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Foroshani S, Karp A, Aronow WS, Lanier GM. The role of phosphodiesterase 9A inhibitors in heart failure. Expert Opin Investig Drugs 2024:1-6. [PMID: 38702878 DOI: 10.1080/13543784.2024.2349813] [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: 01/08/2024] [Accepted: 04/26/2024] [Indexed: 05/06/2024]
Abstract
INTRODUCTION There are currently limited effective treatments available to improve lusitropy in patients suffering from heart failure with preserved ejection fraction. The role of PDE9A in diastolic dysfunction has been well-studied over recent years, with a special focus on its association with myocardial hypertrophy. Recent insights into PDE9A inhibition have brought to light the potential for reversal of cardiac remodeling, with multiple studies showing promising results in preclinical data. AREAS COVERED This expert opinion provides an overview of the role of PDE9A in diastolic heart dysfunction along with the efficacy of PDE9A inhibitors in laboratory models of heart failure with preserved ejection fraction. EXPERT OPINION The available data on PDE9A inhibition in preclinical studies suggest that there is potential for reversal of diastolic dysfunction and myocardial hypertrophy, however, conflicting data suggests that further studies are required before progressing to clinical trials.
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Affiliation(s)
| | - Avrohom Karp
- Medicine, New York Medical College, Valhalla, NY, USA
| | - Wilbert S Aronow
- Departments of Cardiology and Medicine Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Gregg M Lanier
- Departments of Cardiology and Medicine Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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2
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Sherif AA, Gilvaz VJ, Abraham S, Saji AM, Mathew D, Isath A, Rajendran A, Contreras J, Lanier GM, Reginato AM. Systemic sclerosis is associated with increased in-patient mortality in patients hospitalized for heart failure. ESC Heart Fail 2024. [PMID: 38472730 DOI: 10.1002/ehf2.14457] [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: 12/22/2022] [Revised: 05/08/2023] [Accepted: 06/21/2023] [Indexed: 03/14/2024] Open
Abstract
AIMS We aimed to analyse the characteristics and in-hospital outcomes of patients hospitalized for heart failure (HF) with co-morbid systemic sclerosis (SSc) and compare them to those without SSc, using data from the National Inpatient Sample from years 2016 to 2019. METHODS AND RESULTS International Classification of Diseases, Tenth Revision diagnosis codes were used to identify hospitalized patients with a primary diagnosis of HF and secondary diagnoses of SSc from the National Inpatient Sample database from 2016 to 2019. Patients were divided into two groups: those with and without a secondary diagnosis of SSc. Baseline characteristics including demographics and co-morbidities, outcomes of mortality, length of stay (LOS), and costs were compared between the two groups. Multivariable logistic regression analysis was performed to adjust for confounders and assess the impact of SSc on in-hospital mortality, cost, and LOS. A total of 4 709 724 hospitalizations for HF were identified, with 8150 (0.17%) having a secondary diagnosis of SSc. These patients were predominantly female (82.3% vs. 47.8%; P = 0.01), younger (mean age of 67.4 vs. 71.4; P < 0.01), and had significantly lower rates of traditional cardiovascular risk factors such as coronary artery disease (35.8% vs. 50.6%; P < 0.01), hyperlipidaemia (39.1% vs. 52.9%; P < 0.01), diabetes (22.5% vs. 49.1%; P < 0.01), obesity (13.2% vs. 25.0%; P < 0.01), and hypertension (20.2% vs. 23.8%; P < 0.01). Higher rates of co-morbid pulmonary disease in the form of interstitial lung disease (23.1% vs. 2.0%; P < 0.01) and pulmonary hypertension (36.6% vs. 12.7%; P < 0.01) were noted in the SSc cohort. Unadjusted in-hospital mortality was significantly higher in the HF with SSc group [5.1% vs. 2.6%; odds ratio: 1.99; 95% confidence interval (CI): 1.60-2.48; P < 0.001]. Unadjusted mortality was also higher among female (86.7% vs. 47.0%; P < 0.01), Black (15.7% vs. 13.0%; P < 0.01), and Hispanic (13.3% vs. 6.9%; P < 0.01) patients in the SSc cohort. After adjusting for potential confounders, SSc remained independently associated with higher in-hospital mortality (adjusted odds ratio: 1.81; 95% CI: 1.44-2.28; P < 0.001). Patients with HF and SSc also had longer LOS (6.4 vs. 5.4; adjusted mean difference [AMD]: 0.37, 95% CI: 0.05-0.68; P = 0.02) and higher hospitalization costs ($67 363 vs. $57 128; AMD: 198.9; 95% CI: -4780 to 5178; P = 0.93). CONCLUSIONS In patients hospitalized for HF, those with SSc were noted to have higher odds of in-hospital mortality than those without SSc. Patients with HF and SSc were more likely to be younger, female, and have higher rates of co-morbid interstitial lung disease and pulmonary hypertension at baseline with fewer traditional cardiovascular risk factors.
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Affiliation(s)
- Akil A Sherif
- Division of Cardiovascular Diseases, St Vincent Hospital, Worcester, MA, USA
| | - Vinit J Gilvaz
- Department of Rheumatology, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Sonu Abraham
- Divison of Cardiovascular diseases, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Anu Mariam Saji
- Department of Medicine, St Vincent Hospital, Worcester, MA, USA
| | - Don Mathew
- Department of Internal Medicine, University of Pittsburgh Medical Center, McKeesport, PA, USA
| | - Ameesh Isath
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Aiswarya Rajendran
- School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, USA
| | - Johanna Contreras
- Department of Cardiology, Division of Advanced Heart Failure and Transplant, Mount Sinai Morningside and West, New York, NY, USA
| | - Gregg M Lanier
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Anthony M Reginato
- Department of Rheumatology, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA
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Sreenivasan J, Malik A, Khan MS, Lloji A, Hooda U, Aronow WS, Lanier GM, Pan S, Greene SJ, Murad MH, Michos ED, Cooper HA, Gass A, Gupta R, Desai NR, Mentz RJ, Frishman WH, Panza JA. Pharmacotherapies in Heart Failure With Preserved Ejection Fraction: A Systematic Review and Network Meta-Analysis. Cardiol Rev 2024; 32:114-123. [PMID: 36576372 DOI: 10.1097/crd.0000000000000484] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Various pharmacotherapies exist for heart failure with preserved ejection fraction (HFpEF), but with unclear comparative efficacy. We searched EMBASE, Medline, and Cochrane Library from inception through August 2021 for all randomized clinical trials in HFpEF (EF >40%) that evaluated beta-blockers, mineralocorticoid receptor antagonist (MRA), angiotensin-converting enzyme inhibitors (ACE), angiotensin receptor blockers (ARB), angiotensin receptor-neprilysin inhibitor (ARNI), and sodium-glucose cotransporter-2 inhibitors (SGLT2i). Outcomes assessed were cardiovascular mortality, all-cause mortality, and HF hospitalization. A frequentist network meta-analysis was performed with a random-effects model. We included 22 randomized clinical trials (30,673 participants; mean age = 71.7 ± 4.2 years; females = 49.3 ± 7.7%; median follow-up = 24.4 ± 11.1 months). Compared with placebo, there was no statistically significant difference in cardiovascular mortality [beta-blockers; odds ratio (OR) 0.79 (0.46-1.34), MRA; OR 0.90 (0.70-1.14), ACE OR 0.95 (0.59-1.53), ARB; OR 1.02 (0.87-1.19), ARNI; OR 0.97 (0.74-1.26) and SGLT2i; OR 1.00 (0.84-1.18)] or all-cause mortality [beta blockers; OR 0.75 (0.54-1.04), MRA; OR 0.90 (0.75-1.08) ACE; OR 1.05 (0.71-1.54), ARB; OR 1.03 (0.91-1.15), ARNI; OR 0.99 (0.82-1.20) and SGLT2i; OR 1.00 (0.89-1.13)]. The certainty in these estimates was low or very low. There was a significantly reduction in HF hospitalization with the use of SGLT2i [OR 0.71 (0.62-0.82), moderate certainty], ARNI [OR 0.77 (0.63-0.94), low certainty], and MRA [OR 0.81 (0.66-0.98), moderate certainty]; with corresponding P scores of 0.84, 0.68, and 0.58, respectively. In HFpEF, the use of beta-blockers, MRA, ACE/ARB/ARNI, or SGLT2i was not associated with improved cardiovascular or all-cause mortality. SGLT2i, ARNI, and MRA reduced the risk of HF hospitalizations.
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Affiliation(s)
- Jayakumar Sreenivasan
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Aaqib Malik
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Muhammad Shahzeb Khan
- Duke Clinical Research Institute, Durham, NC
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Amanda Lloji
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Urvashi Hooda
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Gregg M Lanier
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Stephen Pan
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - M Hassan Murad
- Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
| | - Erin D Michos
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Howard A Cooper
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Alan Gass
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Rahul Gupta
- Division of Cardiology, Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, NC
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | | | - Julio A Panza
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
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Seplowe M, Isath A, Michaud L, Frishman WH, Levine A, Aronow WS, Lanier GM. Pulmonary Artery Hypertension: Fifty Years Following Pneumonectomy in Infancy. Cardiol Rev 2024:00045415-990000000-00221. [PMID: 38411185 DOI: 10.1097/crd.0000000000000678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Pulmonary hypertension (PH) may be the result of many different pathological processes. PH is a rare but recognized vascular complication following major lung resection. We describe the diagnosis and management of moderate PH resulting more than 50 years in a patient who underwent a total unilateral pneumonectomy in infancy. Unfortunately, patients who undergo pneumonectomy will likely go on to develop PH and their functional status will be greatly impacted. In the case presented, we report on a patient whose PH and symptoms improved following off-label WHO group 1 treatment.
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Affiliation(s)
- Matthew Seplowe
- From the Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Ameesh Isath
- Departments of Cardiology and Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Liana Michaud
- From the Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - William H Frishman
- From the Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Avi Levine
- Departments of Cardiology and Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- From the Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
- Departments of Cardiology and Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Gregg M Lanier
- From the Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
- Departments of Cardiology and Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
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5
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Foroshani S, Airo M, Levine A, Frishman WH, Aronow WS, Lanier GM. COVID-19 and Pulmonary Hypertension: An Interesting Dynamic. Cardiol Rev 2024:00045415-990000000-00220. [PMID: 38400720 DOI: 10.1097/crd.0000000000000679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2024]
Abstract
The dynamic between pulmonary hypertension (PH) and COVID-19 has been under investigation since 2020, early in the pandemic. Although the pathophysiology of PH has been well-studied, new discoveries regarding the multisystemic effects of COVID-19 are still being uncovered. The cardiopulmonary effects of COVID-19 have led investigators to inquire about the interplay between these 2 conditions. Several factors are suggested to contribute to an increased risk of developing PH after infection with SARS-CoV-2. This includes cytokine storm, acute respiratory distress syndrome, and fibrotic changes seen in post-COVID-19 lung disease. Additionally, it has been proposed that certain medications used to treat PH may be applied to patients suffering from the cardiopulmonary complications of COVID-19. This review will focus on the interplay between COVID-19 and PH, with a special focus on the risk of developing PH after SARS-CoV-2 infection and the outcomes of patients with preexisting PH who are diagnosed with COVID-19. The potential benefits of utilizing off-label PH medications for COVID-19 patients will also be discussed.
