne C, Mulukutla S, Saeed A. Statin utilization and cardiovascular outcomes in a real-world primary prevention cohort of older adults. Am J Prev Cardiol 2024; 18:100664. [PMID: 38665251 PMCID: PMC11043821 DOI: 10.1016/j.ajpc.2024.100664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 03/25/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
Background Statins are a cost-effective therapy for prevention of atherosclerotic cardiovascular disease (ASCVD). Guidelines on statins for primary prevention are unclear for older adults (>75 years). Objective Investigate statin utility in older adults without ASCVD events, by risk stratifying in a large healthcare network. Methods We included 8,114 older adults, without CAD, PVD or ischemic stroke. Statin utilization based on ACC/AHA 10-year ASCVD risk calculation, was evaluated in intermediate (7.5%-19.9%) and high-risk patients (≥ 20%); and categorized using low and 'moderate or high' intensity statins with a follow up period of ∼7 years. Cox regression models were used to calculate hazard ratios for incident ASCVD and mortality across risk categories stratified by statin utilization. Data was adjusted for competing risk using Elixhauser Comorbidity Index. Results Compared with those on moderate or high intensity statins, high-risk older patients not on any statin had a significantly increased risk of MI [HR 1.51 (1.17-1.95); p<0.01], stroke [HR 1.47 (1.14-1.90); p<0.01] and all-cause mortality [HR 1.37 (1.19-1.58); p<0.001] in models adjusted for Elixhauser Comorbidity Index. When comparing the no statin group versus the moderate or high intensity statin group in the intermediate risk cohort, although a trend for increased risk was seen, it did not meet statistical significance thresholds for MI, stroke or all-cause mortality. Conclusion Lack of statin use was associated with increased cardiovascular events and mortality in high-risk older adults. Given the benefits appreciated, statin use may need to be strongly considered for primary ASCVD prevention among high-risk older adults. Future studies will assess the risk-benefit ratio of statin intervention in older adults.
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Affiliation(s)
- Aaron J. Walker
- Florida State University College of Medicine, Tallahassee, FL, United States
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Jianhui Zhu
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Floyd Thoma
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Oscar Marroquin
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Amber Makani
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Martha Gulati
- Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | | | | | | | - Steven E. Reis
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | | | - Suresh Mulukutla
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Anum Saeed
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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Preisendörfer S, Singla V, Bhonsale A, Kancharla K, Thoma F, Mulukutla S, Voigt A, Shalaby A, Estes NAM, Jain S, Saba S. Heart Rate at Rest and Incident Atrial Fibrillation in Patients With Diastolic Dysfunction. Am J Cardiol 2024; 218:72-76. [PMID: 38461926 DOI: 10.1016/j.amjcard.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 01/28/2024] [Accepted: 03/01/2024] [Indexed: 03/12/2024]
Abstract
Diastolic dysfunction (DD) is associated with incident atrial fibrillation (AF). The influence of heart rate at rest (RHR) on incident AF in patients with DD has not been investigated. The goal of this study is to assess the influence of RHR on incident AF in patients with DD. Patients from a large health system with no previous history of AF, a left ventricular ejection fraction ≥50%, and documented DD on echocardiography were divided into quartiles (<66, 66 to 76, 77 to 91, >91 beats per minute) based on RHR. Incident AF was estimated using AF hospitalization during follow-up. Hazard ratios (HR) for AF hospitalization and all-cause death were calculated with a Cox proportional hazards model. A total of 19,046 patients were analyzed. Over a median follow-up of 42.2 months, 742 (3.9%) patients were hospitalized for AF. Both slower and faster RHR were associated with increased risk of AF hospitalization (HR 1.40, confidence interval [CI] 1.14 to 1.71, p = 0.001, HR 1.23, CI 0.99 to 1.53, p = 0.06 and HR 1.72, CI 1.38 to 2.14, p <0.001, for quartiles 1, 2, and 4, respectively), suggesting a J-shaped relation. Progressive increase in all-cause death was noted with faster RHR (HR1.19 per quartile increase, CI 1.16 to 1.22, p <0.001). These results persisted after adjustment for age, cardiovascular co-morbidities, grade of DD, and β-blocker use. In conclusion, this large, real-world analysis indicates increased risk of incident AF with slower and faster RHR in patients with DD. Randomized trials are needed to evaluate the potential of RHR modification to mitigate the risk of incident AF.
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Affiliation(s)
- Stefan Preisendörfer
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Virginia Singla
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Aditya Bhonsale
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Krishna Kancharla
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Suresh Mulukutla
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew Voigt
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Alaa Shalaby
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - N A Mark Estes
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sandeep Jain
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Samir Saba
- Heart and Vascular Institute, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Brown JA, Yousef S, Garvey J, Ogami T, Serna-Gallegos D, Sá MP, Thoma F, Zhu J, Phillippi J, Sultan I. Reinterventions After Repair of Acute Type A Aortic Dissection: Incidence, Outcomes, and Risk Factors. Ann Thorac Surg 2024; 117:915-921. [PMID: 38036024 DOI: 10.1016/j.athoracsur.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/19/2023] [Accepted: 11/06/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND This study reports the incidence, outcomes, and risk factors for aortic reinterventions after repair of acute type A aortic dissection (ATAAD). METHODS This was an observational study of aortic operations from 2010 to 2021. All patients with ATAAD undergoing open aortic arch reconstruction were included. Patients were dichotomized by the need for reintervention, which included reinterventions proximal to or distal to the index aortic repair. Propensity matching was used to determine the impact of reintervention on long-term outcomes. The cumulative incidence function for reintervention was estimated, and multivariable Fine-Gray analysis was performed to identify variables associated with reintervention, with death treated as a competing event. RESULTS We identified 601 patients undergoing surgery for ATAAD. An aortic reintervention was required in 71 (11.8%), comprising a proximal reintervention in 12 patients, a distal reintervention in 56, and both in 3. The cumulative incidence of reintervention was 11.6% (95% CI, 8.9%-14.6%) at 5 years and was 16.0% (95% CI, 12.2%-20.3%) at 10 years, with a median time to reintervention of 4.0 years (interquartile range, 0.9-7.5 years). Multivariable analysis using the Fine-Gray method showed no operative variables were associated with reinterventions. Among the 71 reinterventions, there were 4 (5.6%) operative deaths. After propensity matching, there was no difference in Kaplan-Meier survival estimates across each group (P = .138 by log-rank statistics). CONCLUSIONS The cumulative incidence of aortic reintervention after ATAAD repair was reasonably low (16% at 10 years), reinterventions were relatively safe (6% operative mortality), and reinterventions did not significantly impact long-term survival.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joseph Garvey
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Takuya Ogami
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michel Pompeu Sá
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jianhui Zhu
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Julie Phillippi
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Diaz-Castrillon CE, Brown JA, Navid F, Serna-Gallegos D, Yousef S, Thoma F, Punu K, Zhu J, Sultan I. The impact of prolonged mechanical ventilation after acute type A aortic dissection repair. J Thorac Cardiovasc Surg 2024; 167:1672-1679.e2. [PMID: 35989122 DOI: 10.1016/j.jtcvs.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 06/24/2022] [Accepted: 07/03/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Patients with type A aortic dissection have increased resource use. The objective of this study was to describe the relationship between prolonged mechanical ventilation and longitudinal survival in patients undergoing type A aortic dissection repair. METHODS We conducted a retrospective analysis of patients with type A aortic dissection undergoing repair from 2010 to 2018; Kaplan-Meier function and adjusted Cox regression analysis were used to compare in-hospital mortality and longitudinal survival accounting for time on mechanical ventilatory support. RESULTS A total of 552 patients were included. The study population was divided into 12 hours or less (n = 291), more than 12 to 24 or less hours (n = 101), more than 24 to 48 hours or less (n = 60), and more than 48 hours (n = 100) groups. Patients within the 12 or less hours group were the youngest (60.0 vs 63.5 years vs 63.6 vs 62.8 years; P = .03) and less likely to be female (31.6% vs 43.6% vs 46.7% vs 56.0%; P < .001). On the other hand, the more than 48 hours group presented with malperfusion syndrome at admission more often (24.4% vs 29.7% vs 28.3% vs 53.0%; P < .001) and had longer cardiopulmonary and ischemic times (P < .05). In-hospital mortality was significantly higher in the more than 48 hours group (5.2% vs 6.9% vs 3.3% vs 30.0%; P < .001). Multivariable analysis demonstrated worse longitudinal survival for the 24 to 48 hours group (hazard ratio, 1.94, confidence interval, 1.10-3.43) and more than 48 hours ventilation group (hazard ratio, 2.25, confidence interval, 1.30-3.92). CONCLUSIONS The need for prolonged mechanical ventilatory support is prevalent and associated with other perioperative complications. More important, after adjusting for other covariates, prolonged mechanical ventilation is an independent factor associated with increased longitudinal mortality.
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Affiliation(s)
- Carlos E Diaz-Castrillon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Kristian Punu
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Jianhui Zhu
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Bhonsale A, Zhu J, Thoma F, Koscumb S, Kancharla K, Voigt A, Magnani J, Estes NA, Saba S, Marroquin O, Mulukutla S, Jain S. Mortality, Hospitalization, and Cardiac Interventions in Patients With Atrial Fibrillation Aged <65 Years. Circ Arrhythm Electrophysiol 2024:e012143. [PMID: 38646831 DOI: 10.1161/circep.123.012143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 02/12/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND The risk factor (RF) burden, clinical course, and long-term outcome among patients with atrial fibrillation (AF) aged <65 years is unclear. METHODS Adult (n=67 221; mean age, 72.4±12.3 years; and 45% female) patients with AF evaluated at the University of Pittsburgh Medical Center between January 2010 and December 2019 were studied. Hospital system-wide electronic health records and administrative data were utilized to ascertain RFs, comorbidities, and subsequent hospitalization and cardiac interventions. The association of AF with all-cause mortality among those aged <65 years was analyzed using an internal contemporary cohort of patients without AF (n=918 073). RESULTS Nearly one-quarter (n=17 335) of the cohort was aged <65 years (32% female) with considerable cardiovascular RFs (current smoker, 16%; mean body mass index, 33.0±8.3; hypertension, 55%; diabetes, 21%; heart failure, 20%; coronary artery disease, 19%; and prior ischemic stroke, 6%) and comorbidity burden (chronic obstructive pulmonary disease, 11%; obstructive sleep apnea, 18%; and chronic kidney disease, 1.3%). Over mean follow-up of >5 years, 2084 (6.7%, <50 years; 13%, 50-65 years) patients died. The proportion of patients with >1 hospitalization for myocardial infarction, heart failure, and stroke was 1.3%, 4.8%, and 1.1% for those aged <50 years and 2.2%, 7.4%, and 1.1% for the 50- to 65-year subgroup, respectively. Multiple cardiac and noncardiac RFs were associated with increased mortality in younger patients with AF with heart failure and hypertension demonstrating significant age-related interaction (P=0.007 and P=0.013, respectively). Patients with AF aged <65 years experienced significantly worse survival compared with comorbidity-adjusted patients without AF (males aged <50 years and hazard ratio, 1.5 [95% CI, 1.24-1.79]; 50-65 years and hazard ratio, 1.3 [95% CI, 1.26-1.43]; females aged <50 years and hazard ratio, 2.4 [95% CI, 1.82-3.16]; 50-65 years and hazard ratio, 1.7 [95% CI, 1.6-1.92]). CONCLUSIONS Patients with AF aged <65 years have significant comorbidity burden and considerable long-term mortality. They are also at a significantly increased risk of hospitalization for heart failure, stroke, and myocardial infarction. These patients warrant an aggressive focus on RF and comorbidity evaluation and management.
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Affiliation(s)
- Aditya Bhonsale
- Division of Cardiac Electrophysiology, University of Pittsburgh Medical Center, PA. (A.B., K.K., A.V., N.A.E., S.S., S.J.)
| | - Jianhui Zhu
- Department of Cardiology, University of Pittsburgh Medical Center, PA. (J.Z., F.T., J.M., S.S., S.M.)
| | - Floyd Thoma
- Department of Cardiology, University of Pittsburgh Medical Center, PA. (J.Z., F.T., J.M., S.S., S.M.)
| | - Steve Koscumb
- Clinical Analytics, University of Pittsburgh Medical Center, PA. (S.K., O.M.)
| | - Krishna Kancharla
- Division of Cardiac Electrophysiology, University of Pittsburgh Medical Center, PA. (A.B., K.K., A.V., N.A.E., S.S., S.J.)
| | - Andrew Voigt
- Division of Cardiac Electrophysiology, University of Pittsburgh Medical Center, PA. (A.B., K.K., A.V., N.A.E., S.S., S.J.)
| | - Jared Magnani
- Department of Cardiology, University of Pittsburgh Medical Center, PA. (J.Z., F.T., J.M., S.S., S.M.)
| | - N A Estes
- Division of Cardiac Electrophysiology, University of Pittsburgh Medical Center, PA. (A.B., K.K., A.V., N.A.E., S.S., S.J.)
| | - Samir Saba
- Division of Cardiac Electrophysiology, University of Pittsburgh Medical Center, PA. (A.B., K.K., A.V., N.A.E., S.S., S.J.)
