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Oliveros E, Islam S, Keane MG. The Pregnant Patient and the Cardiologist: Should We Embrace Our Fears? JACC Case Rep 2023; 14:101796. [PMID: 37342093 PMCID: PMC10277672 DOI: 10.1016/j.jaccas.2023.101796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Affiliation(s)
- Estefania Oliveros
- Address for correspondence: Dr Estefania Oliveros, Temple University Hospital, 3401 N Broad Street, 9th Floor Pavilion, Philadelphia, Pennsylvania 19140, USA. @EstefaniaOS
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Pellikka PA, Strom JB, Pajares-Hurtado GM, Keane MG, Khazan B, Qamruddin S, Tutor A, Gul F, Peterson E, Thamman R, Watson S, Mandale D, Scott CG, Naqvi T, Woodward GM, Hawkes W. Automated analysis of limited echocardiograms: Feasibility and relationship to outcomes in COVID-19. Front Cardiovasc Med 2022; 9:937068. [PMID: 35935624 PMCID: PMC9353267 DOI: 10.3389/fcvm.2022.937068] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 06/27/2022] [Indexed: 11/19/2022] Open
Abstract
Background As automated echocardiographic analysis is increasingly utilized, continued evaluation within hospital settings is important to further understand its potential value. The importance of cardiac involvement in patients hospitalized with COVID-19 provides an opportunity to evaluate the feasibility and clinical relevance of automated analysis applied to limited echocardiograms. Methods In this multisite US cohort, the feasibility of automated AI analysis was evaluated on 558 limited echocardiograms in patients hospitalized with COVID-19. Reliability of automated assessment of left ventricular (LV) volumes, ejection fraction (EF), and LV longitudinal strain (LS) was assessed against clinically obtained measures and echocardiographic findings. Automated measures were evaluated against patient outcomes using ROC analysis, survival modeling, and logistic regression for the outcomes of 30-day mortality and in-hospital sequelae. Results Feasibility of automated analysis for both LVEF and LS was 87.5% (488/558 patients). AI analysis was performed with biplane method in 300 (61.5%) and single plane apical 4- or 2-chamber analysis in 136 (27.9%) and 52 (10.7%) studies, respectively. Clinical LVEF was assessed using visual estimation in 192 (39.3%), biplane in 163 (33.4%), and single plane or linear methods in 104 (21.2%) of the 488 studies; 29 (5.9%) studies did not have clinically reported LVEF. LV LS was clinically reported in 80 (16.4%). Consistency between automated and clinical values demonstrated Pearson's R, root mean square error (RMSE) and intraclass correlation coefficient (ICC) of 0.61, 11.3% and 0.72, respectively, for LVEF; 0.73, 3.9% and 0.74, respectively for LS; 0.76, 24.4ml and 0.87, respectively, for end-diastolic volume; and 0.82, 12.8 ml, and 0.91, respectively, for end-systolic volume. Abnormal automated measures of LVEF and LS were associated with LV wall motion abnormalities, left atrial enlargement, and right ventricular dysfunction. Automated analysis was associated with outcomes, including survival. Conclusion Automated analysis was highly feasible on limited echocardiograms using abbreviated protocols, consistent with equivalent clinically obtained metrics, and associated with echocardiographic abnormalities and patient outcomes.