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Affiliation(s)
- Saam Foroshani
- From the Department of Medicine, New York Medical College, Valhalla, NY
| | - Michael Airo
- From the Department of Medicine, New York Medical College, Valhalla, NY
| | - Avi Levine
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - William H Frishman
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
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6
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Khan S, Randhawa S, Patail H, Spira Y, Frishman WH, Aronow WS, Lanier GM. Pharmacological Update and Emerging Treatments of Pulmonary Hypertension. Cardiol Rev 2024:00045415-990000000-00192. [PMID: 38294225 DOI: 10.1097/crd.0000000000000647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Pulmonary hypertension (PH) is defined as elevated pressures in the pulmonary artery and is associated with significant morbidity and mortality. The World Health Organization classifies PH into 5 distinct groups based on underlying etiology, pathology, and modality of treatment. Therapeutic approach may be challenging due to the extensive spectrum of causes and underlying mechanisms mediating PH. The 5 groups include pulmonary arterial hypertension (group 1), PH secondary to left heart disease (group 2), PH secondary to chronic lung disease (group 3), chronic thromboembolic pulmonary hypertension (group 4), and PH due to miscellaneous causes (group 5). Although significant progress has been made in the treatment of group 1 PH, there is a continued need to develop new therapies for all types of PH. Additionally, most treatments currently available improve functional capacity and symptoms but without a significant benefit in mortality. In this review, we aim to describe the various etiologies of PH and their established pharmacotherapies, as well as expand on emerging therapeutic options for each group.
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Affiliation(s)
- Shazli Khan
- From the Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Sukhbir Randhawa
- Department of Internal Medicine, Samaritan Medical Center, Watertown, NY
| | - Haris Patail
- Department of Internal Medicine, University of Connecticut School of Medicine, Hartford, CT
| | - Yaakov Spira
- Department of Internal Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - William H Frishman
- Department of Internal Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- From the Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Gregg M Lanier
- From the Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
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7
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Hirani R, Okumura K, Isath A, Gregory V, Khan S, Dhand A, Lanier GM, Spielvogel D, Kai M, Ohira S. Utilization of hepatitis C virus infected donors in heart transplant recipients with elevated MELD-XI score. Clin Transplant 2023; 37:e15124. [PMID: 37688341 DOI: 10.1111/ctr.15124] [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: 04/28/2023] [Revised: 08/30/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND The advent of direct-acting antivirals has helped to increase the safe utilization of organs from hepatitis C virus positive (HCV+) donors. However, the outcomes of heart transplantation (HT) using an HCV+ donor are unclear in recipients with underlying liver disease represented by an elevated model for end-stage liver disease excluding international normalized ratio (MELD-XI). METHODS The United Network of Organ Sharing database was queried from Jan 2016 to Dec 2021. Post-transplant outcomes stratified by recipient MELD-XI score (low <10.37, medium, 10.38-13.39, and high >13.4) was compared between patients with HT from HCV+ (N = 792) and patients with HT from HCV-negative donors (N = 15,266). RESULTS The median MELD-XI score was comparable (HCV+, 12.1, vs. HCV-negative, 11.8, p = .37). In the HCV+ group, donors were older (33 vs. 31 years, p < .001). Ischemic time of donor hearts (3.48 vs. 3.28 h, p < .001) and travel distance (250 vs. 157 miles, p < .001) were longer in HCV+ group. In the Kaplan Meier analysis with a median follow-up of 750 days, survival was comparable between the two groups (2-year survival, MELD-XI Low: HCV+, 92.4 ± 3.6% vs. HCV-negative, 91.1 ±.8%, p = .83, Medium: HCV+ 89.2 ± 4.3% vs. HCV-negative, 88.2 ± 1.0%, p = .68, and High: HCV+, 84.9 ± 4.5% vs. HCV-negative, 84.6 ± 1.1%, p = .75) In multivariate Cox hazard models, HCV donors were not associated with mortality in each MELD-XI subgroup (Low: adjusted hazard ratio (aHR), 1.02, p = .94; Medium: aHR, .95, p = .81; and High: aHR, .93, p = .68). CONCLUSION Utilization of HCV+ hearts was not associated with an increased risk of adverse outcomes in recipients with an elevated MELD- XI score.
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Affiliation(s)
- Rahim Hirani
- New York Medical College, Valhalla, New York, USA
| | - Kenji Okumura
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Ameesh Isath
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | | | - Shazli Khan
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Abhay Dhand
- Transplant Infectious Disease, Department of Medicine, Westchester Medical Center, Valhalla, New York, USA
| | - Gregg M Lanier
- New York Medical College, Valhalla, New York, USA
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - David Spielvogel
- New York Medical College, Valhalla, New York, USA
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Masashi Kai
- Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Suguru Ohira
- New York Medical College, Valhalla, New York, USA
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
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Rzechorzek W, Dey S, Shah A, Michaud L, Boyle D, Pitaktong A, Levine A, Pan S, Ohira S, Gass A, Kai M, Lanier GM. High-Risk Pulmonary Hypertension Does Not Worsen Outcomes in Heart Transplantation. Am J Cardiol 2023; 205:290-297. [PMID: 37625227 DOI: 10.1016/j.amjcard.2023.07.009] [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: 05/06/2023] [Revised: 06/17/2023] [Accepted: 07/05/2023] [Indexed: 08/27/2023]
Abstract
Pulmonary hypertension (PH) is a relative contraindication to heart transplantation (HT). Multiple studies showed increased mortality in patients with PH. Advances in care may have led to improved outcomes in the modern era. We analyzed patients who underwent HT at our institution between 2014 and 2018. We divided patients into 2 groups based on the presence of high-risk PH defined as either pulmonary vascular resistance >3 Wood units or transpulmonary gradient >15 mm Hg. The primary outcome was survival. Secondary outcomes were post-HT morbidity and changes in hemodynamics. Subsequently, we analyzed national trends of single organ HT recipients with a high-risk PH between 1994 and 2018 from the United Network for Organ Sharing registry. Of 98 patients who underwent HT at our center, 32% had PH. In patients without and with PH, the survival was 100% at 30 days, 87%, and 81% at 3 years (p = 0.96). In both groups, pulmonary vascular resistance and trans-pulmonary gradient decreased after HT. Nationwide data revealed 30-day survival without and with PH at 97% and 98% (p = 0.47) and 3-year survival at 86% and 87% (p = 0.84), respectively, in 2018. The proportion of recipients with PH decreased from 25% in 1994 to 19% in 2018. Recipients of HT with and without high-risk PH had similar early and late mortality in a single-center and nationwide analysis. PH improved immediately after transplant. The United Network for Organ Sharing registry analysis demonstrates continued improvement in survival in patients with PH in the modern era, whereas the relative percentage of recipients with PH decreased over time.
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Affiliation(s)
- Wojciech Rzechorzek
- Departments of Cardiology, New York Medical College/Westchester Medical Center, Valhalla, New York
| | - Subo Dey
- Departments of Internal Medicine, New York Medical College/Westchester Medical Center, Valhalla, New York.
| | - Avisha Shah
- Departments of Internal Medicine, New York Medical College/Westchester Medical Center, Valhalla, New York
| | - Liana Michaud
- Departments of Internal Medicine, New York Medical College/Westchester Medical Center, Valhalla, New York
| | - Dennis Boyle
- Departments of Internal Medicine, New York Medical College/Westchester Medical Center, Valhalla, New York
| | - Areen Pitaktong
- Departments of Internal Medicine, New York Medical College/Westchester Medical Center, Valhalla, New York
| | - Avi Levine
- Departments of Cardiology, New York Medical College/Westchester Medical Center, Valhalla, New York
| | - Stephen Pan
- Departments of Cardiology, New York Medical College/Westchester Medical Center, Valhalla, New York
| | - Suguru Ohira
- Departments of Cardiothoracic Surgery, New York Medical College/Westchester Medical Center, Valhalla, New York
| | - Alan Gass
- Departments of Cardiothoracic Surgery, New York Medical College/Westchester Medical Center, Valhalla, New York
| | - Masashi Kai
- Departments of Cardiothoracic Surgery, New York Medical College/Westchester Medical Center, Valhalla, New York
| | - Gregg M Lanier
- Departments of Cardiology, New York Medical College/Westchester Medical Center, Valhalla, New York
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Ahmed MS, Ghallab M, Ostrow T, Nashawi M, Alagha Z, Levine A, Aronow WS, Lanier GM. Pharmacotherapy of refractory pulmonary arterial hypertension. Expert Opin Pharmacother 2023; 24:1861-1874. [PMID: 37698041 DOI: 10.1080/14656566.2023.2257134] [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: 04/27/2023] [Accepted: 09/06/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION Treatment of refractory pulmonary arterial hypertension (PAH) is challenging and rarely the focus of reviews. The purpose of this review is to discuss current treatment options of refractory PAH, along with the state of research of several new medications. AREAS COVERED We conducted a comprehensive PubMed search on the relevant literature on treating PAH, with a focus on approved and investigational interventions for high-risk patients. Our strategy used keywords 'Treatment' AND 'Pulmonary Hypertension,' without date restrictions, ensuring a thorough survey of available literature for our review. EXPERT OPINION By utilizing serial risk assessment to identify patients remaining intermediate or high-risk, more patients are likely to survive longer. This is done by earlier use of combination or triple therapy with prostacyclin drugs. Current medications for PAH are all essentially vasodilators that improve physiology, but do not truly modify the disease process. The potential application of new investigational medications is exciting as they work by novel pathways likely to change the landscape of refractory PAH treatment.
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Affiliation(s)
- Mahmoud Samy Ahmed
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Muhammad Ghallab
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Talia Ostrow
- Department of Medicine, New York Medical College, Valhalla, New York, USA
| | - Mouhamed Nashawi
- Department of Medicine, Baylor Scott & White Health, Dallas, TX, USA
| | - Zakaria Alagha
- Department of Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia, USA
| | - Avi Levine
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
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10
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Ohira S, Okumura K, Hirani R, Martinez S, Ichikawa H, Isath A, Lanier GM, De La Pena C, Spielvogel D, Kai M. Use of Donor Hearts ≥50 Years Old for Septuagenarians in Heart Transplantation. Ann Thorac Surg 2023; 116:580-586. [PMID: 37146787 DOI: 10.1016/j.athoracsur.2023.04.032] [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: 12/23/2022] [Revised: 04/04/2023] [Accepted: 04/24/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND The impact of using donors ≥50 years old on heart transplantation outcomes of septuagenarians is unknown, which may have a potential to expand the donor pool. METHODS From January 2011 to December 2021, 817 septuagenarians received donor hearts <50 years old (DON<50) and 172 septuagenarians received donor hearts ≥50 years old (DON≥50) in the United Network for Organ Sharing database. Propensity score matching was performed using recipient characteristics (167 pairs). The Kaplan-Meier method and Cox proportional hazards model were used to analyze death and graft failure. RESULTS The number of heart transplants in septuagenarians has been increasing (54 per year in 2011 to 137 per year in 2021). In a matched cohort, the donor age was 30 years in DON<50 and 54 years in DON≥50. In DON≥50, cerebrovascular disease was the main cause of death (43%), whereas head trauma (38%) and anoxia (37%) were the causes in DON<50 (P < .001). The median heart ischemia time was comparable (DON<50, 3.3 hours; DON≥50, 3.2 hours; P = .54). In matched patients, 1- and 5-year survival rates were 88.0% (DON<50) vs 87.2% (DON≥50) and 79.2% (DON<50) vs 72.3% (DON≥50), respectively (log-rank, P = .41). In the multivariable Cox proportional hazards models, donors ≥50 years old were not associated with death in matched (hazard ratio, 1.05; 95% CI, 0.67-1.65; P = .83) and nonmatched groups (hazard ratio, 1.11; 95% CI, 0.82-1.50; P = .49). CONCLUSIONS The use of donor hearts older than 50 years can be an effective option for septuagenarians, thereby potentially increasing organ availability without compromising outcomes.