- Department of Cardiology, University of Pittsburgh Medical Center, PA. (J.Z., F.T., J.M., S.S., S.M.)
| | - Oscar Marroquin
- Clinical Analytics, University of Pittsburgh Medical Center, PA. (S.K., O.M.)
| | - Suresh Mulukutla
- Department of Cardiology, University of Pittsburgh Medical Center, PA. (J.Z., F.T., J.M., S.S., S.M.)
| | - Sandeep Jain
- Division of Cardiac Electrophysiology, University of Pittsburgh Medical Center, PA. (A.B., K.K., A.V., N.A.E., S.S., S.J.)
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Brown JA, Verghis NM, Yousef S, Serna-Gallegos D, Zhu J, Thoma F, Kaczorowski D, Chu D, Bonatti J, Yoon P, Phillippi J, Sultan I. Outcomes of Aortomitral Continuity Reconstruction During Concomitant Aortic and Mitral Valve Replacement. J Cardiothorac Vasc Anesth 2024; 38:905-910. [PMID: 38350743 DOI: 10.1053/j.jvca.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/16/2023] [Accepted: 01/10/2024] [Indexed: 02/15/2024]
Abstract
OBJECTIVES To describe outcomes of reconstruction of the aortomitral continuity (AMC) during concomitant aortic and mitral valve replacement (ie, the "Commando" procedure). DESIGN A retrospective study of consecutive cardiac surgeries from 2010 to 2022. SETTING At a single institution. PARTICIPANTS All patients undergoing double aortic and mitral valve replacement. INTERVENTIONS Patients were dichotomized by the performance (or not) of AMC reconstruction. MEASUREMENTS AND MAIN RESULTS A total of 331 patients underwent double-valve replacement, of whom 21 patients (6.3%) had a Commando procedure. The Commando group was more likely to have had a previous aortic valve replacement (AVR) or mitral valve replacement (MVR) (66.7% v 27.4%, p < 0.001), redo cardiac surgery (71.4% v 31.3%, p < 0.001), and emergent/salvage surgery (14.3% v 1.61%, p = 0.001), whereas surgery was more often performed for endocarditis in the Commando group (52.4% v 22.9%, p = 0.003). The Commando group had higher operative mortality (28.6% v 10.7%, p = 0.014), more prolonged ventilation (61.9% v 31.9%, p = 0.005), longer cardiopulmonary bypass time (312 ± 118 v 218 ± 85 minutes, p < 0.001), and longer ischemic time (252 ± 90 v 176 ± 66 minutes, p < 0.001). Despite increased short-term morbidity in the Commando group, Kaplan-Meier survival estimation showed no difference in long-term survival between each group (p = 0.386, log-rank). On multivariate Cox analysis, the Commando procedure was not associated with an increased hazard of death, compared to MVR + AVR (hazard ratio 1.29, 95% CI: 0.65-2.59, p = 0.496). CONCLUSIONS Although short-term postoperative morbidity and mortality were found to be higher for patients undergoing the Commando procedure, AMC reconstruction may be equally durable in the long term.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Nina M Verghis
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jianhui Zhu
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - David Kaczorowski
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Danny Chu
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Johannes Bonatti
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Pyongsoo Yoon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Julie Phillippi
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA.
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Brown JA, Aranda-Michel E, Navid F, Serna-Gallegos D, Thoma F, Sultan I. Outcomes of emergency surgery for acute type A aortic dissection complicated by malperfusion syndrome. J Thorac Cardiovasc Surg 2024; 167:882-892.e2. [PMID: 35989124 DOI: 10.1016/j.jtcvs.2022.04.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 03/13/2022] [Accepted: 04/10/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The study objective was to determine the impact of malperfusion syndrome on in-hospital mortality and midterm survival after emergency aortic arch reconstruction for acute type A aortic dissection. METHODS This was an observational study of aortic surgeries from 2010 to 2018. All patients with acute type A aortic dissection undergoing open aortic arch reconstruction were included. Patients were dichotomized by the presence or absence of malperfusion syndrome and were analyzed for differences in short-term postoperative outcomes, including morbidity and in-hospital mortality. Kaplan-Meier survival estimation and multivariable Cox analysis were performed to identify variables associated with survival. RESULTS A total of 467 patients undergoing aortic arch reconstruction for acute type A aortic dissection were identified, of whom 332 (71.1%) presented without malperfusion syndrome and 135 (28.9%) presented with malperfusion syndrome. Patients with malperfusion syndrome had higher in-hospital mortality (21.5% vs 5.7%) than patients without malperfusion syndrome. After multivariable adjustment, malperfusion syndrome was associated with worse survival (hazard ratio, 2.43, 95% confidence interval, 1.61-3.66, P < .001) compared with patients without malperfusion syndrome. The predicted risk of mortality increased as the number of malperfused vascular beds increased. Patients with coronary malperfusion syndrome and neuro-malperfusion syndrome had reduced survival compared with the rest of the cohort (P < .05). CONCLUSIONS Malperfusion syndrome is associated with higher in-hospital mortality and reduced survival for patients with acute type A aortic dissection, with the risk of mortality increasing as the number of malperfused vascular beds increases. Coronary malperfusion syndrome and neuro-malperfusion syndrome may represent a high-risk subgroup of patients presenting with acute type A aortic dissection complicated by malperfusion syndrome. Finally, malperfusion syndrome may benefit from immediate surgical intervention to restore true lumen perfusion, as opposed to operative delay.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Levene J, Voigt A, Thoma F, Mulukutla S, Bhonsale A, Kancharla K, Shalaby A, Estes NM, Jain S, Saba S. Patient Outcomes by Ventricular Systolic and Diastolic Function. J Am Heart Assoc 2024; 13:e033211. [PMID: 38353214 PMCID: PMC11010111 DOI: 10.1161/jaha.123.033211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/27/2023] [Indexed: 02/21/2024]
Abstract
BACKGROUND Left ventricular dysfunction is characterized by systolic and diastolic parameters, leading to heart failure (HF) with reduced or preserved ejection fraction (EF), respectively. The goal of this study is to examine the impact of left ventricular systolic and diastolic dysfunction (DD) on patient outcomes. METHODS AND RESULTS Two cohorts were used in this analysis: Cohort A included 136 455 patients with EF ≥50%, stratified by the presence and grade of DD. Cohort B included 16 850 patients with EF <50%, stratified by EF quartiles. Patients were followed to the end points of all-cause death and cardiovascular, HF, or cardiac arrest hospitalizations. Over a median follow-up of 3.42 years, 23 946 (16%) patients died and 31 113 (20%), 13 305 (9%), and 1269 (1%) were hospitalized for cardiovascular, HF, or cardiac arrest causes, respectively. With adjustment for comorbidities, the risk of all-cause mortality and of cardiovascular and HF hospitalizations increased steadily with increasing grade of DD in patients with normal EF, and even more so in patients with worsening EF. The risk of hospitalization for cardiac arrest in patients with grade III DD, however, was comparable to that of patients with EF <25% (hazard ratio, 1.00 [95% CI, 0.98-1.01]) and worse than that of patients in better EF quartiles. CONCLUSIONS Although systolic dysfunction is associated with a greater risk of overall death and HF hospitalizations than DD, the risk of cardiac arrest in patients with grade II and III DD is comparable to that of patients with moderate and severe systolic dysfunction, respectively. Future studies are needed to examine treatment strategies than can improve these outcomes.
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Affiliation(s)
- Jacqueline Levene
- Heart and Vascular Institute at the University of Pittsburgh School of MedicinePittsburghPAUSA
| | - Andrew Voigt
- Heart and Vascular Institute at the University of Pittsburgh School of MedicinePittsburghPAUSA
| | - Floyd Thoma
- Heart and Vascular Institute at the University of Pittsburgh School of MedicinePittsburghPAUSA
| | - Suresh Mulukutla
- Heart and Vascular Institute at the University of Pittsburgh School of MedicinePittsburghPAUSA
| | - Aditya Bhonsale
- Heart and Vascular Institute at the University of Pittsburgh School of MedicinePittsburghPAUSA
| | - Krishna Kancharla
- Heart and Vascular Institute at the University of Pittsburgh School of MedicinePittsburghPAUSA
| | - Alaa Shalaby
- Heart and Vascular Institute at the University of Pittsburgh School of MedicinePittsburghPAUSA
| | - N.A. Mark Estes
- Heart and Vascular Institute at the University of Pittsburgh School of MedicinePittsburghPAUSA
| | - Sandeep Jain
- Heart and Vascular Institute at the University of Pittsburgh School of MedicinePittsburghPAUSA
| | - Samir Saba
- Heart and Vascular Institute at the University of Pittsburgh School of MedicinePittsburghPAUSA
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9
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Koczo A, Brickshawana A, Zhu J, Thoma F, Countouris M, Berlacher K, Gulati M, Michos ED, Reis S, Mulukutla S, Saeed A. Sex-Based Utilization of Guideline Recommended Statin Therapy and Cardiovascular Disease Outcomes: A Primary Prevention Healthcare Network Registry. medRxiv 2024:2024.01.22.24301511. [PMID: 38343794 PMCID: PMC10854347 DOI: 10.1101/2024.01.22.24301511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
Background In the US, women have similar cardiovascular death rates than men. Less is known about sex differences in statin use for primary prevention and associated atherosclerotic cardiovascular disease (ASCVD) outcomes. Methods Statin prescriptions using electronic health records were examined in patients without ASCVD (myocardial infarction (MI), revascularization or ischemic stroke) between 2013-2019. Guideline-directed statin intensity (GDSI) at index and follow-up visits were compared among sexes across ASCVD risk groups, defined by pooled-cohort equation. Cox regression hazard ratios (HR) [95% CI] were calculated for statin use and outcomes (myocardial infarction, stroke/transient ischemic attack (TIA), and all-cause mortality) stratified by sex. Interaction terms (statin and sex) were applied. Results Among 282,298 patients, (mean age ∼ 50 years) 17.1% women and 19.5% men were prescribed any statin at index visit. Time to GDSI was similar between sexes, but the proportion of high-risk women on GDSI at follow-ups was lower compared to high-risk men (2-years: 27.7 vs 32.0%, and 5-years: 47.2 vs 55.2%, p<0.05). When compared to GDSI, no statin use was associated with higher risk of MI and ischemic stroke/TIA amongst both sexes. High-risk women on GDSI had a lower risk of mortality (HR=1.39 [1.22-1.59]) versus men (HR=1.67 [1.50-1.86]) of similar risk (p value interaction=0.004). Conclusion In a large contemporary healthcare system, there was underutilization of statins across both sexes in primary prevention. High-risk women were less likely to be initiated on GDSI compared with high-risk men. GDSI significantly improved the survival in both sexes regardless of ASCVD risk group. Future strategies to ensure continued use of GDSI, specifically among women, should be explored.
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10
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Jain U, Jain B, Brown J, Sultan IB, Thoma F, Anetakis KM, Balzer JR, Subramaniam K, Yousef S, Wang Y, Nogueira R, Thirumala PD. Outcomes after Perioperative Transient Ischemic Attack Following Cardiac Surgery. J Cardiovasc Dev Dis 2024; 11:27. [PMID: 38248897 PMCID: PMC10816235 DOI: 10.3390/jcdd11010027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 01/14/2024] [Accepted: 01/15/2024] [Indexed: 01/23/2024] Open
Abstract
Perioperative transient ischemic attacks (PTIAs) are associated with significantly increased rates of postoperative complications such as low cardiac output, atrial fibrillation, and significantly higher mortality in cardiac procedures. The current literature on PTIAs is sparse and understudied. Therefore, we aim to understand the effects of PTIA on hospital utilization, readmission, and morbidity. Using data on all the cardiac procedures at the University of Pittsburgh Medical Center from 2011 to 2019, fine and gray analysis was performed to identify whether PTIAs and covariables correlate with increased hospital utilization, stroke, all-cause readmission, Major Adverse Cardiac and Cerebrovascular Events (MACCE), MI, and all-cause mortality. Logistic regression for longer hospitalization showed that PTIA (HR: 2.199 [95% CI: 1.416-3.416] increased utilization rates. Fine and gray modeling indicated that PTIA (HR: 1.444 [95% CI: 1.096-1.902], p < 0.01) increased the rates of follow-up all-cause readmission. However, PTIA (HR: 1.643 [95% CI: 0.913-2.956] was not statistically significant for stroke readmission modeling. Multivariate modeling for MACCE events within 30 days of surgery (HR: 0.524 [95% CI: 0.171-1.605], p > 0.25) and anytime during the follow-up period (HR: 1.116 [95% CI: 0.825-1.509], p > 0.45) showed no significant correlation with PTIA. As a result of PTIA's significant burden on the healthcare system due to increased utilization, it is critical to better define and recognize PTIA for timely management to improve perioperative outcomes.