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Affiliation(s)
- Patricia A. Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- *Correspondence: Patricia A. Pellikka
| | - Jordan B. Strom
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Gabriel M. Pajares-Hurtado
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Martin G. Keane
- Temple Heart and Vascular Center, Philadelphia, PA, United States
| | - Benjamin Khazan
- Temple Heart and Vascular Center, Philadelphia, PA, United States
| | | | - Austin Tutor
- Ochsner Health System, New Orleans, LA, United States
| | - Fahad Gul
- Einstein Medical Center, Philadelphia, PA, United States
| | - Eric Peterson
- Einstein Medical Center, Philadelphia, PA, United States
| | - Ritu Thamman
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Shivani Watson
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Deepa Mandale
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ, United States
| | - Christopher G. Scott
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States
| | - Tasneem Naqvi
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ, United States
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Ibrahim KD, Tragesser LA, Soans R, Haddad A, Eddy VJ, McComb J, Keane MG, Whitman IR. Impact of Racial Disparities in Preoperative Cardiovascular Evaluation and Surgical Outcomes in Patients Undergoing Metabolic and Bariatric Surgery: A Retrospective Cohort Analysis. J Am Heart Assoc 2022; 11:e024499. [PMID: 35624077 PMCID: PMC9238690 DOI: 10.1161/jaha.121.024499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background We investigated preoperative referral patterns, rates of cardiovascular testing, surgical wait times, and postoperative outcomes in White versus Black, Hispanic, or other racial or ethnic groups of patients undergoing metabolic and bariatric surgery. Methods and Results This was a single center retrospective cohort analysis of 797 consecutive patients undergoing metabolic and bariatric surgery from January 2014 to December 2018; 86% (n=682) were Black, Hispanic, or other racial or ethnic groups. White versus Black, Hispanic, or other racial or ethnic groups had similar baseline comorbidities and were referred for preoperative cardiovascular evaluation in similar proportion (65% versus 68%, P=0.529). Black, Hispanic, or other racial or ethnic groups of patients were less likely to undergo preoperative cardiovascular testing (unadjusted odds ratio [OR], 0.56; 95% CI, 0.33–0.95; P=0.031; adjusted for Revised Cardiac Risk Index OR, 0.59; 95% CI, 0.35–0.996; P=0.049). White patients had a shorter wait time for surgery (unadjusted hazard ratio [HR], 0.7; 95% CI, 0.58–0.87; P=0.001; adjusted HR, 0.7; 95% CI, 0.56–0.95; P=0.018). Reduction in body mass index at 6 months was greater in White patients (12.9 kg/m2 versus 12.0 kg/m2, P=0.0289), but equivalent at 1 year (14.9 kg/m2 versus 14.3 kg/m2, P=0.330). Conclusions White versus Black, Hispanic, or other racial or ethnic groups of patients were referred for preoperative cardiovascular evaluation in similar proportion. White patients underwent more preoperative cardiac testing yet had a shorter wait time for surgery. Early weight loss was greater in White patients, but equivalent between groups at 12 months.
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Affiliation(s)
- Kaitlyn D Ibrahim
- Lewis Katz School of Medicine at Temple University Philadelphia PA.,Division of Cardiology Temple University Hospital Philadelphia PA.,Main Line Health Broomall PA
| | | | - Rohit Soans
- Lewis Katz School of Medicine at Temple University Philadelphia PA.,Division of Bariatric Surgery Temple University Hospital Philadelphia PA
| | - Abdullah Haddad
- Lewis Katz School of Medicine at Temple University Philadelphia PA.,Division of Cardiology Temple University Hospital Philadelphia PA
| | - Vikram J Eddy
- Lewis Katz School of Medicine at Temple University Philadelphia PA.,Division of Bariatric Surgery Temple University Hospital Philadelphia PA
| | - Joseph McComb
- Lewis Katz School of Medicine at Temple University Philadelphia PA.,Division of Anesthesiology Temple University Hospital Philadelphia PA
| | - Martin G Keane
- Lewis Katz School of Medicine at Temple University Philadelphia PA.,Division of Cardiology Temple University Hospital Philadelphia PA
| | - Isaac R Whitman
- Lewis Katz School of Medicine at Temple University Philadelphia PA.,Division of Cardiology Temple University Hospital Philadelphia PA
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Hawkes W, Keane MG, Khazan B, QAMRUDDIN SALIMA, Tutor A, Thamman R, Naqvi TZ, Mandale D, Strom JB, Hurtado GP, Peterson E, Gul FI, Watson S, Tilkes K, Davidson H, Scott C, Piotrowska H, Hansen WH, Woodward G, Pellikka PA. FULLY AUTOMATED ANALYSIS OF CARDIAC POINT OF CARE ULTRASOUND: FEASIBILITY AND CLINICAL RELEVANCE IN COVID-19 PATIENTS. J Am Coll Cardiol 2022. [PMCID: PMC8972461 DOI: 10.1016/s0735-1097(22)02998-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Romero CM, Tragesser L, Haddad A, Ibrahim K, Soans R, Vikram E, McComb J, Whitman IR, Keane MG. Abstract P168: Predictors Of Htn Remission Post-bariatric Surgery: A Contemporary Analysis. Hypertension 2021. [DOI: 10.1161/hyp.78.suppl_1.p168] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
The effect of bariatric surgery on improvement and remission of hypertension (HTN) is well documented. However, the factors that influence HTN remission in this population are poorly understood and have not been investigated in over a decade. We aim to describe predictors of HTN remission post-bariatric surgery in a contemporary patient population.