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Affiliation(s)
- Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York; New York Medical College, Valhalla, New York.
| | - Kenji Okumura
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York
| | | | | | - Hajime Ichikawa
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Ameesh Isath
- Department of Cardiology, Westchester Medical Center, Valhalla, New York
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center, Valhalla, New York
| | - Corazon De La Pena
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York; New York Medical College, Valhalla, New York
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York; New York Medical College, Valhalla, New York
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11
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Isath A, Ohira S, Levine A, Lanier GM, Pan S, Aggarwal-Gupta C, Mason I, Gregory V, Spielvogel D, Gass AL, Kai M. Evolution of concomitant use of veno-arterial extracorporeal membrane oxygenation support with Impella in cardiogenic shock: From percutaneous femoral Impella to axillary Impella 5.5. Artif Organs 2023; 47:1404-1412. [PMID: 37335815 DOI: 10.1111/aor.14594] [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: 03/20/2023] [Revised: 05/05/2023] [Accepted: 05/30/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Little is known about safety and efficacy of the use of Impella 5.5 compared to previous iterations in the setting of Impella with Veno-Arterial Extracorporeal Membrane Oxygenation Support as ECPELLA. METHODS Consecutive patients who were treated by ECPELLA with surgically implanted axillary Impella 5.5 (N = 13) were compared with patients supported by ECPELLA with percutaneous femoral Impella CP or 2.5 (Control, N = 13). RESULTS The total ECPELLA flow was higher in ECPELLA 5.5 group (6.9 vs. 5.4 L/min, p = 0.019). Actual hospital survival was higher than predicted and comparable in both groups (ECPELLA 5.5, 61.5% vs. Control, 53.8%, p = 0.691). Both total device complications (ECPELLA 5.5, 7.7% vs. Control, 46.1%, p = 0.021) and Impella-specific complications (ECPELLA 5.5, 0% vs. Control, 30.8%, p = 0.012) were significantly lower in the ECPELLA 5.5 group. CONCLUSIONS Utilization of Impella 5.5 in the setting of ECPELLA provides greater hemodynamic support with a lower risk of complications compared to Impella CP or 2.5.
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Affiliation(s)
- Ameesh Isath
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
- New York Medical College, Valhalla, New York, USA
| | - Avi Levine
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Stephen Pan
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Chhaya Aggarwal-Gupta
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Ian Mason
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Vasiliki Gregory
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
- New York Medical College, Valhalla, New York, USA
| | - Alan L Gass
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
- New York Medical College, Valhalla, New York, USA
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12
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Isath A, Malik A, Bandyopadhyay D, Goel A, Hajra A, Dhand A, Lanier GM, Fonarow GC, Lavie CJ, Gass AL. COVID-19, Heart Failure Hospitalizations, and Outcomes: A Nationwide Analysis. Curr Probl Cardiol 2023; 48:101541. [PMID: 36529234 PMCID: PMC9754747 DOI: 10.1016/j.cpcardiol.2022.101541] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
Heart Failure (HF) patients are at a higher risk of adverse events associated with Coronavirus disease 2019 (COVID-19). Large population-based reports of the impact of COVID-19 on patients hospitalized with HF are limited. The National Inpatient Sample database was queried for HF admissions during 2020 in the United States (US), with and without a diagnosis of COVID-19 based on ICD-10-CM U07. Propensity score matching was used to match patients across age, race, sex, and comorbidities. Multivariate logistic regression analysis was used to identify predictors of mortality. A weighted total of 1,110,085 hospitalizations for HF were identified of which 7,905 patients (0.71%) had a concomitant diagnosis of COVID-19. After propensity matching, HF patients with COVID-19 had higher rate of in-hospital mortality (8.2% vs 3.7%; odds ratio [OR]: 2.33 [95% confidence interval [CI]: 1.69, 3.21]; P< 0.001), cardiac arrest (2.9% vs 1.1%, OR 2.21 [95% CI: 1.24,3.93]; P<0.001), and pulmonary embolism (1.0% vs 0.4%; OR 2.68 [95% CI: 1.05, 6.90]; P = 0.0329). During hospitalizations for HF, COVID-19 was also found to be an independent predictor of mortality. Further, increasing age, arrythmias, and chronic kidney disease were independent predictors of mortality in HF patients with COVID-19. COVID-19 is associated with increased in-hospital mortality, longer hospital stays, higher cost of hospitalization and increased risk of adverse outcomes in patients admitted with HF.
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Affiliation(s)
- Ameesh Isath
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Aaqib Malik
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | | | - Akshay Goel
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Adrija Hajra
- Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Abhay Dhand
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Gregg M. Lanier
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Gregg C. Fonarow
- Department of Cardiology, University of California Los Angeles Medical Center, Los Angeles, CA
| | - Carl J. Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA
| | - Alan L. Gass
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY,Corresponding author: Alan L. Gass, MD, Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
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13
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Ohira S, Pan S, Levine A, Aggarwal-Gupta C, Lanier GM, Gass AL, Spielvogel D, Kai M. Simple technique of distal leg perfusion during heart transplant in patients with preoperative veno-arterial extracorporeal membrane oxygenation support. Perfusion 2023; 38:473-476. [PMID: 34958280 DOI: 10.1177/02676591211064721] [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] [Indexed: 11/16/2022]
Abstract
Direct heart transplant from veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support is challenging. Continuation of postoperative VA-ECMO support may be required in the setting of primary graft dysfunction or severe vasoplegia. We describe a simple technique to perfuse the ipsilateral leg of an arterial ECMO cannula during heart transplant while the ECMO circuit is turned off but maintaining the arterial cannula and distal perfusion catheter in place. This technique minimizes the number of intraoperative procedures with a minimal risk of leg ischemia, and provides a smooth transition to postoperative VA-ECMO support if necessary.
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Affiliation(s)
- Suguru Ohira
- Department of Surgery, Division of Cardiothoracic Surgery, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - Stephen Pan
- Department of Cardiology, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - Avi Levine
- Department of Cardiology, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - Chhaya Aggarwal-Gupta
- Department of Cardiology, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - Gregg M Lanier
- Department of Cardiology, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - Alan L Gass
- Department of Cardiology, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - David Spielvogel
- Department of Surgery, Division of Cardiothoracic Surgery, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
| | - Masashi Kai
- Department of Surgery, Division of Cardiothoracic Surgery, New York Medical College, 8138Westchester Medical Center, Valhalla, NY, USA
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14
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Isath A, Malik A, Bandyopadhyay D, Goel A, Hajra A, Contreras J, Lanier GM, Fonarow GC. A Comparison of COVID-19 and Influenza-Associated Myocarditis: A Nationwide Study in the United States. Curr Probl Cardiol 2023; 48:101680. [PMID: 36918088 PMCID: PMC10008141 DOI: 10.1016/j.cpcardiol.2023.101680] [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: 02/27/2023] [Accepted: 03/02/2023] [Indexed: 03/14/2023]
Abstract
We aimed to compare the characteristics and outcomes of adult patients hospitalized with myocarditis and either concomitant COVID-19 or influenza, and elucidate clinical predictors associated with adverse outcomes in both groups. The study used the National Inpatient Sample (NIS) from 2019 to 2020 to identify 27,725 adult myocarditis hospitalizations, of which 5,840 had concomitant COVID-19 and 1,045 had concomitant influenza. After propensity score matching, the in-hospital mortality from myocarditis was significantly higher in COVID-19 compared to influenza. Patients with myocarditis and COVID-19 were more likely to have cardiovascular comorbidities and be older than those with influenza-associated myocarditis. Predictors of mortality were also different in both groups.
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Affiliation(s)
- Ameesh Isath
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Aaqib Malik
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | | | - Akshay Goel
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Adrija Hajra
- Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Johanna Contreras
- Department of Cardiology, Division of Advanced Heart Failure and Transplant, Mount Sinai, Icahn School of Medicine, New York City, NY
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Gregg C Fonarow
- Department of Cardiology, University of California Los Angeles Medical Center, Los Angeles, CA.
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15
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Isath A, Lanier GM, Spielvogel D, Malekan R, Steinmetz C, Fishkin T, Semaan R, Panza JA, Naidu SS. OUTCOMES OF PATIENTS WITH OBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY AND PULMONARY HYPERTENSION UNDERGOING SEPTAL REDUCTION THERAPY STRATIFIED BY TREATMENT MODALITY. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00994-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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16
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Gupta R, Lin M, Maitz T, Egeler DJ, Sood A, Aronow WS, Rajeswaran Y, Ahnert AM, Vyas AV, Frishman WH, Lanier GM. Vericiguat: A Novel Soluble Guanylate Cyclase Stimulator for Use in Patients With Heart Failure. Cardiol Rev 2023; 31:87-92. [PMID: 35609251 DOI: 10.1097/crd.0000000000000431] [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] [Indexed: 02/07/2023]
Abstract
Heart failure (HF) affects 6.2 million Americans and is increasing annually in its frequency. Treatment of HF has been at the forefront of medical advancements due to the financial burden on our health care system. As such, changes to the guidelines regarding standard of care have been evolving over the last decade with the recent additions of sacubitril-valsartan and sodium glucose co-transporter-2 inhibitors to standard of care in the treatment of HF. Despite the aforementioned expansions in treatment options, HF continues to have a significant impact on the American health care system. Most recently, a novel drug vericiguat that targets an unprecedented pathway for the treatment of HF was Food and Drug Administration approved for the management of patients with HF with a reduced ejection fraction with a recent hospitalization or need for outpatient intravenous diuretics. In clinical trials, vericiguat was associated with a reduction in death from cardiovascular causes and first hospitalization in comparison to placebo. The aim of this review is to provide a comprehensive literature analysis of the various trials surrounding the approval of vericiguat and to both inform and synthesize the data surrounding the clinical use of vericiguat. The introduction of Vericiguat should be considered as a treatment option in patients to decrease the mortality/morbidity of HF with reduced ejection fraction and to increase the quality of life.