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Affiliation(s)
- Urvish Jain
- School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA;
| | - Bhav Jain
- School of Medicine, Stanford University, Stanford, CA 94305, USA;
| | - James Brown
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (J.B.); (S.Y.); (Y.W.)
| | - Ibrahim B. Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (J.B.); (S.Y.); (Y.W.)
| | - Floyd Thoma
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (J.B.); (S.Y.); (Y.W.)
| | - Katherine M. Anetakis
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (K.M.A.); (J.R.B.); (P.D.T.)
| | - Jeffrey R. Balzer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (K.M.A.); (J.R.B.); (P.D.T.)
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA;
| | - Sarah Yousef
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (J.B.); (S.Y.); (Y.W.)
| | - Yisi Wang
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (J.B.); (S.Y.); (Y.W.)
| | - Raul Nogueira
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA;
| | - Parthasarathy D. Thirumala
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (K.M.A.); (J.R.B.); (P.D.T.)
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA;
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11
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Bianco V, Aranda-Michel E, Serna-Gallegos D, Dunn-Lewis C, Wang Y, Thoma F, Navid F, Sultan I. Transfusion of non-red blood cell blood products does not reduce survival following cardiac surgery. J Thorac Cardiovasc Surg 2024; 167:243-253.e5. [PMID: 35337681 DOI: 10.1016/j.jtcvs.2022.02.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 02/05/2022] [Accepted: 02/14/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The literature supports the assertion that patients undergoing cardiac surgery who receive perioperative packed red blood cell (pRBC) transfusions have increased associated mortality. The aim of the current study is to assess whether there is an association between non-pRBC blood product transfusions and increased mortality. METHODS Data from our center's Society of Thoracic Surgeons database included patients who underwent cardiac surgery from 2010 to 2018. Patients with pRBC transfusions or circulatory arrest were excluded. Propensity matching was performed (1:1; caliper = 0.2 times the standard deviation of logit of propensity score). Kaplan-Meier estimates and Cox regression were used. Cardiac transplant, ventricular assist devices, transcatheter aortic valves, and patients who had experienced circulatory arrest were excluded from this analysis. RESULTS A total of 8042 patients met criteria for analysis. Following propensity matching (1:1), 395 patients requiring perioperative non-pRBC blood products (platelets, fresh-frozen plasma, and cryoprecipitate) were matched with 395 nontransfusion patients, yielding equitable patient cohorts. Median follow-up was 4.5 (3.0-6.4) years. Patients received platelets (327 [82.8%]), fresh-frozen plasma (141 [35.7%]), and cryoprecipitate (60 [15.2%]). There was no significant difference in the postoperative mortality (6 [1.5%] vs 4 [1.0%]; P = .52). Reoperation (20 [5.0%] vs 8 [2.0%]; P < .02) and prolonged ventilation (36 [9.1%] vs 19 [4.8%]; P < .02) were greater in the transfusion group. Emergent operation (odds ratio [OR] 2.86 [1.72-4.78]; P < .001), intra-aortic balloon pump (OR 3.24 [1.64-6.39]; P < .001), and multivalve operation (OR 4.34 [2.83-6.67]; P < .001) were significantly associated with blood product use. Blood product transfusion (hazard ratio; 1.15 [0.89-1.48]; P = .3) was not significantly associated with increased mortality risk. There was no significant long-term survival difference between cohorts. CONCLUSIONS Patients who undergo cardiac surgery requiring blood products alone, without pRBC transfusion, have similar postoperative and long-term survival compared with patients not requiring blood products. These data are based on a limited patient sample, and future studies will aid in improving the generalizability of these results.
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Affiliation(s)
- Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Courtenay Dunn-Lewis
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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12
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Muluk P, Zhu J, Thoma F, Hay E, Marroquin O, Makani A, Aiyer A, Nasir K, Gulati M, Shapiro MD, Mulukutla S, Saeed A. Impact of Guideline-Directed Statin Intervention for Primary Prevention in Patients With Diabetes. Diabetes Care 2023; 46:2273-2277. [PMID: 37851356 DOI: 10.2337/dc23-0816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 09/20/2023] [Indexed: 10/19/2023]
Abstract
OBJECTIVE We examined guideline-directed statin intensity (GDSI) use and atherosclerotic cardiovascular disease (ASCVD) outcomes in patients with diabetes across a contemporary health care system. RESEARCH DESIGN AND METHODS Patients without preexisting ASCVD were categorized by diabetes status and 10-year ASCVD risk (borderline [5-7.4%], intermediate [7.5-19.9%], high [≥20%]). Mean ±SD time to start of or change to GDSI was calculated. Incident ASCVD and all-cause mortality association, stratified by ASCVD risk, was calculated using Cox regression. RESULTS Among 282,298 patients, 28,807 (10.2%) had diabetes and 253,491 (89.8%) did not. Only two-thirds of intermediate- and high-risk patients with diabetes were receiving GDSI therapy at 5-year follow-up. In fully adjusted models, patients with diabetes not taking a statin (vs. GDSI) had a significantly higher risk of stroke and mortality in the intermediate- and high-risk groups (hazard ratio for mortality 1.81 [95% CI 1.58-2.07] vs. 1.41 [1.26-1.57]; P for interaction < 0.01). CONCLUSIONS Significant gaps remain in GDSI use for high-risk patients with diabetes, conferring an increased risk of ASCVD outcomes and all-cause mortality.
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Affiliation(s)
- Pallavi Muluk
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jianhui Zhu
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Floyd Thoma
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Eli Hay
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Oscar Marroquin
- University of Pittsburgh School of Medicine, Pittsburgh, PA
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Amber Makani
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Aryan Aiyer
- University of Pittsburgh School of Medicine, Pittsburgh, PA
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Khurram Nasir
- Houston Methodist, Houston, TX
- Weil Cornell Medical College, New York, NY
| | - Martha Gulati
- Smidt Heart Institute, Cedars Sinai, Los Angeles, CA
| | | | - Suresh Mulukutla
- University of Pittsburgh School of Medicine, Pittsburgh, PA
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Anum Saeed
- University of Pittsburgh School of Medicine, Pittsburgh, PA
- University of Pittsburgh Medical Center, Pittsburgh, PA
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13
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Brown JA, Yousef S, Toma C, Kliner D, Serna-Gallegos D, Makani A, West D, Wang Y, Thoma F, Pompeu Sá M, Sultan I. Self-Expanding Transcatheter Aortic Valves Optimize Transvalvular Hemodynamics Independent of Intra- Versus Supra-Annular Design. Am J Cardiol 2023; 207:48-53. [PMID: 37722201 DOI: 10.1016/j.amjcard.2023.08.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/14/2023] [Accepted: 08/20/2023] [Indexed: 09/20/2023]
Abstract
This study sought to characterize transvalvular hemodynamics during the first 30 days after transcatheter aortic valve implantation (TAVI) across various transcatheter heart valves (THVs), while adjusting for annular dimensions. This was an observational study of TAVIs from September 2021 to October 2022. The primary outcome was mean transvalvular pressure gradient (TVPG), measured using transthoracic echocardiography at day 0, day 1, and day 30 post-TAVI, and were compared across 3 THV, including the self-expandable intra-annular Portico (Abbott Vascular, Santa Clara, California) valve, the balloon-expandable SAPIEN 3 Ultra (Edwards Lifesciences, Irvine, California), and the self-expandable supra-annular Evolut Pro+ (Medtronic, Minneapolis, Minnesota). A total of 560 patients who underwent TAVI were identified, of which 106 (18.9%) received a Portico THV, 176 (31.4%) received a SAPIEN THV, and 278 (49.6%) received an Evolut THV. For Portico THV, the TVPG on day 0 increased from 6.0 (4.7 to 9.0) to 7.0 (6.0 to 10.0) by day 30 (p = 0.009). For SAPIEN THV, the TVPG on day 0 increased from 6.5 (5.0 to 8.0) to 12.0 (9.0 to 15.0) by day 30 (p <0.001). For Evolut THV, the TVPG on day 0 increased from 6.0 (5.0 to 9.0) to 7.2 (5.0 to 10.0) by day 30 (p = 0.001). Adjusting for time and annular diameter in a multivariable mixed effects model, the SAPIEN group had a significantly greater increase in TVPG over time than the Evolut reference group (p <0.001), while there was no difference in the change of TVPG over time for the Portico group vs. the Evolut group (p = 0.874). In conclusion, compared with balloon-expandable valves, self-expanding THV may optimize transvalvular hemodynamics across all annular diameters, independent of their supra-annular and intra-annular design.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dustin Kliner
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amber Makani
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David West
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michel Pompeu Sá
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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14
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Bianco V, Kilic A, Yousef S, Serna-Gallegos D, Aranda-Michel E, Wang Y, Thoma F, Navid F, Sultan I. The long-term impact of postoperative atrial fibrillation after cardiac surgery. J Thorac Cardiovasc Surg 2023; 166:1073-1083.e10. [PMID: 35248360 DOI: 10.1016/j.jtcvs.2021.10.072] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The literature has reported worse in-hospital outcomes for patients with atrial fibrillation. The objective of the following study is to provide detailed results on the long-term impact of postoperative atrial fibrillation on survival and hospital readmission in cardiac surgery. METHODS All patients undergoing open cardiac surgery were reviewed with the exclusion of preoperative atrial fibrillation or patients undergoing ventricular assist device, transplant, or Cox-Maze procedures. Propensity matching (1:1) was performed to ensure similar baseline characteristics. Multivariable analysis identified significant associations with mortality and readmission. RESULTS A total of 12,227 patients with cardiac disease were divided into 7927 patients (64.8%) without postoperative atrial fibrillation and 4300 patients (35.2%) with new-onset postoperative atrial fibrillation. Propensity matching (1:1) yielded 4275 risk-adjusted pairs. There was no difference between the nonpostoperative atrial fibrillation versus postoperative atrial fibrillation cohorts regarding operative mortality (4.61% vs 4.12%; P = .26) and stroke (2.32% vs 2.76%; P = .191). Patients with postoperative atrial fibrillation had higher rates of reoperation (12.12% vs 6.83%; P < .001), transfusion (43.42% vs 36.94%; P < .001), sepsis (1.99% vs 0.80%; P < .001), prolonged ventilation (15.88% vs 9.24% vs; P < .001), pneumonia (6.60% vs 2.36%; P < .001), renal failure (6.90% vs 3.37%; P < .001), and dialysis (4.94% vs 2.08%; P < .001). The postoperative atrial fibrillation cohort had a significantly higher incidence of atrial fibrillation on follow-up (11.74% vs 4.75%; P < .001). Postoperative atrial fibrillation was independently associated with mortality (hazard ratio, 1.21; 1.12-1.33; P < .001), all-cause readmissions (hazard ratio, 1.05; 1.01-1.1; P = .010), and heart failure-specific readmission (hazard ratio, 1.14; 1.04-1.26; P = .01). CONCLUSIONS Patients in the postoperative atrial fibrillation cohort had worse perioperative morbidity, lower survival, and more readmissions for heart failure on long-term follow-up.
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Affiliation(s)
- Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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15
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Dhande M, Barakat A, Canterbury A, Thoma F, Mulukutla S, Sezer A, Aronis KN, Bhonsale A, Kancharla K, Voigt AH, Wang NC, Shalaby A, Mark Estes NA, Saba S, Jain SK. Cardiovascular Hospitalizations and Resource Use Following Atrial Fibrillation Ablation. J Am Heart Assoc 2023; 12:e028609. [PMID: 37681551 PMCID: PMC10547277 DOI: 10.1161/jaha.122.028609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 06/06/2023] [Indexed: 09/09/2023]
Abstract
Background Over the next few years, atrial fibrillation (AF)-related morbidity and costs will increase significantly. Thus, it is prudent to examine the impact of AF treatment on health care resource use. This study examined the impact of AF ablation on hospitalization, length of stay, and resource use for patients undergoing AF ablation in a multihospital system. Methods and Results In an observational analysis, outcomes of total, cardiovascular, and AF hospitalizations, emergency department visits, and length of stay were compared for 3417 patients between 12 months before and 24 months following AF ablation. Use of electrical cardioversions and antiarrhythmic use were also compared 1 year before to 2 years after AF ablation. There were fewer total (0.7±1.3 versus 0.3±0.7; P<0.001), cardiovascular (0.7±1.2 versus 0.2±0.6; P<0.001), and AF (0.6±1.1 versus 0.1±0.3; P<0.001) hospitalizations and emergency department visits (0.8±2.1 versus 0.4±0.9; P<0.001) per patient-year for the 2 years following AF ablation compared with 1 year before. Average length of stay per patient-year (1.4±7.9 versus 3.6±5.3 days; P<0.0001), the percentage of patients on antiarrhythmic therapy (21.2% versus 58.5%; P<0.0001), and those undergoing electrical cardioversions (16.1% versus 28.1%; P<0.0001) were lower 2 years following AF ablation versus 1 year before. Conclusions We noted a decrease in total, cardiovascular, and AF hospitalizations and health care resource use during the 2-year period after index AF ablation, compared with the 1 year before. AF ablation may portend a decline in patient morbidity and health care costs.