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Affiliation(s)
- Rahul Gupta
- From the Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA
| | - Muling Lin
- University of South Florida, Morsani College of Medicine, Tampa, FL
| | - Theresa Maitz
- Department of Medicine, Lehigh Valley Health Network, Allentown, PA
| | - David J Egeler
- Department of Medicine, Lehigh Valley Health Network, Allentown, PA
| | | | | | - Yasotha Rajeswaran
- From the Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA
| | - Amy M Ahnert
- From the Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA
| | - Apurva V Vyas
- From the Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA
| | - William H Frishman
- Department of Internal Medicine
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Gregg M Lanier
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
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17
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Isath A, Lanier GM, Spielvogel D, Malekan R, Steinmetz C, Semaan R, Fishkin T, Panza JA, Naidu SS. IMPACT OF PULMONARY HYPERTENSION ON SEPTAL REDUCTION THERAPY OUTCOMES FOR HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00993-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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18
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Ohira S, Dhand A, Hirani R, Martinez S, Lanier GM, Levine A, Pan S, Aggarwal-Gupta C, Gass AL, Wolfe K, Spielvogel D, Kai M. Cannulation-related adverse events of peripheral veno-arterial extracorporeal membrane oxygenation support in heart transplantation: Axillary versus femoral artery cannulation. Clin Transplant 2023; 37:e14871. [PMID: 36468757 DOI: 10.1111/ctr.14871] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/14/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND In heart transplantation (HT), peripheral veno-arterial extracorporeal membranous oxygenation (VA-ECMO) is utilized preoperatively as a direct bridge to HT or postoperatively for primary graft dysfunction (PGD). Little is known about wound complications of an arterial VA-ECMO cannulation site which can be fatal. METHODS From 2009 to 2021, outcomes of 80 HT recipients who were supported with peripheral VA-ECMO either preoperatively or postoperatively were compared based on the site of arterial cannulation: axillary (AX: N = 49) versus femoral artery (FA: N = 31). RESULTS Patients in the AX group were older (AX: 59 years vs. 52 years, p = .006), and less likely to have extracorporeal cardiopulmonary resuscitation (0% vs. 12.9%, p = .040). Survival to discharge (AX, 81.6% vs. FA. 90.3%, p = .460), incidence of stroke (10.2% vs. 6.5%, p = .863), VA-ECMO cannulation-related bleeding (6.1% vs. 12.9%, p = .522), and arm or limb ischemia (0% vs. 3.2%, p = .816) were comparable. ECMO cannulation-related wound complications were lower in the AX group (AX, 4.1% vs. FA, 45.2%, p < .001) including the wound infections (2.0% vs. 32.3%, p < .001). In FA group, all organisms were gram-negative species. In univariate logistic regression analysis, AX cannulation was associated with less ECMO cannulation-related wound complications (Odds ratio, .23, p < .001). There was no difference between cutdown and percutaneous FA insertion regarding cannulation-related complications. CONCLUSIONS Given the lower rate of wound complications and comparable hospital outcomes with femoral cannulation, axillary VA-ECMO may be an excellent option in HT candidates or recipients when possible.
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Affiliation(s)
- Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA.,New York Medical College, Valhalla, New York, USA
| | - Abhay Dhand
- New York Medical College, Valhalla, New York, USA.,Transplant Infectious Disease, Department of Medicine, Westchester Medical Center, Valhalla, New York, USA
| | - Rahim Hirani
- New York Medical College, Valhalla, New York, USA
| | | | - Gregg M Lanier
- New York Medical College, Valhalla, New York, USA.,Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Avi Levine
- New York Medical College, Valhalla, New York, USA.,Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Stephen Pan
- New York Medical College, Valhalla, New York, USA.,Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Chhaya Aggarwal-Gupta
- New York Medical College, Valhalla, New York, USA.,Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Alan L Gass
- New York Medical College, Valhalla, New York, USA.,Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Kevin Wolfe
- Division of Data Compliance, Transplant Services, Westchester Medical Center, Valhalla, New York, USA
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA.,New York Medical College, Valhalla, New York, USA
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA.,New York Medical College, Valhalla, New York, USA
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19
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Ahsan SA, Laird R, Dooley C, Akbar S, Sweeney J, Ohira S, Kai M, Levine A, Gass AL, Frishman WH, Aronow WS, Lanier GM. An Update on the Diagnosis and Management of Acute Right Heart Failure. Cardiol Rev 2023:e000538. [PMID: 36847512 DOI: 10.1097/crd.0000000000000538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Right ventricular (RV) dysfunction and resultant acute right heart failure (ARHF) is a rapidly growing field of interest, driven by increasing appreciation of its contribution to heart failure morbidity and mortality. Understanding of ARHF pathophysiology has advanced dramatically over recent years and can be broadly described as RV dysfunction related to acute changes in RV afterload, contractility, preload, or left ventricular dysfunction. There are several diagnostic clinical signs and symptoms as well as imaging and hemodynamic assessments that can provide insight into the degree of RV dysfunction. Medical management is tailored to the different causative pathologies, and in cases of severe or end-stage dysfunction, mechanical circulatory support can be utilized. In this review, we describe the pathophysiology of ARHF, how its diagnosis is established by clinical signs and symptoms and imaging findings, and provide an overview of treatment options, both medical and mechanical.
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Affiliation(s)
- Syed Adeel Ahsan
- From the Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Rachel Laird
- Department of Medicine, Houston Methodist Hospital, Houston, TX
| | - Caroline Dooley
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Sara Akbar
- Department of pulmonary and critical care medicine, Spectrum Health/Michigan State University, Detroit, MI
| | - James Sweeney
- Division of Cardiology, Hackensack Meridian Jersey Shore University Medical Center, Neptune, NJ
| | - Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, NY
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, NY
| | - Avi Levine
- Departments of Cardiology and Medicine Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Alan L Gass
- Departments of Cardiology and Medicine Westchester Medical Center and New York Medical College, Valhalla, NY
| | - William H Frishman
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- Departments of Cardiology and Medicine Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Gregg M Lanier
- Departments of Cardiology and Medicine Westchester Medical Center and New York Medical College, Valhalla, NY
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20
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Grunfeld M, Ohira S, Choe J, Lanier GM, Martin K, Spielvogel D, Kai M. Heart recovery from a brain-dead donor with a history of Ravitch procedure for repair of pectus excavatum. J Card Surg 2022; 37:5531-5533. [PMID: 36273420 DOI: 10.1111/jocs.17065] [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: 05/03/2022] [Revised: 09/06/2022] [Accepted: 10/15/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND We describe the successful heart transplantation of a brain-dead male donor with a remote history of pectus excavatum repair. METHOD AND RESULTS On computed tomography, the ascending aorta was in close proximity to metallic struts from the donor's sternal repair. Before harvesting the heart, visual and digital inspections revealed minimal space between the sternum and ascending aorta, complicated by severe adhesions in the lower sternum. After the pericardium was opened, the subsequent recovery of the heart was performed in a standard fashion. At one-year post-transplant, the recipient continues to have normal graft function. CONCLUSIONS Careful evaluation, intraoperative consideration, and coordination with other transplant teams were essential in the successful recovery of the heart during a time of organ shortages.
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Affiliation(s)
| | - Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Joshua Choe
- New York Medical College, Valhalla, New York, USA
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Kathryn Martin
- Division of Pediatric Surgery, Department of Surgery, Maria Fareri Children's Hospital, Valhalla, New York, USA
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
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21
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Ohira S, Spielvogel D, Lanier GM, Kai M. Heart transplantation using manubrium-sparing sternotomy for sternal re-entry. J Card Surg 2022; 37:5643-5645. [PMID: 36316823 DOI: 10.1111/jocs.17071] [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: 04/12/2022] [Revised: 07/29/2022] [Accepted: 09/21/2022] [Indexed: 11/06/2022]
Abstract
We report a technique of heart transplantation performed by manubrium-sparing sternotomy for challenging re-entry after minimally invasive left ventricular assist device insertion. A T-shaped, manubrium-sparing sternotomy was performed using an oscillating saw up to the first intercostal space. After cardiopulmonary bypass was established via the right axillary artery and percutaneous venous cannulation of the right jugular and femoral vein, the outflow graft was ligated and divided via a left thoracotomy. All anastomoses were performed with a standard technique with an excellent exposure and outcome.
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Affiliation(s)
- Suguru Ohira
- Department of Surgery, Division of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - David Spielvogel
- Department of Surgery, Division of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Masashi Kai
- Department of Surgery, Division of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
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22
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Kanwal A, Ohira S, Levine A, Isath A, Pan S, Dhand A, Aggarwal-Gupta C, Lanier GM, Gass A, Spielvogel D, Kai M. Survival and renal outcomes of direct heart transplant from veno-arterial extracorporeal membrane oxygenation support. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Backgrounds
Patients on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support are given the highest priority for cardiac transplantation (OHT) in the new UNOS heart allocation policy adopted in October 2018. Although patients may receive an organ quicker there may not be enough time to recover end-organ function. To date, little is known about survival and renal outcomes of direct OHT in patients that have been supported with VA-ECMO as a bridge to transplant due to limited experience in most transplant centers.
Purpose
The aim of this study was to investigate survival and renal outcomes of direct OHT in patients supported with VA-ECMO prior to transplant.
Methods
From January 2010 to February 2022, 23 patients who received single organ OHT alone directly from VA-ECMO support were retrospectively analyzed (16 patients after the new allocation policy). Kaplan-Meier analysis was used to estimate event-free survival.
Results
The median age of recipients was 48 years. The median length of pre-transplant VA-ECMO support was 5 days. Additional pre-transplant support with intra-aortic balloon pump or Impella was utilized in 15 patients (65.2%) and 2 patients (9%) respectively. There was a trend toward improvement of serum creatinine after initiation of VA-ECMO support (Pre-ECMO: 1.66±1.22 mg/dl vs. Pre-OHT: 1.20±0.74 mg/dl, P=0.084). Four patients required preoperative renal replacement therapy (RRT); three were on RRT at the time of OHT. The median ischemic time of donor hearts was 168 minutes. VA-ECMO support was continued in 10 patients (43.5%) after OHT.
Hospital mortality was 8.7% (2 patients). Post-transplant RRT was required in 9 patients (39.1%), and, of these, 5 patients were transitioned to permanent dialysis. Among the 14 patients who did not require post-transplant RRT, none required RRT during the follow-up period (median, 21.5 months). Kaplan-Meier survival analysis showed that estimated survival at 1 year and 3 years were 86.1%, and 77.5%, respectively (Figure 1A). The freedom from dialysis rate was 82.4% at 1 year, and 74.9% at 3 years (Figure 2A). Both survival (100% vs. 66.7%, P=0.008, Fig.1B) and dialysis free rate (100% vs. 55.6%, P=0.002, Figure 2B) at one-year were significantly worse in patients who required postoperative RRT.
Conclusions
To our knowledge this is the largest single center study of OHT in patients that were supported with VA-ECMO. VA-ECMO as a bridge to end-organ recovery and OHT resulted in excellent outcomes. Patients who required post-transplant RRT more likely to require long-term dialysis, while those that did not receive RRT showed favorable outcomes. Overall survival in this patient population is comparable to patients that were not on VA-ECMO prior to transplant.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- A Kanwal
- Westchester Medical Center , New York , United States of America
| | - S Ohira
- Westchester Medical Center , New York , United States of America
| | - A Levine
- Westchester Medical Center , New York , United States of America
| | - A Isath
- Westchester Medical Center , New York , United States of America
| | - S Pan
- Westchester Medical Center , New York , United States of America
| | - A Dhand
- Westchester Medical Center , New York , United States of America
| | - C Aggarwal-Gupta
- Westchester Medical Center , New York , United States of America
| | - G M Lanier
- Westchester Medical Center , New York , United States of America
| | - A Gass
- Westchester Medical Center , New York , United States of America
| | - D Spielvogel
- Westchester Medical Center , New York , United States of America
| | - M Kai
- Westchester Medical Center , New York , United States of America
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Sharma D, Shah RJ, Sreenivasan J, Kafle P, Gupta R, Levine A, Lanier GM, Aronow WS. The role of serial right heart catheterization in risk stratification and management of pulmonary arterial hypertension. Expert Rev Cardiovasc Ther 2022; 20:543-547. [PMID: 35726644 DOI: 10.1080/14779072.2022.2092095] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial blood pressure secondary to increased pulmonary vascular resistance. AREAS COVERED Invasive hemodynamic assessment by heart catheterization (RHC) remains the gold standard to confirm the diagnosis, to determine the severity of right ventricular dysfunction and to test for pulmonary vasoreactivity. After diagnosis and initiation of therapy, many PAH centers continue to perform RHC at regular intervals to monitor for disease progression and alter management. We discuss the importance of risk stratification in PAH, the role of RHC in the evaluation and treatment of these patients and compare non-invasive risk assessment tools to that of RHC. EXPERT OPINION RHC is useful for diagnosis of PAH, assessing the risk of mortality and morbidity, directing the escalation and de-escalation of therapy, and monitoring for disease progression. In the current era of improved non-invasive cardiac hemodynamic assessment, the role for routine follow-up serial RHC in patients with PAH needs to be reassessed in future studies. With the availability of non-invasive risk assessment tools such as REVEAL Lite 2, it may be reasonable to reconsider the role of annual or protocoled RHC, and instead, move on to an "as needed" and individual approach.
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Affiliation(s)
- Dikshya Sharma
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Ravi J Shah
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Jayakumar Sreenivasan
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Paritosh Kafle
- Dvision of Cardiology, Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Rahul Gupta
- Division of Cardiology, Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA, USA
| | - Avi Levine
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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Kishino Y, Kuno T, Malik AH, Lanier GM, Sims DB, Ruiz Duque E, Briasoulis A. Effect of pulmonary artery pressure-guided therapy on heart failure readmission in a nationally representative cohort. ESC Heart Fail 2022; 9:2511-2517. [PMID: 35560987 PMCID: PMC9288808 DOI: 10.1002/ehf2.13956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/28/2022] [Accepted: 04/14/2022] [Indexed: 11/05/2022] Open
Abstract
AIMS Pulmonary artery pressure (PAP)-guided therapy in patients with heart failure (HF) using the CardioMEMS (CMM) device, an implantable PAP sensor, has been shown to reduce HF hospitalizations in previous studies. We sought to evaluate the clinical benefit of the CMM device in regard to 30, 90, and 180 day readmission rates in real-world usage. METHODS AND RESULTS We queried the Nationwide Readmissions Database (NRD) to identify patients who underwent CMM implantation (International Classification of Diseases 9 and 10 codes) between the years 2014 and 2019 and studied their HF readmissions. Moreover, we compared CMM patients and their readmissions with a matched cohort of patients with HF but without CMM. Multivariable Cox regression analysis was performed to adjust for other predictors of readmissions. Prior to matching, we identified 5 326 530 weighted HF patients without CMM and 1842 patients with CMM. After propensity score matching for several patients and hospital-related characteristics, the cohort consisted of 1839 patients with CMM and 1924 with HF without CMM. Before matching, CMM patients were younger (67.0 ± 13.5 years vs. 72.3 ± 14.1 years, P < 0.001), more frequently male (62.7% vs. 51.5%, P < 0.001), with higher rates of prior percutaneous coronary intervention (16.9% vs. 13.2%, P = 0.002), peripheral vascular disease (29.6% vs. 17.8%, P < 0.001), pulmonary circulatory disorder (38.7% vs. 23.2%, P < 0.001), atrial fibrillation (51.2% vs. 45.3%, P = 0.002), prior left ventricular assist device (1.8% vs. 0.2%, P < 0.001), high income (32.2% vs. 16.4%, P < 0.001), and acute kidney disease (43.8% vs. 29.9%, P < 0.001). Readmission rates at 30 days were 17.3% vs. 20.9% for patients with vs. without CMM, respectively, and remained statistically significant after matching (17.3% vs. 21.5%, P = 0.002). The rates of 90 day (29.6% vs. 36.5%, P = 0.002) and 180 day (39.6% vs. 46.6%, P = 0.009) readmissions were lower in the CMM group. In a multivariable regression model, CMM was associated with lower risk of readmissions (hazard ratio 0.75, 95% confidence interval 0.63-0.89, P = 0.001). CONCLUSIONS The CMM device was associated with reduced HF rehospitalization rates in a nationally representative cohort of HF patients, validating the clinical trial that led to the approval of this device and its utilization in the treatment of HF.
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Affiliation(s)
- Yoshikazu Kishino
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Aaqib H Malik
- Department of Cardiology, Westchester Medical Center, New York, NY, USA
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center, New York, NY, USA
| | - Daniel B Sims
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Ernesto Ruiz Duque
- Division of Cardiovascular Medicine, Section of Heart Failure and Transplantation, University of Iowa, Iowa, IA, USA
| | - Alexandros Briasoulis
- Division of Cardiovascular Medicine, Section of Heart Failure and Transplantation, University of Iowa, Iowa, IA, USA
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25
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D’Addario CA, Lanier GM, Jacob C, Bauer N, Hewes JL, Bhadra A, Gupte SA. Differences in the expression of DNA methyltransferases and demethylases in leukocytes and the severity of pulmonary arterial hypertension between ethnic groups. Physiol Rep 2022; 10:e15282. [PMID: 35581740 PMCID: PMC9114656 DOI: 10.14814/phy2.15282] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/29/2022] [Accepted: 04/02/2022] [Indexed: 04/29/2023] Open
Abstract
The loss of ten-eleven translocation (TET2) methylcytosine dioxygenase expression contributes to the pathobiology of pulmonary arterial hypertension (PAH). However, whether the expression and activity of other TETs and DNA methyltransferases (DNMTs) are altered in PAH remains enigmatic. Therefore, our objective was to determine the expression of DNMT (1, 3a, and 3b) and TET (1, 2, and 3) and their total activity. We assessed the expression of DNMT and TET enzymes in the leukocytes and their activity in extracellular vesicles (EVs). Expression of DNMT (1, 3a, and 3b), TET (2 and 3) in leukocytes, and total activity in EVs, from PAH patients was higher than in healthy controls. Additionally, we noticed there were difference in expression of these epigenetic enzyme based on ethnicity and found higher DNMT1 and lower TET2/TET3 expression in Caucasian than Hispanic/African American (combine) patients. Since loss-of-function mutation(s) and down-regulation of TET enzymes are associated with hematological malignancies and cytokine production, we determined the expression of genes that encode cytokines in samples of Caucasian and Hispanic/African American patients. Expression of IL6, CSF2, and CCL5 genes were higher in the leukocytes of Caucasian than Hispanic/African American patients, and CSF2 and CCL5 negatively correlated with the decreased expression of TET3. Interestingly, the expression of gene encoding CD34, a marker of myeloid and lymphoid precursor cells, and CD163, a monocyte/macrophage protein, was higher in the leukocytes of Caucasian than Hispanic/African American patients. Furthermore, Hispanic/African American patients having higher TET2/TET3 expression had higher pulmonary capillary wedge pressure. In conclusion, our results revealed higher DNMT1 and lower TET2/TET3 in Caucasian than Hispanic/African American patients together potentially augmented genes encoding inflammation causing cytokines, and CD34+ -derived immunogenic cells, and the severity of PAH.
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Affiliation(s)
| | - Gregg M. Lanier
- Department of Cardiology, and Heart and Vascular InstituteWestchester Medical Center and New York Medical CollegeValhallaNYUSA
| | - Christina Jacob
- Department of PharmacologyNew York Medical CollegeValhallaNYUSA
| | - Natalie Bauer
- Department of PharmacologyCollege of MedicineUniversity of South AlabamaMobileALUSA
| | - Jenny L. Hewes
- Department of PharmacologyCollege of MedicineUniversity of South AlabamaMobileALUSA
| | - Aritra Bhadra
- Department of PharmacologyCollege of MedicineUniversity of South AlabamaMobileALUSA
| | - Sachin A. Gupte
- Department of PharmacologyNew York Medical CollegeValhallaNYUSA
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26
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Aronow WS, Lloji A, Sreenivasan J, Novograd J, Pan S, Lanier GM. Heart failure with preserved ejection fraction: key stumbling blocks for experimental drugs in clinical trials. Expert Opin Investig Drugs 2022; 31:463-474. [PMID: 35443138 DOI: 10.1080/13543784.2022.2069009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Heart failure with preserved ejection fraction (HFpEF) is a disease process with a high prevalence. Accounting for more than 50% of all heart failure cases, it carries a significant mortality. So far, there has been a lack of therapeutic options that truly show improvement in morbidity and mortality. Certain novel therapies have shown a decrease in heart failure hospitalizations, however, this beneficial effect was more pronounced for heart failure patients with mildly reduced ejection fraction (EF). AREAS COVERED This review summarizes the pathophysiology of the disease to help elucidate the differences between heart failure with reduced ejection fraction (HFrEF), and HFpEF, which could explain why therapies are successful in one (rather than the other). At the focus of this review are non-standardized nomenclature across major trials, the challenges of finding a therapeutic agent for such a heterogeneous population, and identification of specific phenotypes that have different outcomes and could be a target for future therapies. EXPERT OPINION Lack of standardized diagnostic criteria, associated with population heterogeneity, might explain why trials have failed to improve outcomes for patients with HFpEF. Standardizing phenotypes and recapitulating these phenotypes in animal models, as well as understanding the mechanisms of the disease at the molecular level could be the first steps in identifying promising therapeutic options.
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Affiliation(s)
- Wilbert S Aronow
- Westchester Medical Center, New York Medical College,New York, USA
| | - Amanda Lloji
- Westchester Medical Center, New York Medical College,New York, USA
| | | | - Joel Novograd
- Westchester Medical Center, New York Medical College,New York, USA
| | - Stephen Pan
- Westchester Medical Center, New York Medical College,New York, USA
| | - Gregg M Lanier
- Westchester Medical Center, New York Medical College,New York, USA
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27
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Varadhan A, Stephan K, Gupta R, Vyas AV, Ranchal P, Aronow WS, Hawwa N, Lanier GM. Growing role of SGLT2i in heart failure: evidence from clinical trials. Expert Rev Clin Pharmacol 2022; 15:147-159. [PMID: 35264076 DOI: 10.1080/17512433.2022.2051480] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : There is an unmet need for therapies that improve overall mortality and morbidity for patients with preserved ejection fraction, who comprise roughly half of all heart failure (HF) cases. The growing role of sodium-glucose cotransporter-2 inhibitors (SGLT2is) in cardiovascular outcomes provide a paradigm shift in the treatment of HF. AREAS COVERED : This review article provides a general overview of the growing role of SGLT2is and summarizes the mechanism of action, side effects, and contraindications for the treatment of HF. We also discuss recent clinical trials measuring the effects of different SGLT2is as possible treatment options for HF with reduced ejection fraction and HF with mid-range and preserved EF. We conducted a review of all the randomized, controlled studies with SGLT2is in patients with known heart failure with and without type-2 diabetes (T2DM). We performed a literature search in PubMed, Google Scholar, the Web of Science, and the Cochrane Library while screening results by the use of titles and abstracts. EXPERT OPINION : The promising pathophysiological profile of SGLT2i and their role in cardioprotective effects demonstrate an invaluable discovery in the management of patients with HF irrespective of their diabetes status.