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Affiliation(s)
- Mehak Dhande
- Center for Atrial FibrillationUniversity of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Heart and Vascular InstitutePittsburghPA
| | - Amr Barakat
- Center for Atrial FibrillationUniversity of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Heart and Vascular InstitutePittsburghPA
| | - Ann Canterbury
- Center for Atrial FibrillationUniversity of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Heart and Vascular InstitutePittsburghPA
| | - Floyd Thoma
- Center for Atrial FibrillationUniversity of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Heart and Vascular InstitutePittsburghPA
- Clinical AnalyticsUniversity of Pittsburgh Medical CenterPittsburghPA
| | - Suresh Mulukutla
- Center for Atrial FibrillationUniversity of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Heart and Vascular InstitutePittsburghPA
- Clinical AnalyticsUniversity of Pittsburgh Medical CenterPittsburghPA
| | - Ahmet Sezer
- Center for Atrial FibrillationUniversity of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Heart and Vascular InstitutePittsburghPA
| | - Konstantinos N. Aronis
- Center for Atrial FibrillationUniversity of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Heart and Vascular InstitutePittsburghPA
| | - Aditya Bhonsale
- Center for Atrial FibrillationUniversity of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Heart and Vascular InstitutePittsburghPA
| | - Krishna Kancharla
- Center for Atrial FibrillationUniversity of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Heart and Vascular InstitutePittsburghPA
| | - Andrew H. Voigt
- Center for Atrial FibrillationUniversity of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Heart and Vascular InstitutePittsburghPA
| | - Norman C. Wang
- Center for Atrial FibrillationUniversity of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Heart and Vascular InstitutePittsburghPA
| | - Alaa Shalaby
- Center for Atrial FibrillationUniversity of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Heart and Vascular InstitutePittsburghPA
| | - N. A. Mark Estes
- Center for Atrial FibrillationUniversity of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Heart and Vascular InstitutePittsburghPA
| | - Samir Saba
- Center for Atrial FibrillationUniversity of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Heart and Vascular InstitutePittsburghPA
| | - Sandeep K. Jain
- Center for Atrial FibrillationUniversity of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Heart and Vascular InstitutePittsburghPA
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16
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Saba S, Mulukutla S, Thoma F, Aronis KN, Bhonsale A, Kancharla K, Voigt A, Shalaby AA, Estes NAM, Jain S. Impact of Diastolic Dysfunction on the Risk of Sudden Cardiac Arrest. Circ Arrhythm Electrophysiol 2023; 16:475-477. [PMID: 37485680 DOI: 10.1161/circep.123.012089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Affiliation(s)
- Samir Saba
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, PA
| | - Suresh Mulukutla
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, PA
| | - Floyd Thoma
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, PA
| | - Konstantinos N Aronis
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, PA
| | - Aditya Bhonsale
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, PA
| | - Krishna Kancharla
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, PA
| | - Andrew Voigt
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, PA
| | - Alaa A Shalaby
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, PA
| | - N A Mark Estes
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, PA
| | - Sandeep Jain
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, PA
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Verghis NM, Brown JA, Yousef S, Aranda-Michel E, Serna-Gallegos D, Levenson J, Ogami T, Diaz-Castrillon C, Thoma F, Singh M, Sultan I. Long-Term Outcomes of Patients With Carotid and Aortic Body Tumors. Am J Cardiol 2023; 199:78-84. [PMID: 37262989 DOI: 10.1016/j.amjcard.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/13/2023] [Accepted: 05/04/2023] [Indexed: 06/03/2023]
Abstract
Chemodectomas are tumors derived from parasympathetic nonchromaffin cells and are often found in the aortic and carotid bodies. They are generally benign but can cause mass-effect symptoms and have local or distant spread. Surgical excision has been the main curative treatment strategy. The National Cancer Database was reviewed to study all patients with carotid or aortic body tumors from 2004 to 2015. Demographic data, tumor characteristics, treatment strategies, and patient outcomes were examined, split by tumor location. Kaplan-Meier survival estimates were generated for both locations. In total, 248 patients were examined, with 151 having a tumor in the carotid body and 97 having a tumor in the aortic body. Many variables were similar between both tumor locations. However, aortic body tumors were larger than those in the carotid body (477.80 ± 477.58 mm vs 320.64 ± 436.53 mm, p = 0.008). More regional lymph nodes were positive in aortic body tumors (65.52 ± 45.73 vs 35.46 ± 46.44, p <0.001). There were more distant metastases at the time of diagnosis in carotid body tumors (p = 0.003). Chemotherapy was used more for aortic body tumors (p = 0.001); surgery was used more for carotid body tumors (p <0.001). There are slight differences in tumor characteristics and response to treatment. Surgical resection is the cornerstone of management, and radiation can often be considered. In conclusion, chemodectomas are generally benign but can present with metastasis and compressive symptoms that make understanding their physiology and treatment important.
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Affiliation(s)
- Nina M Verghis
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Josh Levenson
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Takuya Ogami
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Carlos Diaz-Castrillon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael Singh
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Ayub MT, Rangavajla G, Thoma F, Mulukutla S, Aronis K, Bhonsale A, Kancharla K, Voigt A, Shalaby A, Estes NAM, Jain S, Saba S. Relative Contribution of Atrial Fibrillation to Outcomes of Patients With Cardiomyopathy Based on Severity of Left Ventricular Dysfunction. Am J Cardiol 2023; 198:9-13. [PMID: 37182255 DOI: 10.1016/j.amjcard.2023.04.033] [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] [Received: 02/14/2023] [Revised: 03/22/2023] [Accepted: 04/14/2023] [Indexed: 05/16/2023]
Abstract
In patients with left ventricular (LV) dysfunction, the risk of death or heart failure hospitalizations (HFHs) increases with worsening ejection fraction (EF). Whether the relative contribution of atrial fibrillation (AF) to outcomes is more pronounced in patients with worse EF is not confirmed. The present study aimed to investigate the relative influence of AF on the outcome of cardiomyopathy patients by severity of LV dysfunction. In this observational study, data from 18,003 patients with EF ≤50% seen at a large academic institution between 2011 and 2017 were analyzed. Patients were stratified by EF quartiles (EF<25%, 25%≤EF<35%, 35%≤EF<40%, and EF≥40%, for quartiles 1, 2, 3, and 4, respectively). and followed to the end point of death or HFH. Outcomes of AF versus non-AF patients were compared within each EF quartile. During a median follow-up of 3.35 years, 8,037 patients (45%) died and 7,271 (40%) had at least 1 HFH. Rates of HFH and all-cause mortality increased as EF decreased. The hazard ratios (HRs) of death or HFH for AF versus non-AF patients increased steadily with increasing EF (HR of 1.22, 1.27, 1.45, 1.50 for quartiles 1, 2, 3, and 4, respectively, p = 0.045) driven primarily by the risk of HFH (HR of 1.26, 1.45, 1.59, 1.69 for quartiles 1, 2, 3, and 4, respectively, p = 0.045). In conclusion, in patients with LV dysfunction, the detrimental influence of AF on the risk of HFH is more pronounced in those with more preserved EF. Mitigation strategies for AF with the goal of decreasing HFH may be more impactful in patients with more preserved LV function.
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Affiliation(s)
- Mumammad Talha Ayub
- The Heart and Vascular Institute at the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Gautam Rangavajla
- The Heart and Vascular Institute at the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- The Heart and Vascular Institute at the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Suresh Mulukutla
- The Heart and Vascular Institute at the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Konstantinos Aronis
- The Heart and Vascular Institute at the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Aditya Bhonsale
- The Heart and Vascular Institute at the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Krishna Kancharla
- The Heart and Vascular Institute at the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Andrew Voigt
- The Heart and Vascular Institute at the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alaa Shalaby
- The Heart and Vascular Institute at the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Nathan Anthony Mark Estes
- The Heart and Vascular Institute at the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sandeep Jain
- The Heart and Vascular Institute at the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Samir Saba
- The Heart and Vascular Institute at the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
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Dhande M, Aronis KN, Thoma F, Mulukutla S, Bhonsale A, Kancharla K, Shalaby A, Voigt A, Mark Estes NA, Jain SK, Saba S. Ventricular conduction abnormality in patients with mild to moderate cardiomyopathy. Clin Cardiol 2023; 46:543-548. [PMID: 36883012 DOI: 10.1002/clc.24001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 01/21/2023] [Accepted: 02/16/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND In mild-to-moderate cardiomyopathy, cardiac resynchronization therapy (CRT) is indicated in patients with high burden of right ventricular pacing but not in those with intrinsic ventricular conduction abnormalities. HYPOTHESIS We hypothesized that CRT positively impacts outcomes of patients with intrinsic ventricular conduction delay and left ventricular ejection fraction (LVEF) of 36%-50%. METHODS Of 18 003 patients with LVEF ≤ 50%, 5966 (33%) patients had mild-to-moderate cardiomyopathy, of whom 1741 (29%) have a QRS duration ≥120 ms. Patients were followed to the endpoints of death and heart failure (HF) hospitalization. Outcomes were compared between patients with narrow versus wide QRS. RESULTS Of the 1741 patients with mild-to-moderate cardiomyopathy and wide QRS duration, only 68 (4%) were implanted with a CRT device. Over a median follow-up of 3.35 years, 849 (51%) died and 1004 (58%) had a HF hospitalization. The adjusted risk of death (hazard ratio (HR) = 1.11, p = 0.046) and of death or HF hospitalization (HR = 1.10, p = 0.037) were significantly higher in patients with wide versus narrow QRS duration. In patients with wide QRS complex, CRT was associated with reduction in the adjusted risk of death (HR = 0.47, p = 0.020) and of death or HF hospitalization (HR = 0.58, p = 0.008). CONCLUSIONS Patients with mild-to-moderate cardiomyopathy and wide QRS duration are rarely implanted with CRT devices and have worse outcomes compared to those with narrow QRS. Randomized trials are needed to examine if CRT has salutary effects in this population.
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Affiliation(s)
- Mehak Dhande
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Konstantinos N Aronis
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Suresh Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Aditya Bhonsale
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Krishna Kancharla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alaa Shalaby
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew Voigt
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - N A Mark Estes
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sandeep K Jain
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Samir Saba
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Very B, Sejpal M, Pham R, Kainat A, Thoma F, Sezer A, Boyle B, Topoll A, Johnson AE, Hickey GW. THE IMPACT OF PALLIATIVE CARE ON HOSPITALIZATION AND READMISSION IN HEART FAILURE. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01080-x] [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: 03/06/2023]
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Medhekar A, Mulukutla S, Adams W, Kristofik A, Byers E, Thoma F, Aronis K, Barrington W, Bazaz R, Bhonsale A, Estes NAM, Kancharla K, Voigt A, Wang NC, Saba S, Jain SK. Impact of a dedicated center for atrial fibrillation on resource utilization and costs. Clin Cardiol 2023; 46:304-309. [PMID: 36660876 PMCID: PMC10018075 DOI: 10.1002/clc.23974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/19/2022] [Accepted: 01/04/2023] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) affects millions of Americans each year and can lead to high levels of resource utilization through emergency department (ED) visits and inpatient stays. HYPOTHESIS We hypothesized that referral of patients to a dedicated Center for AF from the ED would reduce costs of care. METHODS The University of Pittsburgh Center for AF serves as a rapid referral center for patients with AF to avoid unnecessary inpatient admissions and provide specialized care. Patients that presented to the ED with AF and met prespecified criteria were directed to rapid outpatient follow-up instead of inpatient admission. The primary outcome of interest was 30-day total costs. Secondary outcomes included outpatient costs, inpatient costs, 90-day costs, and inpatient stay characteristics. RESULTS We identified 96 patients (median age 65, 38% women) referred to the center for AF for a new diagnosis of AF between October 2017 and December 2019 and matched 96 control patients. After 30 days of follow-up, patients referred to the center for AF had a lower average cost ($619 vs. $1252, p < 0.001) compared to controls, driven by lower costs of ED care tempered by slightly higher outpatient costs. Thirty-day admissions and lengths of stay were also lower. These differences were persistent at 90 days. CONCLUSION Directing patients with AF that present to the ED to follow-up at a dedicated Center for AF significantly reduced overall costs, while reducing subsequent inpatient admissions and total lengths of stay in the hospital.