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Affiliation(s)
- Ajay Varadhan
- University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Katarina Stephan
- Department of Biomedical Engineering, Columbia University, New York, NY, USA
| | - Rahul Gupta
- Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA, USA
| | - Apurva V Vyas
- Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA, USA
| | - Purva Ranchal
- Department of Internal Medicine, Boston University, Boston, MA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, Valhalla, NY, USA
| | - Nael Hawwa
- Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA, USA
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center, Valhalla, NY, USA
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Hassanin A, Hassanein M, Lanier GM, Sadaka M, Rifaat M, Sanhoury M. Prevalence of obesity and its association with cardiometabolic risk factors, heart failure phenotype and mortality among patients hospitalized for heart failure in Egypt. Egypt Heart J 2022; 74:1. [PMID: 34978627 PMCID: PMC8724509 DOI: 10.1186/s43044-021-00232-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Obesity is an established risk factor for cardiometabolic disease and heart failure (HF). Nevertheless, the relationship between obesity and HF mortality remains controversial. RESULTS The goal of this study was to describe the prevalence of obesity in patients hospitalized for HF in Egypt and investigate the relationship of obesity to cardiometabolic risk factors, HF phenotype and mortality. Between 2011 and 2014, 1661 patients hospitalized for HF across Egypt were enrolled as part of the European Society of Cardiology HF Long-term Registry. Obese patients, defined by a BMI ≥ 30 kg/m2, were compared to non-obese patients. Factors associated with mortality on univariate analysis were entered into a logistic regression model to identify whether obesity was an independent predictor of mortality during hospitalization and at one-year follow-up. The prevalence of obesity was 46.5% and was higher in females compared to males. Obese as compared to non-obese patients had a higher prevalence of diabetes mellitus (47.0% vs 40.2%, p = 0.031), hypertension (51.3% vs 33.0%, p < 0.001) and history of myocardial infarction (69.2% vs 62.8% p = 0.005). Obese patients as compared to non-obese patient were more likely to have acute coronary syndrome on admission (24.8% vs 14.2%, p < < 0.001). The dominant HF phenotype in obese and non-obese patients was HF with reduced ejection fraction (EF); however, obese patients as compared to non-obese patient had higher prevalence of HF with preserved EF (22.3% vs 12.4%, p < 0.001). Multivariable analysis demonstrated that obesity was associated with an independent survival benefit during hospitalization, (OR for mortality 0.52 [95% CI 0.29-0.92]). Every point increase in BMI was associated with an OR = 0.93 [95% CI 0.89-0.98] for mortality during hospitalization. The survival benefit was not maintained at one-year follow-up. CONCLUSIONS Obesity was highly prevalent among the study cohort and was associated with higher prevalence of cardiometabolic risk factors as compared to non-obese patients. Obesity was associated with an independent "protective effect" from in-hospital mortality but was not a predictor of mortality at 1-year follow-up.
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Affiliation(s)
- Ahmed Hassanin
- Westchester Medical Center/New York Medical College, Valhalla, USA
| | | | - Gregg M. Lanier
- Westchester Medical Center/New York Medical College, Valhalla, USA
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Jain A, Devarajan A, Assallum H, Malekan R, Lanier GM, Epelbaum O. Characteristics of early pleural effusions after orthotopic heart transplantation: comparison with coronary artery bypass graft surgery. Pleura Peritoneum 2021; 6:161-165. [PMID: 35071737 PMCID: PMC8719445 DOI: 10.1515/pp-2021-0143] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/18/2021] [Indexed: 11/15/2022] Open
Abstract
Objectives Pleural effusions appearing within the first 30 postoperative days following coronary artery bypass grafting (CABG) are classified as early and believed to be directly related to the surgery. The characteristics of such effusions are well-described. Orthotopic heart transplantation is also known to be complicated by pleural effusions; however, their characteristics have not been systematically reported. We assessed the features of early postoperative pleural effusions after heart transplantation and compared them to those of early effusions following CABG. Methods We retrospectively collected demographic, clinical, and laboratory data for patients who underwent either orthotopic heart transplantation (study group) or CABG (comparison group) at our institution and whose postoperative course within 30 days was complicated by new or worsening pleural effusion that prompted drainage. Patients subjected to analysis consisted only of those with sufficiently complete laboratory profiles to permit adequate characterization of the nature of their pleural fluid. Results Out of 251 orthotopic heart transplant recipients, seven (2.8%) were found to have sufficiently complete pleural fluid results to be included in the study group. Out of 1,506 patients who underwent CABG, 32 (2.1%) had sufficiently complete pleural fluid results and formed the comparison group. The radiological appearance of pleural effusions in both groups was similar: bilateral in at least half and exclusively moderate to large. Effusions complicating both surgeries were exudative in close to 90% of cases. For those with available leukocyte differential counts, the pleural fluid of the post-orthotopic heart transplantation group was more often neutrophilic (3/5, 60%), whereas the fluid of the post-coronary artery bypass grafting group was more often lymphocytic (22/32, 69%) and tended to be hemorrhagic (median RBC count 33,000 cells/µL vs. 10,000 cells/µL). None of the comparisons of pleural fluid characteristics between the two groups reached statistical significance. Conclusions This small, descriptive study is the first to systematically report the fluid characteristics of pleural effusions complicating orthotopic heart transplantation within the first 30 postoperative days and to compare this group to those who developed effusions after CABG. Our findings revealed both similarities and differences in the pleural fluid characteristics between these two types of patients.
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Affiliation(s)
- Anant Jain
- Pulmonary Critical Care , Westchester County Medical Center , Valhalla , NY , USA
| | - Anusha Devarajan
- Internal Medicine , Westchester Medical Center , Valhalla , NY , USA
| | - Hussein Assallum
- Pulmonary Critical Care , Westchester County Medical Center , Valhalla , NY , USA
| | - Ramin Malekan
- Cardiothoracic Surgery , Westchester County Medical Center , Valhalla , NY , USA
| | - Gregg M. Lanier
- Transplant Cardiology , Westchester County Medical Center , Valhalla , NY , USA
| | - Oleg Epelbaum
- Pulmonary Critical Care , Westchester County Medical Center , Valhalla , NY , USA
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Abstract
There has been significant interest in research for the development of device-based therapy as a treatment option of heart failure (HF), whether it is with reduced or preserved ejection fraction. This is due to the high morbidity and mortality rate in patients with HF despite recent advances in pharmacologic treatment. Following the success of cardiac resynchronization therapy, baroreceptor activation therapy has emerged as another novel device-based treatment for HF. The Barostim neo was developed by CVRx Minneapolis, MN for the treatment of mild to severe HF. The device works by electrically activating the baroreceptor reflex with the goal to restore the maladaptive autonomic imbalance that is seen in patients with HF. Preliminary clinical investigations have given promising results with an encouraging safety profile. Baroreceptor activation therapy as a treatment option is still investigational at this time; however, several trials in different patient populations have already shown benefit with a very good safety profile. In this review, we will summarize the current state of technology and the available literature of the use of baroreceptor activation therapy in patients with different comorbidities, with a focus on this device-based therapy in patients with HF.
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Affiliation(s)
- Boniface Malangu
- From the Department of Internal Medicine, Rutgers-New Jersey Medical School, Newark, NJ
| | - Gregg M Lanier
- Department of Medicine, Division of Cardiology, New York Medical College/Westchester Medical Center, Valhalla, NY
| | - William H Frishman
- Department of Medicine, Division of Cardiology, New York Medical College/Westchester Medical Center, Valhalla, NY
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31
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Kozlova N, Lanier GM, Kleinman G, Epelbaum O. Acute amiodarone pulmonary toxicity in the form of organizing pneumonia triggered by orthotopic heart transplantation. Respir Med Case Rep 2021; 34:101532. [PMID: 34745869 PMCID: PMC8551649 DOI: 10.1016/j.rmcr.2021.101532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/19/2021] [Indexed: 11/07/2022] Open
Abstract
We report a case of a 60-year-old man who underwent orthotopic heart transplantation after short-term receipt of low-dose oral amiodarone for the management of ventricular tachycardia. Prior to transplant surgery, he had a normal chest radiograph and was free of supplemental oxygen. His initial postoperative chest radiograph showed subtle infiltrates, and thereafter his chest imaging continued to worsen. Although he was eventually able to wean off mechanical ventilation via a tracheostomy, he remained dyspneic and oxygen-dependent with persistently abnormal chest imaging as his post-transplant corticosteroid regimen was being tapered. In light of progressively worsening diffuse lung disease, he underwent bronchoscopy with transbronchial biopsies. Histology revealed foamy macrophages in association with foci of organizing pneumonia, a picture consistent with amiodarone pulmonary toxicity. Given these findings, corticosteroid dosing was increased for the clinical diagnosis of acute amiodarone pulmonary toxicity with subsequent normalization of oxygen saturation and chest radiography. Our case is the first to identify orthotopic heart transplantation as a potential trigger for acute amiodarone pulmonary toxicity. It is also only the second documented example of organizing pneumonia as the histological substrate of amiodarone pulmonary toxicity, which is an association that has therapeutic implications. Amiodarone pulmonary toxicity can present acutely, often precipitated by cardiothoracic interventions. Organizing pneumonia has only rarely been shown to underlie acute amiodarone pulmonary toxicity. Orthotopic heart transplantation surgery was the putative trigger in the present case, making this the first such description.
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Affiliation(s)
- Natalya Kozlova
- Division of Pulmonary, Critical Care, and Sleep Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Gregg M Lanier
- Division of Transplant Cardiology, Westchester Medical Center, Valhalla, NY, USA
| | - George Kleinman
- Department of Pathology, Westchester Medical Center, Valhalla, NY, USA
| | - Oleg Epelbaum
- Division of Pulmonary, Critical Care, and Sleep Medicine, Westchester Medical Center, Valhalla, NY, USA
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Hassanin A, Rzechorzek W, Naidu SS, Lanier GM. A haemodynamic conundrum: a case report of a patient with concurrent pulmonary arterial hypertension and hypertrophic obstructive cardiomyopathy. Eur Heart J Case Rep 2021; 5:ytab354. [PMID: 34557642 PMCID: PMC8453412 DOI: 10.1093/ehjcr/ytab354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/19/2021] [Accepted: 08/23/2021] [Indexed: 12/04/2022]
Abstract
Background The co-existence of hypertrophic obstructive cardiomyopathy (HOCM) and pulmonary arterial hypertension (PAH) is extremely rare and poses a management conundrum. This is the first case report in the published literature to describe the diagnosis and management of a patient with both conditions. Case summary A 49-year-old female with a history of HOCM and recently diagnosed scleroderma presented to the clinic with progressive dyspnoea. Transthoracic echocardiogram demonstrated left ventricular outflow tract (LVOT) obstruction at rest, and elevated pulmonary artery (PA) pressure. Cardiac catheterization (CC) demonstrated an LVOT gradient of 150 mmHg, PA pressure of 88/32 mmHg, pulmonary capillary wedge pressure (PCWP) 12 mmHg, pulmonary vascular resistance 14.8 Wu, and a cardiac index of 1.6 L/min/m2. The differential diagnosis for the dyspnoea included combined pre- and post-capillary pulmonary hypertension from longstanding HOCM vs. scleroderma associated PAH. Tadalafil was added to the patient’s medical regimen of metoprolol but it was stopped because the patient developed pulmonary oedema. Alcohol septal ablation was undertaken with improvement in the LVOT gradient, but only a modest improvement in her dyspnoea. Repeat CC demonstrated worsening PAH. Vasodilatory testing with nitric oxide led to an improvement in the PA pressure with minimal increase of the PCWP. Hence, she was started on treprostinil and macitentan, with significant improvement in her dyspnoea on follow-up. Conclusion In patients with concurrent HOCM and advanced PAH, a multidisciplinary treatment approach is needed to rapidly and safely optimize the background of HOCM in order to permit the use of PAH-specific medications.