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Affiliation(s)
- Ankit Medhekar
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Suresh Mulukutla
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Whitney Adams
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amanda Kristofik
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Erica Byers
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Floyd Thoma
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Konstantinos Aronis
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - William Barrington
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Raveen Bazaz
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Aditya Bhonsale
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nathan Anthony Mark Estes
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Krishna Kancharla
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew Voigt
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Norman C Wang
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Samir Saba
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sandeep K Jain
- Heart and Vascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Ayub MT, Rangavajla G, Aronis KN, Thoma F, Mulukutla S, Bhonsale A, Kancharla K, Voigt AH, Shalaby AA, Estes NA, Jain SK, Saba SF. PROGNOSTIC IMPLICATIONS OF ATRIAL FIBRILLATION IN PATIENTS WITH CARDIOMYOPATHY BASED ON SEVERITY OF LEFT VENTRICULAR DYSFUNCTION. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00625-3] [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: 03/06/2023]
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23
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Brown JA, Yousef S, Zhu J, Thoma F, Serna-Gallegos D, Joshi R, Subramaniam K, Kaczorowski DJ, Chu D, Aranda-Michel E, Bianco V, Sultan I. The Long-Term Impact of Diastolic Dysfunction After Routine Cardiac Surgery. J Cardiothorac Vasc Anesth 2023; 37:927-932. [PMID: 36863985 DOI: 10.1053/j.jvca.2023.01.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 01/16/2023] [Accepted: 01/27/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVE To determine the impact of diastolic dysfunction (DD) on survival after routine cardiac surgery. DESIGN This was an observational study of consecutive cardiac surgeries from 2010 to 2021. SETTING At a single institution. PARTICIPANTS Patients undergoing isolated coronary, isolated valvular, and concomitant coronary and valvular surgery were included. Patients with a transthoracic echocardiogram (TTE) longer than 6 months prior to their index surgery were excluded from the analysis. INTERVENTIONS Patients were categorized via preoperative TTE as having no DD, grade I DD, grade II DD, or grade III DD. MEASUREMENTS AND MAIN RESULTS A total of 8,682 patients undergoing a coronary and/or valvular surgery were identified, of whom 4,375 (50.4%) had no DD, 3,034 (34.9%) had grade I DD, 1,066 (12.3%) had grade II DD, and 207 (2.4%) had grade III DD. The median (IQR) time of the TTE prior to the index surgery was 6 (2-29) days. Operative mortality was 5.8% in the grade III DD group v 2.4% for grade II DD, 1.9% for grade I DD, and 2.1% for no DD (p = 0.001). Atrial fibrillation, prolonged mechanical ventilation (>24 hours), acute kidney injury, any packed red blood cell transfusion, reexploration for bleeding, and length of stay were higher in the grade III DD group compared to the rest of the cohort. The median follow-up was 4.0 (IQR: 1.7-6.5) years. Kaplan-Meier survival estimates were lower in the grade III DD group than in the rest of the cohort. CONCLUSIONS These findings suggested that DD may be associated with poor short-term and long-term outcomes.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Jianhui Zhu
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Rama Joshi
- Department of Anesthesiology and Perioperative Medicine, Pittsburgh, PA
| | | | - David J Kaczorowski
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Danny Chu
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA.
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24
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Coons JC, Kliner J, Mathier MA, Mulukutla S, Thoma F, Sezer A, Beisel C, Glassbrenner T, Keebler M. Impact of a Medication Optimization Clinic on Heart Failure Hospitalizations. Am J Cardiol 2023; 188:102-109. [PMID: 36493606 DOI: 10.1016/j.amjcard.2022.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/28/2022] [Accepted: 11/12/2022] [Indexed: 12/12/2022]
Abstract
Efforts to optimize guideline-directed medical therapy (GDMT) through team-based care may affect outcomes in patients with heart failure with reduced ejection fraction (HFrEF). This study evaluated the impact of an innovative medication optimization clinic (MOC) on GDMT and outcomes in patients with HFrEF. Patients with HFrEF who are not receiving optimal GDMT are referred to MOC and managed by a team comprised of a nurse practitioner or physician assistant, clinical pharmacist, and HF cardiologist. We retrospectively evaluated the impact of MOC (n = 206) compared with usual care (n = 412) with a 2:1 propensity-matched control group. The primary clinical outcome was the incidence of HF hospitalizations at 3 months after the index visit. Kaplan-Meier cumulative event curves and Cox proportional hazards regression models with adjustment were conducted. A significantly higher proportion of patients in MOC received quadruple therapy (49% vs 4%, p <0.0001), angiotensin receptor neprilysin inhibitor (60% vs 27%, p <0.0001), mineralocorticoid receptor antagonist (59% vs 37%, p <0.0001), and sodium-glucose cotransporter-2 inhibitor (60% vs 10%, p <0.0001). The primary outcome was significantly lower in the MOC versus the control group (log-rank, p = 0.0008). Cox regression showed that patients in the control group were more than threefold more likely to be hospitalized because of HF than those in the MOC group (p = 0.0014). In conclusion, the MOC was associated with improved GDMT and lower risk of HF hospitalizations in patients with HFrEF.
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Affiliation(s)
- James C Coons
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center Presbyterian-Shadyside Hospital, Pittsburgh, Pennsylvania.
| | - Jennifer Kliner
- Heart and Vascular Institute, University of Pittsburgh Medical Center Presbyterian-Shadyside Hospital, Pittsburgh, Pennsylvania
| | - Michael A Mathier
- Heart and Vascular Institute, University of Pittsburgh Medical Center Presbyterian-Shadyside Hospital, Pittsburgh, Pennsylvania
| | - Suresh Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center Presbyterian-Shadyside Hospital, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center Presbyterian-Shadyside Hospital, Pittsburgh, Pennsylvania
| | - Ahmet Sezer
- Heart and Vascular Institute, University of Pittsburgh Medical Center Presbyterian-Shadyside Hospital, Pittsburgh, Pennsylvania
| | - Chad Beisel
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Taylor Glassbrenner
- Heart and Vascular Institute, University of Pittsburgh Medical Center Presbyterian-Shadyside Hospital, Pittsburgh, Pennsylvania
| | - Mary Keebler
- Heart and Vascular Institute, University of Pittsburgh Medical Center Presbyterian-Shadyside Hospital, Pittsburgh, Pennsylvania
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Bianco V, Mulukutla S, Aranda-Michel E, Chu D, Kaczorowski D, Bonatti J, Yoon P, Kliner D, Toma C, Wang Y, Koscumb S, Thoma F, Navid F, Serna-Gallegos D, Sultan I. Coronary Artery Bypass With Multiarterial Grafting vs Percutaneous Coronary Intervention. Ann Thorac Surg 2023; 115:404-410. [PMID: 35835208 DOI: 10.1016/j.athoracsur.2022.06.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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] [Received: 01/27/2022] [Revised: 06/01/2022] [Accepted: 06/13/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Data comparing patients who undergo multiarterial grafting during coronary artery bypass grafting (CABG) vs percutaneous coronary intervention (PCI) in patients with multivessel coronary disease are scarce. This study addresses the relevance of using multiple arterial conduits vs PCI for appropriate patients. METHODS This retrospective study included all patients with coronary artery disease who underwent CABG with multiple arterial conduits or PCI. Propensity score matching was performed for baseline characteristics. Kaplan-Meier estimates, cumulative incidence, and freedom from major adverse cardiac and cerebrovascular events (MACCE) curves were performed. RESULTS The total patient population consisted of 3648 patients from 2011 to 2018 divided into 902 CABG patients and 2746 PCI patients. Patients were propensity matched (PCI, n = 838; CABG, n = 838). In the CABG cohort the left internal mammary artery was used in 837 patients (99.9%), the right internal mammary artery in 770 patients (92%), and radial arteries in 108 patients (12.9%). Patients in the PCI cohort had significantly higher 30-day mortality (24 [2.9%] vs 7 [0.8%], P < .01). Survival over follow-up (median, 4.9 years; range, 3.3-6.8) was better for the CABG cohort (730 [87.1%] vs 625 [74.6%], P < .01). Patients in the CABG cohort had greater freedom from MACCE (607 [72.4%] vs 339 [40.5%], P < .01). Cox multivariable regression showed that patients who underwent CABG had a significantly reduced risk of mortality (hazard ratio, 0.49; 95% confidence interval, 0.39-0.61; P < .01) and of MACCE (hazard ratio, 0.33; 95% confidence interval, 0.28-0.38; P < .01). CONCLUSIONS Patients with coronary artery disease who undergo CABG with multiple arterial conduits have significantly fewer major adverse events, improved survival, and reduced hospital readmissions.
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Affiliation(s)
- Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Suresh Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Danny Chu
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David Kaczorowski
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Johannes Bonatti
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pyongsoo Yoon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Dustin Kliner
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Steve Koscumb
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Brown J, Yousef S, Kliner D, Toma C, Serna-Gallegos D, Makani A, West D, Thoma F, Wang Y, Sultan I. CRT-700.39 Transcatheter Aortic Valve Implantation With a Self-Expanding Intra-Annular Valve: Institutional Experience With Over 100 Patients. JACC Cardiovasc Interv 2023. [DOI: 10.1016/j.jcin.2023.01.294] [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: 02/22/2023]
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Dhande M, Rangavajla G, Canterbury A, Hamandi M, Boricha H, Newhouse D, Osterhaus EC, Thoma F, Mulukutla S, Aronis KN, Bhonsale A, Kancharla K, Shalaby A, Estes NM, Jain SK, Saba S. Guideline-Directed Medical Therapy and the Risk of Death in Primary Prevention Defibrillator Recipients. JACC Clin Electrophysiol 2022; 8:1024-1030. [DOI: 10.1016/j.jacep.2022.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 12/15/2022]
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Zacharia EM, Istvanic F, Mulukutla S, Thoma F, Aronis KN, Bhonsale A, Kancharla K, Voigt A, Shalaby A, Estes NAM, Jain SK, Saba S. Predictors of Hospital Admissions for Ventricular Arrhythmia or Cardiac Arrest in Patients With Cardiomyopathy. Am J Cardiol 2022; 171:127-131. [PMID: 35292146 DOI: 10.1016/j.amjcard.2022.01.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/21/2022] [Accepted: 01/26/2022] [Indexed: 11/19/2022]
Abstract
Although ventricular dysfunction is associated with the occurrence of ventricular arrhythmia (VA), most patients with cardiomyopathy do not experience VA. We therefore investigated other predictors of VA in a large contemporary cohort of patients with cardiomyopathy. All patients at a large academic medical system with left ventricular ejection fraction (LVEF) ≤50% were enrolled at the time of first documented low LVEF. Predictors of hospital admission for VA were examined using multivariable Cox models. The incidence of implantable defibrillator (ICD) placement was also examined. A total of 18,003 patients were enrolled. Over a median follow-up of 3.35 years, 389 patients (2.2%) were admitted for VA (304 of 12,037 [2.5%] among patients with LVEF ≤35% vs 85 of 5,966 [1.4%] among those with LVEF 36% to 50%). Predictors of VA hospitalization included lower LVEF (hazard ratio (HR) = 1.43 per 10% decrease, p <0.001), the presence of an ICD at baseline (HR = 1.63, p = 0.010), higher blood glucose (HR = 1.02 per 10 mg/100 ml increase, p = 0.050), the presence of end-stage renal disease (HR = 3.59, p <0.001), and the presence of liver cirrhosis (HR = 1.93, p = 0.013). During follow-up, 626 patients were implanted with a new ICD. In addition to being admitted with VA, a lower LVEF and a history of coronary artery disease or heart failure were the main predictors of ICD therapy in this population. In conclusion, in addition to more severe cardiomyopathy and the presence of an implanted ICD, metabolic derangements on initial contact are independent predictors of hospital admissions for VA in patients with cardiomyopathy. Noncardiac co-morbidities play an important role in stratifying patients with cardiomyopathy for their risk of VA or cardiac arrest.
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Affiliation(s)
- Effimia M Zacharia
- Cardiology Division of the Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Filip Istvanic
- Cardiology Division of the Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Suresh Mulukutla
- Cardiology Division of the Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Cardiology Division of the Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Konstantinos N Aronis
- Cardiology Division of the Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Aditya Bhonsale
- Cardiology Division of the Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Krishna Kancharla
- Cardiology Division of the Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew Voigt
- Cardiology Division of the Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Alaa Shalaby
- Cardiology Division of the Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - N A Mark Estes
- Cardiology Division of the Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sandeep K Jain
- Cardiology Division of the Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Samir Saba
- Cardiology Division of the Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Diaz-Castrillon CE, Serna-Gallegos D, Aranda-Michel E, Brown JA, Yousef S, Thoma F, Wang Y, Sultan I. Impact of ethnicity and race on outcomes after thoracic endovascular aortic repair. J Card Surg 2022; 37:2317-2323. [PMID: 35510401 DOI: 10.1111/jocs.16580] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/06/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Thoracic endovascular aortic repair (TEVAR) became the standard of care for treating Type B aortic dissections and descending thoracic aortic aneurysms. We aimed to describe the racial/ethnic differences in TEVAR utilization and outcomes. METHODS The National Inpatient Sample was reviewed for all TEVARs performed between 2010 and 2017 for Type B aortic dissection and descending thoracic aortic aneurysm (DTAA). We compared groups stratifying by their racial/ethnicity background in White, Black, Hispanic, and others. Mixed-effects logistic regression was performed to assess the relationship between race/ethnicity and the primary outcome, in-hospital mortality. RESULTS A total of 25,260 admissions for TEVAR during 2010-2017 were identified. Of those, 52.74% (n = 13,322) were performed for aneurysm and 47.2% (n = 11,938) were performed for Type B dissection. 68.1% were White, 19.6% were Black, 5.7% Hispanic, and 6.5% were classified as others. White patients were the oldest (median age 71 years; p < .001), with TEVAR being performed electively more often for aortic aneurysm (58.8% vs. 34% vs. 48.3% vs. 48.2%; p < .001). In contrast, TEVAR was more likely urgent or emergent for Type B dissection in Black patients (65.6% vs. 41.1% vs. 51.6% vs. 51.7%; p < .001). Finally, the Black population showed a relative increase in the incidence rate of TEVAR over time. The adjusted multivariable model showed that race/ethnicity was not associated with in-hospital mortality. CONCLUSION Although there is a differential distribution of thoracic indication and comorbidities between race/ethnicity in TEVAR, racial disparities do not appear to be associated with in-hospital mortality after adjusting for covariates.
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Affiliation(s)
- Carlos E Diaz-Castrillon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Dhande M, Rangavajla G, Canterbury A, Hamandi M, Boricha H, Newhouse D, Thoma F, Mulukutla S, Aronis KN, Bhonsale A, Kancharla K, Shalaby A, Estes M, Jain SK, Saba SF. PO-632-02 GUIDELINE DIRECTED MEDICAL THERAPY AND THE RISK OF DEATH IN PRIMARY PREVENTION DEFIBRILLATOR RECIPIENTS. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.910] [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: 11/04/2022]
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Bhonsale A, Zhu J, Thoma F, Mulukutla S, Marroquin O, Voigt AH, Aronis KN, Kancharla K, Estes M, Saba SF, Jain SK. PO-679-03 IMPACT OF WEIGHT GAIN ON CARDIOVASCULAR OUTCOMES IN PATIENTS WITH ATRIAL FIBRILLATION. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.487] [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: 11/25/2022]
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Dhande M, Bidani S, Zhu J, Thoma F, Mulukutla S, Voigt AH, Aronis KN, Kancharla K, Marroquin O, Estes M, Marroquin O, Marroquin Orantes OK, Bhonsale A. PO-665-04 CARDIOVASCULAR OUTCOMES AMONG PATIENTS WITH OBSTRUCTIVE SLEEP APNEA AND ATRIAL FIBRILLATION. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.363] [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: 11/25/2022]
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Ibrahim J, Fabrizio C, Sezer A, Thoma F, Simon M, Mulukutla S, Hickey GW. Beta-Blockers Are Associated With Reduced All-Cause Mortality Among HFpEF Patients. J Card Fail 2022. [DOI: 10.1016/j.cardfail.2022.03.135] [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: 10/18/2022]
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Wann DG, Baird A, Mulukutla S, Thoma F, Sezer A, Canterbury A, Barakat AF, Gardner MW, Skowronski J, Jain S, Saba S, Bhonsale A, Estes NM, Hickey G, Voigt A, Kaczorowski D, Keebler M, Bazaz R, Kancharla K. Association Of Pre-LVAD ICD Shocks With Post-LVAD Outcomes. J Card Fail 2022. [DOI: 10.1016/j.cardfail.2022.03.253] [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: 11/30/2022]
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Thalappillil A, Johnson A, Althouse A, Thoma F, Lee J, Estes NAM, Jain S, Lee J, Saba S. Impact of an Automated Best Practice Alert on Sex and Race Disparities in Implantable Cardioverter-Defibrillator Therapy. J Am Heart Assoc 2022; 11:e023669. [PMID: 35301858 PMCID: PMC9075484 DOI: 10.1161/jaha.121.023669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Implantable cardioverter‐defibrillators (ICDs) are indicated in patients with severe left ventricular dysfunction, but many eligible patients do not receive them, especially women and Black patients. Our group had previously demonstrated that a best practice alert (BPA) improves overall rates of electrophysiology referrals and ICD implantations. This study examined the impact of a BPA by sex and race. Methods and Results This is a cluster randomized trial of cardiology (n=106) and primary care (n=89) providers who were randomized to receive (BPA, n=93) or not receive (No BPA, n=102) the alert and managed 1856 patients meeting primary prevention criteria for ICD implantation (965 BPA and 891 No BPA). After a median follow up of 34 months, 630 (34%) patients were referred to electrophysiology, and 522 (28%) patients received an ICD. Compared with the No BPA arm, patients in the BPA arm saw a modest differential increase in the rate of electrophysiology referrals at 18 months in men (+4%) compared with women (+7%) but a profound increase in Black patients (+16%) compared with White patients (+2%), thus closing the sex and race gaps. Similar trends were noted for rates of ICD implantation. Conclusions Use of a BPA improves rates of electrophysiology referrals and ICD implantations in all comers with severe cardiomyopathy and no prior ventricular arrhythmias but has a more pronounced impact in women and Black patients. The use of a BPA at the point of care is an effective tool in the fight against sex and race inequities in health care.
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Affiliation(s)
- Alvin Thalappillil
- Department of Medicine University of Pittsburgh Medical Center Pittsburgh PA
| | - Amber Johnson
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA
| | - Andrew Althouse
- Department of Medicine University of Pittsburgh Medical Center Pittsburgh PA
| | - Floyd Thoma
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA
| | - Jae Lee
- Department of Cardiology Inova Heart and Vascular Institute Falls Church VA
| | - N A Mark Estes
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA
| | - Sandeep Jain
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA
| | - Joon Lee
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA
| | - Samir Saba
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA
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Barakat AF, Amuthan R, Hariri E, Chana R, Gupta N, Ibrahim J, Bashir ZS, Hu B, Sezer A, Thoma F, Soman P, Mulukutla S, Barzilai B, Ellis SG, Jaber W, Rothberg MB. A Validated Model to Identify Patients With Low Likelihood of High-Risk Coronary Artery Disease Anatomy. Am J Cardiol 2022; 167:27-34. [PMID: 35031112 DOI: 10.1016/j.amjcard.2021.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/22/2021] [Accepted: 11/29/2021] [Indexed: 11/16/2022]
Abstract
In stable coronary artery disease (CAD), revascularization improves outcomes only for patients with high-risk coronary anatomy (HRCA). We sought to derive and validate a prediction model, incorporating clinical and exercise stress test characteristics, to identify patients with HRCA. We conducted a retrospective analysis of patients undergoing exercise stress testing at Cleveland Clinic (2005 to 2014), followed by invasive coronary angiography within 3 months. We excluded patients with acute coronary syndrome, known CAD or ejection fraction <50%. HRCA was defined as left main, 3-vessel, or 2-vessel disease involving the proximal left anterior descending artery. Clinical and stress test predictors of HRCA were identified in a multivariable logistic regression model, internally validated with 1,000-fold bootstrapping. The model was then externally validated at the University of Pittsburgh Medical Center (2017 to 2019). The model was derived from 2,758 patients with complete data. HRCA was identified in 418 patients (15.2%) in the derivation cohort. The model consisted of 10 variables: age, male gender, hypertension, hypercholesterolemia, diabetes mellitus, family history of premature CAD, high-density lipoprotein, chest pain, exercise time, and Duke Treadmill Score. Bias-corrected c-statistic was 0.79 (95% confidence interval 0.77 to 0.81) with excellent calibration. In all, 762 patients (27.6%) had a predicted probability and observed prevalence of HRCA <5%. In the validation cohort, the model had a c-statistic of 0.79 (95% confidence interval 0.74 to 0.85) and 210 patients had an observed prevalence of HRCA <5% (40%). In conclusion, an externally validated prediction model, based on clinical characteristics and exercise stress test variables, can identify stable patients with CAD who have HRCA.
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Affiliation(s)
- Amr F Barakat
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ram Amuthan
- Cardiovascular Division, Department of Medicine, State University of New York, University at Buffalo, Buffalo, New York
| | - Essa Hariri
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Rajdeep Chana
- Department of Cardiovascular Medicine, Guthrie Robert Packer Hospital, Sayre, Pennsylvania
| | - Niyati Gupta
- Department of Medicine, NYC Health+ Hospitals, New York, New York
| | - Joseph Ibrahim
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Zubair S Bashir
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Bo Hu
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ahmet Sezer
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Prem Soman
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Suresh Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Benico Barzilai
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Stephen G Ellis
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Wael Jaber
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Michael B Rothberg
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio; Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio.
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Hong Y, Rinehardt H, Zhu T, Wang Y, Thoma F, Kilic A. Hyperlactatemia as a prognostic indicator for contemporary left ventricular assist device implantation. Gen Thorac Cardiovasc Surg 2022; 70:705-713. [PMID: 35142970 DOI: 10.1007/s11748-022-01778-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/18/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study evaluates the impact of early post-operative hyperlactatemia on outcomes after left ventricular assist device (LVAD) implantation. METHODS Adults undergoing contemporary LVAD implantation between 2009 to 2018 were included. Peak post-operative (within 24-h) lactate level was analyzed. The cohort was stratified into patients with and without post-operative hyperlactatemia, which was defined as peak > 3.5 mMol/L. The primary outcome was survival, and secondary outcomes included post-implant adverse events. Sub-analysis was performed to evaluate the impact of time for lactate normalization, define as lactate < 2 mMol/L. Multivariable cox regression was used for risk-adjustment. RESULTS A total of 190 patients were included. 49.5% experienced early post-operative hyperlactatemia. Patients with post-operative hyperlactatemia had significantly higher rates of post-implant complications including re-operation, renal failure, and hepatic dysfunction (all, p ≤ 0.05). The post-operative hyperlactatemia group also had significantly higher 90-day and 1-year mortality rates following LVAD implantation (both, p ≤ 0.05). In multivariable analysis, post-operative hyperlactatemia (HR 1.69, 95% CI 1.09-2.60, p = 0.02) was an independent predictor of overall mortality following LVAD implantation. Increased time for normalization of lactate also adversely impacted risk-adjusted overall mortality following implantation as a continuous variable (HR 1.02, 95% CI 1.01-1.03, p < .001). CONCLUSIONS This study demonstrates early post-operative hyperlactatemia is associated with increased morbidity and mortality following LVAD implantation. Even early post-operative lactate trends within the first 24 post-operative hours appear to have a useful role in predicting longitudinal survival following implantation. Careful monitoring of post-operative lactate with measures to normalize levels should be considered in the early care of LVAD patients.
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Affiliation(s)
- Yeahwa Hong
- Department of Surgery, University of Pittsburgh Medical Center Pittsburgh, Pittsburgh, PA, USA
| | - Hannah Rinehardt
- Department of Surgery, University of Pittsburgh Medical Center Pittsburgh, Pittsburgh, PA, USA
| | - Toby Zhu
- School of Medicine, University of Pittsburgh Medical Center Pittsburgh, Pittsburgh, PA, USA
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center Pittsburgh, Pittsburgh, PA, USA
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center Pittsburgh, Pittsburgh, PA, USA
| | - Arman Kilic
- Division of Cardiothoracic Surgery at Medical, University of South Carolina, 25 Courtenay Drive, Charleston, SC, 29425, USA.
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Huckaby LV, Seese LM, Hess N, Aranda-Michel E, Sultan I, Gleason TG, Chu D, Wang Y, Thoma F, Kilic A. Fate of the Kidneys in Patients with Post-Operative Renal Failure After Cardiac Surgery. J Surg Res 2021; 272:166-174. [PMID: 34979472 DOI: 10.1016/j.jss.2021.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 07/20/2021] [Accepted: 08/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND This study evaluates the clinical and renal-related outcomes in patients with acute renal failure (ARF) following cardiac surgery. METHODS Index adult cardiac operations at a single institution from 2010-2018 were reviewed. Patients requiring dialysis pre-operatively were excluded. ARF was stratified as either creatinine rise (≥3-times baseline or ≥4.0 mg/dL) or post-operative dialysis. Outcomes included mortality, rates of progression to dialysis, and renal recovery. Multivariable Cox regression was used for risk-adjustment. RESULTS A total of 10,037 patients, including 6,275 (62.5%) isolated coronary artery bypass grafting (CABG), 2,243 (22.3%) isolated valve, and 1,519 (15.1%) CABG plus valve cases, were included. Post-operative ARF occurred in 346 (3.5%) patients, with 230 (66.5%) requiring dialysis. Survival was significantly reduced in patients with ARF at 30-days (97.9 versus 70.8%, P <0.001), 1-year (94.9 versus 48.0%, P <0.001), and 5-years (86.2 versus 38.2%, P <0.001) with more profound reductions in those requiring dialysis, findings which persisted after risk-adjustment. Progression to subsequent dialysis in the creatinine rise group was rare (n = 1). The median time to dialysis initiation in the dialysis group was 5 days (IQR 2-12 days) with a median time of dialysis dependence of 72 days (IQR 38-1229 days). Of those patients requiring postoperative dialysis, 30.9% demonstrated renal recovery. CONCLUSIONS Post-operative ARF and in particular the need for dialysis are associated with substantial reductions in survival that persist during longitudinal follow-up. This occurs despite the finding that patients experiencing creatinine rise only rarely progress to dialysis, and that nearly one-third of patients requiring post-operative dialysis recover renal function.