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Affiliation(s)
- Ahmed Hassanin
- Westchester Medical Center, New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA
| | - Wojciech Rzechorzek
- Westchester Medical Center, New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA
| | - Srihari S Naidu
- Westchester Medical Center, New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA
| | - Gregg M Lanier
- Westchester Medical Center, New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA
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Patel N, Narasimhan B, Bandyopadhyay D, Amreia M, Chakraborty S, Hajra A, Amgai B, Rai D, Luo Y, Krittanawong C, Dey AK, Ghosh RK, Fonarow GC, Lanier GM, De Marco T, Naidu SS. Impact of Pulmonary Hypertension on In-Hospital Outcomes and 30-Day Readmissions Following Percutaneous Coronary Interventions. Mayo Clin Proc 2021; 96:2058-2066. [PMID: 34353467 DOI: 10.1016/j.mayocp.2021.03.037] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 02/27/2021] [Accepted: 03/08/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the impact of pulmonary hypertension (PH) on percutaneous coronary intervention (PCI) outcomes and 30-day all-cause readmissions by analyzing a national database. METHODS We queried the 2014 National Readmissions Database to identify patients undergoing PCI using International Classification of Diseases, Ninth Revision, Clinical Modification codes. These patients were then subcategorized based on the coded presence or absence of PH and further analyzed to determine the impact of PH on clinical outcomes, health care use, and 30-day readmissions. RESULTS Among 599,490 patients hospitalized for a PCI in 2014, 19,348 (3.2%) had concomitant PH. At baseline, these patients were older with a higher burden of comorbidities. Patients with PH had longer initial hospitalizations and higher 30-day readmission rates and mortality than their non-PH counterparts. This was largely driven by cardiac causes, most commonly heart failure (20.3% vs 9.0%, P<.001) and non-ST-segment elevation myocardial infarction. Recurrent coronary events (17.5% vs 9.5%, P<.05) including ST-segment elevation myocardial infarction predominated in the non-PH group. CONCLUSION Patients with PH undergoing PCI are a high-risk group in terms of mortality and 30-day readmission rates. Percutaneous coronary intervention in patients with PH is associated with higher rates of recurrent heart failure and non-ST-segment elevation myocardial infarction, rather than recurrent coronary events or ST-segment elevation myocardial infarction. This perhaps indicates a predominance of demand ischemia and heart failure syndromes rather than overt atherothrombosis in the etiology of chest pain in these patients.
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Affiliation(s)
| | - Bharat Narasimhan
- Icahn School of Medicine at Mount Sinai, St Luke's-Roosevelt-Mount Sinai, New York, NY
| | | | | | | | - Adrija Hajra
- Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | | | - Devesh Rai
- Rochester General Hospital, Rochester, NY
| | - Yiming Luo
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD
| | | | | | | | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, CA
| | - Gregg M Lanier
- Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Teresa De Marco
- Advanced Heart Failure and Pulmonary Hypertension Program, University of California-San Francisco, San Francisco, CA
| | - Srihari S Naidu
- Westchester Medical Center, New York Medical College, Valhalla, NY.
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Lloji A, Hooda U, Sreenivasan J, Malekan R, Aronow WS, Lanier GM. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. Am J Cardiovasc Dis 2021; 11:330-347. [PMID: 34322303 PMCID: PMC8303037] [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] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/08/2021] [Indexed: 06/13/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary hypertension (PH) caused by thromboembolic disease with the secondary remodeling of the pulmonary vessels. The primary treatment of CTEPH is pulmonary thromboendarterectomy (PTE). However, some patients are not candidates for PTE because of surgically inaccessible thrombi or high operative risk and can be candidates for balloon pulmonary angioplasty (BPA), an emerging, lower risk treatment. This review discusses the patient selection, the technique, and comprehensive review of reported outcomes following BPA. BPA techniques have improved over the years, and so has its safety profile. Recent data show that after several sessions of BPA, patients who were not eligible for PTE had improvement in their hemodynamic profile, functional capacity, and 6-minute walk distance. Studies have shown that compared to riociguat, BPA has shown significant improvement in the functional capacity and hemodynamic measurements. Reperfusion pulmonary edema is a common complication after PTE and BPA, which may be due to vessel injury rather than pulmonary extravasation. Rates of complications have decreased especially after the use of optical coherence tomography, which helps in proper sizing of the balloons. Patients with CTEPH who are ineligible for PTE should be evaluated for BPA. In addition to medical therapy, BPA has shown promising clinical and hemodynamic outcomes in patients with CTEPH.
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Affiliation(s)
- Amanda Lloji
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
| | - Urvashi Hooda
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
| | - Jayakumar Sreenivasan
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
| | - Ramin Malekan
- Division of Cardiothoracic Surgery, Westchester Medical Center, New York Medical CollegeValhalla, New York, The United States
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
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Sreenivasan J, Khan MS, Sharedalal P, Hooda U, Fudim M, Demmer RT, Yuzefpolskaya M, Ahmad H, Khan SS, Lanier GM, Colombo PC, Rich JD. Obesity and Outcomes Following Cardiogenic Shock Requiring Acute Mechanical Circulatory Support. Circ Heart Fail 2021; 14:e007937. [PMID: 33706552 DOI: 10.1161/circheartfailure.120.007937] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The association of obesity on outcomes in patients with cardiogenic shock requiring acute mechanical circulatory support has not been thoroughly investigated. METHODS We evaluated the National Readmission Database for adults with either acute myocardial infarction or heart failure complicated by cardiogenic shock requiring acute mechanical circulatory support between January 2016 and November 2017. Exposure was assessed using International Classification of Diseases, Tenth Revision codes for the degree of obesity with the reference being body mass index (BMI) of 20.0 to 29.9 group. Multiple logistic regression and Cox regression analysis were used to analyze in-hospital mortality and 30-day readmission, respectively. RESULTS The survey-weighted sample included a total of 35 555 hospitalizations with a mean age of 65.4±0.2 years and 29.8% females. Obesity was associated with higher in-hospital mortality (no obesity, 26.4% [BMI, 20.0-29.9] versus class I obesity, 25.0% [BMI, 30.0-34.9] versus class II obesity, 28.7% [BMI, 35.0-39.9] versus class III obesity, 34.9% [BMI, ≥40]; P<0.001). On stratified analysis, compared with a nonobese phenotype, younger adults (age <60) with class II and class III obesity (odds ratio, 1.9 [95% CI, 1.1-3.5], P=0.02; odds ratio, 2.1 [95% CI, 1.2-3.7], P=0.01) and older adults (age ≥60) with class III obesity (odds ratio, 1.7 [95% CI, 1.2-2.4], P=0.005) had higher mortality. There was no association between the degree of obesity and 30-day readmission. CONCLUSIONS Among adults with acute myocardial infarction or acute heart failure resulting in cardiogenic shock requiring acute mechanical circulatory support, younger adults with class II and class III obesity and older patients with class III obesity have a higher risk of in-hospital mortality compared with nonobese patients.
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Affiliation(s)
- Jayakumar Sreenivasan
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY (J.S., P.S., U.H., H.A., G.M.L.)
| | | | - Parija Sharedalal
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY (J.S., P.S., U.H., H.A., G.M.L.)
| | - Urvashi Hooda
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY (J.S., P.S., U.H., H.A., G.M.L.)
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, NC (M.F.).,Division of Cardiology, Duke University Medical Center, Durham, NC, (M.F.)
| | - Ryan T Demmer
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (R.T.D.)
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, NY (M.Y., P.C.C.)
| | - Hasan Ahmad
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY (J.S., P.S., U.H., H.A., G.M.L.)
| | - Sadiya S Khan
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.K., J.D.R.)
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY (J.S., P.S., U.H., H.A., G.M.L.)
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, NY (M.Y., P.C.C.)
| | - Jonathan D Rich
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.K., J.D.R.)
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Shah RJ, Pan S, Lanier GM, Mellela L, Aronow WS, Jain D. Recent advances in the pharmacotherapy of TTR amyloidosis of the heart. VP 2021. [DOI: 10.20517/2574-1209.2021.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
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Bhinder J, Ahsan SA, Zaid S, Sharedalal P, Aggarwal-Gupta C, Levine A, Pan S, Gass A, Lanier GM. Use of Rabbit Anti-thymocyte Globulin as a Renal Sparing Strategy: Outcomes from a Single Center. J Card Fail 2020. [DOI: 10.1016/j.cardfail.2020.09.444] [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: 11/26/2022]
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38
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Ahsan SA, Bhinder J, Zaid S, Sharedalal P, Aggarwal-Gupta C, Levine A, Pan S, Gass A, Lanier GM. A Novel Risk Scoring System for Predicting Primary Graft Dysfunction after Orthotopic Heart Transplantation. J Card Fail 2020. [DOI: 10.1016/j.cardfail.2020.09.397] [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: 11/25/2022]
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39
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Sharedalal PH, Bhinder J, Ahsan S, Zaid S, Pan S, Levine A, Aggarwal-Gupta C, Gass A, Lanier GM. Impact of Therapy with Anti-Thymocyte Globulin in Heart Transplant Recipients on Acute Cellular Rejection and Readmission for Infection - A Single Center Retrospective Study. J Card Fail 2020. [DOI: 10.1016/j.cardfail.2020.09.457] [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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40
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Gupta R, Ranchal P, Mahajan S, Pattarkine R, Patibandla S, Fallon JT, Lanier GM. Lipid inclusions in cardiac myocytes - a rare case of cardiolipotoxicity. Future Cardiol 2020; 17:293-299. [PMID: 32842772 DOI: 10.2217/fca-2020-0076] [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] [Indexed: 11/21/2022] Open
Abstract
The heart oxidizes fatty acids for its energy production. The physiological balance between fatty acid uptake and its oxidation prevents lipid accumulation in cardiac myocytes. However, accumulation of lipids due to various processes such as obesity, diabetes, heart failure, myocardial ischemia or infarction can result in damage to the heart tissue, also known as cardiolipotoxicity. We present a unique case of a 69-year-old gentleman with a history of heart failure and ventricular tachycardia. Endomyocardial biopsy to assess for restrictive cardiomyopathy/amyloid showed no evidence of amyloid, significant inflammation or fibrosis, but did show intracellular accumulation of significant amorphous material in most cardiac myocytes. We review the literature regarding the pathogenesis of cardiolipotoxicity, which has no definite cause or treatment yet identified.