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Affiliation(s)
- Lauren V Huckaby
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Laura M Seese
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Nicholas Hess
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Thomas G Gleason
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Danny Chu
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Yisi Wang
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Chan PG, Seese L, Aranda-Michel E, Sultan I, Gleason TG, Wang Y, Thoma F, Kilic A. Operative mortality in adult cardiac surgery: is the currently utilized definition justified? J Thorac Dis 2021; 13:5582-5591. [PMID: 34795909 PMCID: PMC8575804 DOI: 10.21037/jtd-20-2213] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 12/13/2020] [Indexed: 11/16/2022]
Abstract
Background This study evaluated operative mortalities following adult cardiac surgical operations to determine if this metric remains appropriate for the modern era. Methods This was a retrospective review of Society of Thoracic Surgeons (STS) indexed adult cardiac operations that included coronary artery bypass grafting (CABG), aortic valve replacement (AVR), CABG + AVR, mitral valve repair (MVr), CABG + MVr, mitral valve replacement (MVR) and CABG + MVR, performed at a single institution between 2011 and 2017. The primary outcome was the timing and relatedness of operation mortality, as defined by the STS as mortality within 30-day or during the index hospitalization, compared to the index operation. The secondary outcomes evaluated cause of death and the rates of postoperative complications. Results A total of 11,190 index cardiac operations were performed during the study period and operative mortality occurred in 246 (2.2%) of patients. The distribution of operative mortalities included 83.7% (n=206) who expired within 30-day while an inpatient, 6.9% (n=17) died within 30-day as an outpatient, 11.2% (n=23) expired after 30-day. The most common causes of operative mortality were cardiac (38.7%, n=92), renal failure (15.6%, n=37), and strokes (13.9%, n=33). Furthermore, 98.4% (n=242) of deaths were attributable to the index operation. Postoperative complications occurred frequently in those with operative mortality, with blood transfusions (80.1%), reoperations (65.0%) and prolonged ventilation (62.2%) being most common. Conclusions Most of the operative mortalities seemed to be attributable to the index cardiac operation. We believe that the current definition of mortality remains appropriate in the modern era.
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Affiliation(s)
- Patrick G Chan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Laura Seese
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Thomas G Gleason
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Yisi Wang
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Floyd Thoma
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Brown J, Sultan I, Lewis J, Thoma F, Kliner D, Serna-Gallegos D, Sanon S, Mulukutla S, Navid F, Toma C. TCT-44 The Impact of Transcatheter Aortic Valve Replacement on Gastrointestinal Bleeding in Aortic Stenosis. J Am Coll Cardiol 2021. [DOI: 10.1016/j.jacc.2021.09.894] [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: 11/30/2022]
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Asif A, Sezer A, Thoma F, Toma C, Schindler J, Fowler J, Smith C, Marroquin OC, Mulukutla SR. Relationship between predicting bleeding complication in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score and mortality among patients with atrial fibrillation undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2021; 98:838-845. [PMID: 33300267 DOI: 10.1002/ccd.29399] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 10/11/2020] [Accepted: 11/09/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The predicting bleeding complication in patients undergoing stent implantation and subsequent dual antiplatelet therapy, PRECISE-DAPT (P-DAPT) score has been validated in large cohorts as an effective tool in predicting bleeding complication after dual antiplatelet therapy (DAPT) as well as in predicting in-hospital mortality. The implication of using this score to predict outcomes, including mortality in patients with atrial fibrillation (AF) undergoing PCI is unknown. OBJECTIVE Role of P-DAPT score to study clinical outcomes, including mortality, hospitalization, and major bleeding, particularly among patients with AF. METHODS This is a retrospective observational study of 18,850 consecutive patients who underwent percutaneous coronary intervention (PCI) across a large multihospital healthcare system from 2010 to 2019. Patients were stratified into four groups depending on the presence or absence of AF and P-DAPT score, with score ≥ 25 defined as high risk. The primary outcome was all-cause mortality. The secondary outcomes evaluated were hospitalization and major bleeding. RESULTS In the unadjusted analyses, a P-DAPT score ≥ 25, in both AF and non-AF population, was associated with increased mortality, hospitalization, and bleeding. After adjusting for baseline covariates, no significant differences in major bleeding risk were found across the four groups. However, a P-DAPT score of ≥25 in AF patients was associated with a higher risk for hospitalizations related to cardiovascular causes (HR: 2.15 95% CI 2.00-2.3, p < .0001). Among AF patients, P-DAPT score ≥ 25 was found to be strongly associated with mortality (HR 3.5; 95% CI 2.95-4.25, p < .0001) as compared with AF patients with score < 25 (HR 1.18, 95% CI 0.88-1.54, p = .26). CONCLUSION In this large cohort of patients undergoing PCI, the P-DAPT score can help to identify patients at high risk for long-term mortality, particularly among those with atrial fibrillation.
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Affiliation(s)
- Anum Asif
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ahmet Sezer
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John Schindler
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jeffrey Fowler
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Conrad Smith
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Oscar C Marroquin
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Suresh R Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Hong Y, Dufendach K, Wang Y, Thoma F, Kilic A. Impact of early massive transfusion and blood component ratios in patients undergoing left ventricular assist device implantation. J Card Surg 2021; 36:4519-4526. [PMID: 34558110 DOI: 10.1111/jocs.16010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/29/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study evaluates the impact of early massive transfusion and blood component ratios on outcomes following left ventricular assist device (LVAD) implantation. METHODS Adults undergoing LVAD implantation between 2009 and 2018 at a single institution were included. Transfusions were analyzed during the intraoperative and the initial 24-h postoperative period. Patients were stratified into massive and nonmassive transfusion groups. The primary outcome was survival, and secondary outcomes included postoperative complications. Sub-analyses were performed to evaluate the impact of balanced transfusion. RESULTS A total of 278 patients were included. A total of 45.3% (n = 126) required massive transfusions. The massive transfusion group experienced significantly higher rates of postimplant adverse events, including reoperation, renal failure, and hepatic dysfunction (all, p ≤ .05). Furthermore, the massive transfusion group had significantly lower 30-day, 90-day, 1-year, 2-year, and overall survival rates following LVAD implantation (all, p < .05). In multivariable analysis, massive transfusion significantly impacted overall risk-adjusted mortality rate (hazard ratio: 2.402, 95% confidence Interval: 1.677-3.442, p < .001). In the sub-analyses evaluating the impact of balanced massive transfusion, balanced fresh frozen plasma to packed red blood cell (pRBC) transfusion did not provide any survival benefit (all, p > .05). However, balanced platelet to pRBC massive transfusion did improve 2-year and overall mortality rates in the massive transfusion cohort (both, p ≤ .05). CONCLUSIONS This study demonstrates a significant association between early massive transfusion and adverse outcomes following LVAD implantation. Balancing platelet to pRBC transfusion in the early postoperative period may help mitigate some of these detrimental effects of massive transfusion on subsequent survival.
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Affiliation(s)
- Yeahwa Hong
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Keith Dufendach
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Phillips AR, Reitz KM, Myers S, Thoma F, Andraska EA, Jano A, Sridharan N, Smith RE, Mulukutla SR, Chaer R. Association Between Black Race, Clinical Severity, and Management of Acute Pulmonary Embolism: A Retrospective Cohort Study. J Am Heart Assoc 2021; 10:e021818. [PMID: 34431356 PMCID: PMC8649302 DOI: 10.1161/jaha.121.021818] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Existing evidence indicates Black patients have higher incidence of pulmonary embolism (PE) and PE‐related mortality compared with other races/ethnicities, yet disparities in presenting severity and treatment remain incompletely understood. Methods and Results We retrospectively queried a multihospital healthcare system for all hospitalizations for acute PE (2012–2019). Of 10 329 hospitalizations, 8743 met inclusion criteria. Black patients (14.3%) were significantly younger (54.6±17.8 versus 63.1±16.6 years; P<0.001) and more female (56.1% versus 51.6%; P=0.003) compared with White patients. Using ordinal regression, Black race was significantly associated with higher PE severity after matching 1:3 on age and sex (1210:3264; odds ratio [OR], 1.08; 95% CI, 1.03–1.14), adjusting for clinical (OR, 1.13; 95% CI, 1.01–1.27), and socioeconomic (OR, 1.05; 95% CI, 1.05–1.35) characteristics. Among intermediate and high‐severity PE, Black race was associated with a decreased risk of intervention controlling for the competing risk of mortality and censoring on hospital discharge. This effect was modified by PE severity (P value <0.001), with a lower and higher risk of intervention for intermediate and high‐severity PE, respectively. Race was not associated with in‐hospital mortality (OR, 0.84; 95% CI, 0.69–1.02). Conclusions Black patients hospitalized with PE are younger with a higher severity of disease compared with White patients. Although Black patients are less likely to receive an intervention overall, this differed depending on PE severity with higher risk of intervention only for life‐threatening PE. This suggests nuanced racial disparities in management of PE and highlights the complexities of healthcare inequalities.
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Affiliation(s)
| | - Katherine M Reitz
- Division of Vascular Surgery University of Pittsburgh Pittsburgh PA.,Department of Surgery University of Pittsburgh Pittsburgh PA
| | - Sara Myers
- Department of Surgery University of Pittsburgh Pittsburgh PA
| | - Floyd Thoma
- Division of Cardiology University of Pittsburgh Pittsburgh PA
| | | | - Antalya Jano
- School of Medicine University of Pittsburgh Pittsburgh PA
| | - Natalie Sridharan
- Division of Vascular Surgery University of Pittsburgh Pittsburgh PA.,School of Medicine University of Pittsburgh Pittsburgh PA
| | - Roy E Smith
- School of Medicine University of Pittsburgh Pittsburgh PA.,Division of Hematology/Oncology University of Pittsburgh Pittsburgh PA
| | - Suresh R Mulukutla
- Division of Cardiology University of Pittsburgh Pittsburgh PA.,School of Medicine University of Pittsburgh Pittsburgh PA
| | - Rabih Chaer
- Division of Vascular Surgery University of Pittsburgh Pittsburgh PA.,School of Medicine University of Pittsburgh Pittsburgh PA
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Guhl EN, Zhu J, Johnson A, Essien U, Thoma F, Mulukutla SR, Magnani JW. Area Deprivation Index and Cardiovascular Events: CAN CARDIAC REHABILITATION MITIGATE THE EFFECTS? J Cardiopulm Rehabil Prev 2021; 41:315-321. [PMID: 33758155 PMCID: PMC8410614 DOI: 10.1097/hcr.0000000000000591] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Neighborhood socioeconomic status is associated with health outcomes. Cardiac rehabilitation (CR) provides a cost-effective, multidisciplinary approach to improve outcomes in cardiovascular disease. We aimed to evaluate the association of the Area Deprivation Index (ADI), a marker of neighborhood social composition, with risk of recurrent cardiovascular outcomes and assessed the modifying effect of CR. METHODS We identified patients with a primary diagnosis of (1) myocardial infarction or (2) incident heart failure (HF) admitted to a large-sized regional health center during 2010-2018. We derived the ADI from home addresses and categorized it into quartiles (higher quartiles indicating increased deprivation). We obtained number of CR visits and covariates from the health record. We compared rehospitalization (cardiovascular, acute coronary syndrome [ACS], and HF) and mortality rates across ADI quartiles. RESULTS We included 6957 patients (age 69.2 ± 13.4 yr, 38% women, 89% White race). After covariate adjustment, the ADI was significantly associated with higher incidence rates (IRs)/100 person-yr of cardiovascular rehospitalization (quartile 1, IR 34.6 [95% CI, 31.2-38.2]; quartile 4, 41.5 [95% CI, 39.1-44.1], P < .001). In addition, the ADI was significantly associated with higher rates of rehospitalization for HF (P < .001), ACS (P < .012), and all-cause mortality (P < .04). These differences in rehospitalization and mortality rates by the ADI were no longer significant in those who attended CR. CONCLUSIONS We found the increased ADI was adversely associated with rehospitalizations and mortality. However, in individuals with CR, outcomes were significantly improved compared with those with no CR. Our findings suggest that CR participation has the potential to improve outcomes in disadvantaged neighborhoods.
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Affiliation(s)
- Emily N. Guhl
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Jianhui Zhu
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Amber Johnson
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Utibe Essien
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- Center for Health Equity Research and Promotion, VA Pittsburgh, Healthcare System
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Suresh R. Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Jared W. Magnani
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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Hess NR, Killic A, Serna-Gallegos DR, Navid F, Wang Y, Thoma F, Sultan I. Effect of untreated carotid artery stenosis at the time of isolated coronary artery bypass grafting. JTCVS Open 2021; 7:182-190. [PMID: 36003738 PMCID: PMC9390650 DOI: 10.1016/j.xjon.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 07/07/2021] [Indexed: 11/13/2022]
Abstract
Background Severe carotid artery stenosis (sCAS) is frequently discovered at the time of evaluation for coronary arterial revascularization. However, there has been controversy regarding the optimal management of sCAS. This study evaluated the potential effects of untreated sCAS at time of coronary artery bypass grafting (CABG) in contemporary practice. Methods This was a retrospective study from a multihospital healthcare system including patients undergoing isolated CABG between 2011 and 2018. Patients were stratified by the presence of sCAS (≥80% stenosis) in at least 1 carotid artery. Perioperative and 5-year stroke were compared, and multivariable analysis was used to identify risk-adjusted predictors of stroke and mortality. Results A total of 5475 patients were included, 459 (8.4%) with sCAS and 5016 (91.6%) without sCAS. Patients with sCAS experienced more frequent perioperative stroke (4.4% vs 1.2%; P < .001), with most attributable to ischemic or embolic etiologies. The median duration of follow-up was 4.6 years (interquartile range, 3.0-6.5 years). One-year and 5-year survival were both lower in patients with sCAS (P < .001). In multivariable analysis, sCAS was associated with increased risk-adjusted hazard for both mortality (hazard ratio [HR], 1.28; 95% confidence interval [CI], 1.02-1.60; P = .030) and stroke (HR, 1.76; 95% CI, 1.20-2.59; P = .004). The strongest risk-adjusted predictor for stroke was a previous history of stroke (HR, 2.51; 95% CI, 1.77-3.55; P < .001). Conclusions This contemporary analysis of CABG procedures reveals that concurrent sCAS continues to confer a significant stroke risk, especially in those with history of previous stroke. Although whether sCAS lesions are responsible for most strokes is unclear, they likely serve as a surrogate for other stroke risk factors.