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Affiliation(s)
- Rahul Gupta
- Department of Internal Medicine, Westchester Medical Center & New York Medical College, Valhalla, NY 10595, USA
| | - Purva Ranchal
- Department of Internal Medicine, Westchester Medical Center & New York Medical College, Valhalla, NY 10595, USA
| | - Sugandhi Mahajan
- Department of Internal Medicine, Carle Foundation Hospital, Urbana, IL 61801, USA
| | - Rugved Pattarkine
- Department of Pathology, Westchester Medical Center & New York Medical College, Valhalla, NY 10595, USA
| | - Saikrishna Patibandla
- Department of Internal Medicine, The Brooklyn Hospital Center, Brooklyn, NY 11201, USA
| | - John T Fallon
- Department of Internal Medicine, Westchester Medical Center & New York Medical College, Valhalla, NY 10595, USA.,Department of Pathology, Westchester Medical Center & New York Medical College, Valhalla, NY 10595, USA
| | - Gregg M Lanier
- Department of Internal Medicine, Westchester Medical Center & New York Medical College, Valhalla, NY 10595, USA.,Department of Cardiology, Westchester Medical Center & New York Medical College, Valhalla, NY 10595, USA
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Hashimoto R, Lanier GM, Dhagia V, Joshi SR, Jordan A, Waddell I, Tuder R, Stenmark KR, Wolin MS, McMurtry IF, Gupte SA. Pluripotent hematopoietic stem cells augment α-adrenergic receptor-mediated contraction of pulmonary artery and contribute to the pathogenesis of pulmonary hypertension. Am J Physiol Lung Cell Mol Physiol 2020; 318:L386-L401. [PMID: 31913656 PMCID: PMC7052680 DOI: 10.1152/ajplung.00327.2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 12/10/2019] [Accepted: 12/19/2019] [Indexed: 12/13/2022] Open
Abstract
Pulmonary hypertension (PH) is a multicellular and progressive disease with a high mortality rate. Among many cell types, hematopoietic stem cells (HSCs) are incriminated in the pathogenesis of PH. However, our understanding of the mechanisms that increase HSCs in blood and lungs of hypertensive animals or patients and the role played by HSCs in the pathogenesis of PH remains elusive. Studies suggest that glycolysis is critical for the survival and growth of HSCs. In various cell types from hypertensive lungs of animals and patients, glycolysis and the glucose-6-phosphate dehydrogenase (G6PD) activity are increased. Herein, we demonstrated in mice that chronic hypoxia increased HSCs (CD34+, CD117+, CD133+, CD34+/CD117+, and CD34+/CD133+) in bone marrow and blood and around hypertensive pulmonary arteries in a time-dependent manner. Intriguingly, we found fewer CD133+ cells in the bone marrow of C57BL/6 mice compared with Sv129J mice, and C57BL mice developed less severe chronic hypoxia-elicited PH and heart failure than Sv129J mice. Similarly, the numbers of CD34+ and CD117+ cells in blood of patients with pulmonary arterial hypertension (PAH) were higher (>3-fold) compared with healthy individuals. By allogeneic bone marrow transplantation, we found that GFP+ bone marrow cells infiltrated the lungs and accumulated around the pulmonary arteries in lungs of hypoxic mice, and these cells contributed to increased α-adrenergic receptor-mediated contraction of the pulmonary artery cultured in hypoxia. Inhibition of G6PD activity with (3β,5α)-3,21-dihydroxypregnan-20-one, a novel and potent G6PD inhibitor, decreased HSCs in bone marrow, blood, and lungs of hypoxic mice and reduced α-agonist-induced contraction of the pulmonary artery and established hypoxia-induced PH. We did not observe CD133+ cells around the pulmonary arteries in the lungs of chronically hypoxic G6PD-deficient mice. Furthermore, knockdown of G6PD and inhibition of G6PD activity: 1) downregulated canonical and noncanonical Wnt and Fzd receptors genes; 2) upregulated Bmpr1a; 3) decreased Cxcl12, and 4) reduced HSC (CD117+ and CD133+) numbers. In all, our findings demonstrate unexpected function for bone marrow-derived HSCs in augmenting α-adrenergic receptor-mediated contraction of pulmonary arteries and remodeling of pulmonary arteries that contribute to increase pulmonary vascular resistance in PAH patients and hypoxic mice and suggest that G6PD, by regulating expression of genes in the WNT and BMPR signaling, contributed to increase and release of HSCs from the bone marrow in response to hypoxic stimuli.
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Affiliation(s)
- Ryota Hashimoto
- Department of Pharmacology, New York Medical College, Valhalla, New York
| | - Gregg M Lanier
- Department of Cardiology, and Heart and Vascular Institute, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Vidhi Dhagia
- Department of Pharmacology, New York Medical College, Valhalla, New York
| | - Sachindra R Joshi
- Department of Pharmacology, New York Medical College, Valhalla, New York
| | - Allan Jordan
- Drug Discovery Unit, Cancer Research, UK Manchester Institute, University of Manchester, Manchester, United Kingdom
| | - Ian Waddell
- Drug Discovery Unit, Cancer Research, UK Manchester Institute, University of Manchester, Manchester, United Kingdom
| | - Rubin Tuder
- Department of Pathology, University of Colorado Health Center, Denver, Colorado
| | - Kurt R Stenmark
- Department of Pediatrics, University of Colorado Health Center, Denver, Colorado
| | - Michael S Wolin
- Department of Physiology, New York Medical College, Valhalla, New York
| | - Ivan F McMurtry
- Department of Pharmacology and Medicine, University of South Alabama, Mobile, Alabama
| | - Sachin A Gupte
- Department of Pharmacology, New York Medical College, Valhalla, New York
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Gupta R, Jacobson J, Cooper HA, Lanier GM. Meta-Analysis of n-3 Polyunsaturated Fatty Acid Supplementation for the Prevention of Post-Operative Atrial Fibrillation in Patients Undergoing Coronary Artery Bypass Surgery. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.07.236] [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: 10/26/2022]
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Mody BP, Zaid S, Khan MH, Cooper H, Ahn C, Aronow WS, Lanier GM. Continuous Outpatient Intravenous Inotrope Therapy: Milrinone is Associated with Improved Survival Compared to Dobutamine Irrespective of Indication. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Gupta R, Ranchal P, Pattarkine R, Patibandla S, Fallon J, Lanier GM. Lipid Inclusions in Cardiac Myocytes - A Rare Case of Cardiolipotoxicity. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.07.331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Gupta R, Harburger J, Lanier GM. Effect of Angiotensin Converting Enzyme Inhibitors on Functional Capacity in Elderly Patients with Heart Failure and Preserved Ejection Fraction: A Systematic Review and Meta-Analysis. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.07.040] [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: 10/26/2022]
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Yandrapalli S, Sanaani A, Harikrishnan P, Aronow WS, Frishman WH, Lanier GM, Ahmed A, Fonarow GC. Cardiogenic shock during heart failure hospitalizations: Age-, sex-, and race-stratified trends in incidence and outcomes. Am Heart J 2019; 213:18-29. [PMID: 31078113 DOI: 10.1016/j.ahj.2019.03.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [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: 07/06/2018] [Accepted: 03/27/2019] [Indexed: 02/03/2023]
Abstract
The objectives were to study the overall and age-, sex-, and race-stratified incidence of cardiogenic shock (CS) during heart failure hospitalizations (HFHs) not complicated by acute coronary syndromes (ACS), utilization of short-term mechanical circulatory support (MCS) and in-hospital mortality with non-ACS-related CS, and respective temporal trends. Data are lacking regarding the epidemiology of non-ACS-related CS during HFHs. METHODS Retrospective observational analysis of the National Inpatient Sample 2005-2014 to identify all HFHs in adult patients without concomitant ACS. RESULTS Of 8,333,752 HFHs, incidence rate of non-ACS-related CS was 8.7 per thousand HFHs (N = 72,668), a 4-fold increase from 4.1 to 15.6 per thousand HFHs between 2005 and 2014 (Ptrend < .001). Among those with non-ACS-related CS, utilization rates of intra-aortic balloon pump, extracorporeal membrane oxygenation, and temporary ventricular assist devices were 12.8%, 1.4%, and 2.5%, respectively. Respective 2005 to 2014 trends were 14.2% to 10.7%, 0.6% to 1.8%, and 0.8% to 2.7% (Ptrend for all, <.001). In-hospital mortality rate was 27.1%, with a substantial decrease from 42.4% in 2005 to 23.3% in 2014 (Ptrend < .001). These temporal trends were largely consistent across age, sex, and race subgroups. CONCLUSION During HFHs in the United States, non-ACS-related CS occurred infrequently but was associated with substantial mortality. Non-ACS-related CS incidence and certain MCS utilization rates increased, and in-hospital mortality rate decreased between 2005 and 2014. These trends were generally homogenous across the age, sex, and race groups. The observed trends in incidence and mortality may be a reflection of increased identification of CS during HFHs, although further study is needed to assess whether temporal changes in care may have influenced outcomes.
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Affiliation(s)
- Srikanth Yandrapalli
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Abdallah Sanaani
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Prakash Harikrishnan
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - William H Frishman
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Gregg M Lanier
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Ali Ahmed
- Veterans Affairs Medical Center, George Washington University, and Georgetown University, Washington, DC
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Division of Cardiology, University of California, Los Angeles, CA.
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Affiliation(s)
- Prakash Harikrishnan
- Divsion of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Srikanth Yandrapalli
- Divsion of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Wilbert S. Aronow
- Divsion of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Gregg M. Lanier
- Divsion of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Diwakar Jain
- Divsion of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
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Lanier GM, Fallon JT, Naidu SS. Role of Advanced Testing: Invasive Hemodynamics, Endomyocardial Biopsy, and Cardiopulmonary Exercise Testing. Cardiol Clin 2018; 37:73-82. [PMID: 30447718 DOI: 10.1016/j.ccl.2018.08.010] [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] [Indexed: 11/28/2022]
Abstract
Hypertrophic cardiomyopathy affects 0.5% of the population. Advanced testing is considered, including cardiac catheterization, endomyocardial biopsy, and cardiopulmonary exercise testing. Right and left heart catheterization provides essential hemodynamic data, identifies patients who might benefit from septal reduction therapy, and assesses for comorbidities. Pathologic analysis reveals ventricular hypertrophy, myocardial disarray, and endocardial and interstitial fibrosis. Routine endomyocardial biopsy is not recommended unless other conditions that cause hypertrophy need to be ruled out. Cardiopulmonary exercise testing provides useful physiologic data, allows monitoring of the response to medication and surgical interventions, estimates prognosis, and guides referral for orthotopic heart transplantation.
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Affiliation(s)
- Gregg M Lanier
- Pulmonary Hypertension Program, Heart Failure, Westchester Medical Center, New York Medical College, 100 Woods Road, Macy Pavilion Room 110, Valhalla, NY 10595, USA.
| | - John T Fallon
- Department of Clinical Laboratories and Pathology, Westchester Medical Center, New York Medical College, 100 Woods Road, Macy Pavilion Room 106, Valhalla, NY 10595, USA
| | - Srihari S Naidu
- Hypertrophic Cardiomyopathy Program, Cardiac Catheterization Laboratory, Westchester Medical Center, New York Medical College, 100 Woods Road, Macy Pavilion Room 106, Valhalla, NY 10595, USA
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Abstract
INTRODUCTION Heart failure (HF) is characterized by maladaptive neurohormonal activation of the cardiovascular and renal systems resulting in circulatory inadequacy and frequent acute exacerbations. The increasing burden of HF prompted investigation of underlying pathophysiological mechanisms and the design of pharmacotherapeutics that would target these pathways. AREAS COVERED A MEDLINE search for relevant original investigations and review articles of newer hormonal drugs for HF since the year 2005 till October 2017 provided us with necessary literature. Major trials and relevant clinical investigations were discussed. EXPERT COMMENTARY A multitude of hormonal pathways central to HF were identified, including the natriuretic peptide system and neurohormones such as relaxin, arginine vasopressin, and endothelin. However, drugs targeting these novel pathways (aliskiren, tolvaptan, ularitide, serelaxin, bosentan, macitentan) failed to show mortality benefit. This emphasizes a tremendous unmet need in the pharmacotherapy for HF, especially for the subtypes of acute HF and HF with preserved ejection fraction. Sacubitril/valsartan demonstrated substantial mortality benefit in chronic systolic HF population and is endorsed by international HF guidelines. If proven to be efficacious in larger outcome trials, finerenone can be a valuable addition baseline HF therapy. More basic, translational, and phenotype specific clinical research is warranted to improve HF pharmacotherapy.
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Affiliation(s)
- Srikanth Yandrapalli
- a Department of Internal Medicine , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
| | - George Jolly
- a Department of Internal Medicine , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
| | - Medha Biswas
- b Division of Cardiology , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
| | - Yogita Rochlani
- b Division of Cardiology , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
| | - Prakash Harikrishnan
- b Division of Cardiology , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
| | - Wilbert S Aronow
- b Division of Cardiology , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
| | - Gregg M Lanier
- b Division of Cardiology , New York Medical College at Westchester Medical Center , Valhalla , NY , USA
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Katchi T, Orellana CP, Aggarwal C, Lanier GM, Gass A. Multivessel Spontaneous Coronary Artery Dissection: An Incidental Finding in the Least Expected Patient. J Card Fail 2017. [DOI: 10.1016/j.cardfail.2017.07.269] [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: 10/19/2022]
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