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Bianco V, Kilic A, Aranda-Michel E, Serna-Gallegos D, Dunn-Lewis C, Chen S, Thoma F, Navid F, Sultan I. Permanent pacemaker placement following valve surgery is not independently associated with worse outcomes. JTCVS Open 2021; 7:157-164. [PMID: 36003744 PMCID: PMC9390660 DOI: 10.1016/j.xjon.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 06/01/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Courtenay Dunn-Lewis
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Shangzhen Chen
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
- Address for reprints: Ibrahim Sultan, MD, Division of Cardiac Surgery, Department of Cardiothoracic Surgery, Center for Thoracic Aortic Disease, University of Pittsburgh, Heart and Vascular Institute, University of Pittsburgh Medical Center, 5200 Centre Ave, Suite 715, Pittsburgh, PA 15232.
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Saeed A, Zhu J, Thoma F, Marroquin O, Aiyer A, Agarwala A, Virani SS, Gulati M, Lee JS, Reis S, Saba S, Ballantyne C, Mulukutla S. Cardiovascular Disease Risk-Based Statin Utilization and Associated Outcomes in a Primary Prevention Cohort: Insights From a Large Health Care Network. Circ Cardiovasc Qual Outcomes 2021; 14:e007485. [PMID: 34455825 DOI: 10.1161/circoutcomes.120.007485] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 11/16/2022]
Abstract
BACKGROUND Current American College of Cardiology/American Heart Association guidelines recommend using the 10-year atherosclerotic cardiovascular disease (ASCVD) risk to guide statin therapy for primary prevention. Real-world data on adherence and consequences of nonadherence to the guidelines in primary are limited. We investigated the guideline-directed statin intensity (GDSI) and associated outcomes in a large health care system, stratified by ASCVD risk. METHODS Statin prescription in patients without coronary artery disease, peripheral vascular disease, or ischemic stroke were evaluated within a large health care network (2013-2017) using electronic medical health records. Patient categories constructed by the 10-year ASCVD risk were borderline (5%-7.4%), intermediate (7.5%-19.9%), or high (≥20%). The GDSI (before time of first event) was defined as none or any intensity for borderline, and at least moderate for intermediate and high-risk groups. Mean (±SD) time to start/change to GDSI from first interaction in health care and incident rates (per 1000 person-years) for each outcome were calculated. Cox regression models were used to calculate hazard ratios for incident ASCVD and mortality across risk categories stratified by statin utilization. RESULTS Among 282 298 patients (mean age ≈50 years), 29 134 (10.3%), 63 299 (22.4%), and 26 687 (9.5%) were categorized as borderline, intermediate, and high risk, respectively. Among intermediate and high-risk categories, 27 358 (43%) and 8300 (31%) patients did not receive any statin, respectively. Only 17 519 (65.6%) high-risk patients who were prescribed a statin received GDSI. The mean time to GDSI was ≈2 years among the intermediate and high-risk groups. At a median follow-up of 6 years, there was a graded increase in risk of ASCVD events in intermediate risk (hazard ratio=1.15 [1.07-1.24]) and high risk (hazard ratio=1.27 [1.17-1.37]) when comparing no statin use with GDSI therapy. Similarly, mortality risk among intermediate and high-risk groups was higher in no statin use versus GDSI. CONCLUSIONS In a real-world primary prevention cohort, over one-third of statin-eligible patients were not prescribed statin therapy. Among those receiving a statin, mean time to GDSI was ≈2 years. The consequences of nonadherence to guidelines are illustrated by greater incident ASCVD and mortality events. Further research can develop and optimize health care system strategies for primary prevention.
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Affiliation(s)
- Anum Saeed
- Heart and Vascular Institute (A.S., J.Z., O.M., A.A., J.S.L., S.R., S.M.), University of Pittsburgh Medical Center, PA
| | - Jianhui Zhu
- Heart and Vascular Institute (A.S., J.Z., O.M., A.A., J.S.L., S.R., S.M.), University of Pittsburgh Medical Center, PA
| | | | - Oscar Marroquin
- Heart and Vascular Institute (A.S., J.Z., O.M., A.A., J.S.L., S.R., S.M.), University of Pittsburgh Medical Center, PA.,Department of Data and Analytics (O.M., S.M.), University of Pittsburgh Medical Center, PA
| | - Aryan Aiyer
- Heart and Vascular Institute (A.S., J.Z., O.M., A.A., J.S.L., S.R., S.M.), University of Pittsburgh Medical Center, PA.,Baylor Scott and White Health Heart Hospital Baylor Plano, TX (A.A.)
| | | | - Salim S Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center (S.S.V.).,Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX (S.S.V.).,Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V., C.B.)
| | - Martha Gulati
- Division of Cardiology, University of Arizona, Phoenix (M.G.)
| | - Joon S Lee
- Heart and Vascular Institute (A.S., J.Z., O.M., A.A., J.S.L., S.R., S.M.), University of Pittsburgh Medical Center, PA
| | - Steven Reis
- Heart and Vascular Institute (A.S., J.Z., O.M., A.A., J.S.L., S.R., S.M.), University of Pittsburgh Medical Center, PA
| | | | - Christie Ballantyne
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX (S.S.V., C.B.).,Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX (C.B.)
| | - Suresh Mulukutla
- Heart and Vascular Institute (A.S., J.Z., O.M., A.A., J.S.L., S.R., S.M.), University of Pittsburgh Medical Center, PA.,Department of Data and Analytics (O.M., S.M.), University of Pittsburgh Medical Center, PA
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Rangavajla G, Mulukutla S, Thoma F, Kancharla K, Bhonsale A, Estes NAM, Jain SK, Saba S. Ventricular pacing and myocardial function in patient with congenital heart block. J Cardiovasc Electrophysiol 2021; 32:2684-2689. [PMID: 34409682 DOI: 10.1111/jce.15207] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/12/2021] [Accepted: 07/16/2021] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Pacing-induced cardiomyopathy (PICM) is a potential complication of chronic right ventricular (RV) pacing, but its characterization in adult patients is often complicated by pre-existing cardiomyopathy. This study investigated the incidence of PICM in patients with congenital heart block (cHB) who have conduction disease from birth without confounding pre-existing cardiac conditions. METHODS AND RESULTS This retrospective cohort analysis included 42 patients with cHB and baseline left ventricular ejection fraction (LVEF) ≥50%. Kaplan-Meier analysis was used to assess freedom from cardiomyopathy (defined as LVEF <50%) between paced and nonpaced patients. Patients were 26 ± 3 years old at first presentation, 64% were women and baseline LVEF was 60.0 ± 0.2%. Median follow-up from birth was 35 (interquartile range [IQR]: 20-42) years with a median of 6.7 years (IQR: 3.6-9.2) at our institution. Thirty-two patients received pacing at mean age 21 ± 3 years. Patients receiving a pacemaker (PM) were significantly more likely to develop a cardiomyopathy (p = .021) and no patient developed a cardiomyopathy in the absence of a PM. Four patients who developed a new cardiomyopathy were upgraded to biventricular pacing, leading to stabilization or improvement of LVEF. CONCLUSION In a relatively young and healthy cHB cohort, RV pacing is associated with a higher risk of developing a cardiomyopathy. These data confirm the deleterious effects of RV pacing on myocardial function in patients without pre-existing structural cardiac disease and has clinical implications to the management of patients with cHB.
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Affiliation(s)
- Gautam Rangavajla
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Suresh Mulukutla
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Floyd Thoma
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Krishna Kancharla
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Aditya Bhonsale
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - N A Mark Estes
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sandeep K Jain
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Samir Saba
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Hess NR, Seese LM, Sultan I, Wang Y, Thoma F, Kilic A. Impact of center donor acceptance patterns on utilization of extended-criteria donors and outcomes. J Card Surg 2021; 36:4015-4023. [PMID: 34368992 DOI: 10.1111/jocs.15902] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 07/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study investigated the impact of transplanting center donor acceptance patterns on usage of extended-criteria donors (ECDs) and posttransplant outcomes following orthotopic heart transplantation (OHT). METHODS The Scientific Registry of Transplant Recipients was queried to identify heart donor offers and adult, isolated OHT recipients in the United States from January 1, 2013 to October 17, 2018. Centers were stratified into three equal-size terciles based on donor heart acceptance rates (<13.7%, 13.7%-20.2%, >20.2%). Overall survival was compared between recipients of ECDs (≥40 years, left ventricular ejection fraction [LVEF] <60%, distance ≥500 miles, hepatitis B virus [HBV], hepatitis C virus [HCV], or human immunodeficiency virus [HIV], or ≥50 refusals) and recipients of traditional-criteria donors, and among transplanting terciles. RESULTS A total of 85,505 donor heart offers were made to 133 centers with 15,264 (17.9%) accepted for OHT. High-acceptance programs (>20.2%) more frequently accepted donors with LVEF <60%, HIV, HCV, and/or HBV, ≥50 offers, or distance >500 miles from the transplanting center (each p < .001). Posttransplant survival was comparable across all three terciles (p = .11). One- and five-year survival were also similar across terciles when examining recipients of all five ECD factors. Acceptance tier and increasing acceptance rate were not found to have any impact on mortality in multivariable modeling. Of ECD factors, only age ≥40 years was found to have increased hazards for mortality (hazard ratio, 1.33; 95% confidence interval [CI], 1.22-1.46; p < .001). CONCLUSIONS Of recipients of ECD hearts, outcomes are similar across center-acceptance terciles. Educating less aggressive programs to increase donor acceptance and ECD utilization may yield higher national rates of OHT without major impact on outcomes.
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Affiliation(s)
- Nicholas R Hess
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Laura M Seese
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yisi Wang
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Floyd Thoma
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Bianco V, Aranda-Michel E, Serna-Gallegos D, Kilic A, Kaczarowski DJ, Dunn-Lewis C, Thoma F, Navid F, Sultan I. Cardiac surgery in the afternoon is not associated with increased operative morbidity and mortality. J Card Surg 2021; 36:3599-3606. [PMID: 34363420 DOI: 10.1111/jocs.15890] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/24/2021] [Accepted: 07/14/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Time of day for surgical procedures has been a topic of considerable controversy, with some suggesting that later operating times are associated with worse outcomes. METHODS All patients who underwent open cardiac surgery from 2011 to 2018 were included. Patients that had ventricular assist devices, heart transplant, transcatheter aortic valves, aortic dissections, and emergent operations were excluded. Primary outcomes included postoperative mortality and survival; secondary outcomes included postoperative complications and readmission. RESULTS The initial patient population consisted of 7883 patients who underwent index cardiac surgery. Following propensity matching (3:1), there were 2569 patients in the a.m. cohort (7-11 a.m.) and 860 patients in the p.m. cohort (3-11 p.m.). All baseline characteristics were matched to equivalent proportions. Total intensive care unit time following surgery was longer for the a.m. cohort (46.5 vs. 40.0 h; p<.001). Otherwise, there was no significant difference between cohorts including operative mortality (1.83% vs 2.21%; p= .48). On multivariable analysis, p.m. surgery was not significantly associated with 30 days mortality (hazard ratio [HR]: 0.96 [0.60, 1.53]; p= .86] or mortality over the study follow-up (HR: 0.87 [0.73, 1.03]; p= .10]. For propensity-matched cohorts, Kaplan-Meier survival at 30 days (97.9% vs. 97.4%; p= .44), 1 (93.4% vs 93.9%; p= .51), and 5 years (80.9% vs. 80.2%; p= .84) was not significantly different between cohorts. CONCLUSION Short- and long-term mortality, hospital readmission, and postoperative complications were not significantly different between patients that underwent cardiac surgery starting in the a.m. versus patients who had cases that started in the afternoon.
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Affiliation(s)
- Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Cardiology and Cardiothoracic Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Cardiology and Cardiothoracic Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David J Kaczarowski
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Courtenay Dunn-Lewis
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Floyd Thoma
- Department of Cardiology and Cardiothoracic Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Cardiology and Cardiothoracic Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Cardiology and Cardiothoracic Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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