Methods:
All patients who underwent sleeve gastrectomy or Roux-en-Y gastric bypass from January 2014 to December 2018 at an urban academic institution were included in the analysis. Blood pressure (BP) was recorded pre-operatively, 6-month post operation, and 12-month post operation. HTN was defined as BP ≥ 140/90 or patients on anti-hypertensive medications. Remission was defined as BP < 140/90 off all blood pressure medications. Baseline characteristics of patients with and without HTN remission were described. Logistic regression analysis was performed to assess indicators of HTN remission. A p-value of 0.05 was used for all statistical analyses.
Results:
Among 844 patients who underwent bariatric surgery, 497 (58.9%) patients had HTN. Among HTN patients 167 (33.6%) had remission at 6 months and 126 (25.4%) had remission at 12 months. The major predictor of HTN remission on multivariate analysis was number of pre-operative medications at 6 months (OR 2.5, 95% CI 2.03 to 3.29) and 12 months (OR 2.6, 95% CI 1.99 to 3.56). Major predictors on univariate analysis at 12 months were CVA (OR 4.3, 95% CI 1.40 to 12.47) and HLD (OR 1.76, 95% CI 1.27 to 2.45).
Conclusion:
Number of pre-operative medications is a top predictor of HTN remission. HLD and history of stroke may be present in patients who are less likely to have HTN remission.
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Keady SM, Keane MG, Waters SM, Wylie AR, O'Riordan EG, Keogh K, Kenny DA. Effect of dietary restriction and compensatory growth on performance, carcass characteristics, and metabolic hormone concentrations in Angus and Belgian Blue steers. Animal 2021; 15:100215. [PMID: 34030031 DOI: 10.1016/j.animal.2021.100215] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 11/30/2022] Open
Abstract
Compensatory growth (CG) is the ability of an animal to undergo accelerated growth after a period of restricted feeding. However, there is a dearth of information in relation to the effect of genotype on CG response, thus the objective of this study was to evaluate CG response in two contrasting breed types, namely Aberdeen Angus (AN) and Belgian Blue (BB). Crossbred AN × Holstein-Friesian or BB × Holstein-Friesian steers were assigned to one of two treatment groups in a two (genotypes) × two (diets) factorial design. For 99 days, one group (11 AN and 12 BB) was offered a high energy control diet (H-H) whereas the second group (11 AN and 12 BB) was offered an energy restricted diet (L-H). At the end of the differential feeding period (99 days), both groups of animals were then offered a high energy control diet for a further 200 days. All animals were then slaughtered on day-299 of the study. During feed restriction, L-H had lower DM intake (DMI), had greater feed conversion ratio (FCR) and lower plasma concentrations of insulin, IGF-1, leptin, glucose, urea, betahydroxybutyrate and smaller M. longissimus thoracis or lumborum muscle and fat depths compared to H-H steers. During realimentation, there was no difference in DMI between diets; however, L-H had greater live weight gain compared to H-H steers. Overall, H-H consumed greater quantities on a DM basis, however, had a higher FCR compared to L-H steers. By the end of the realimentation period, there was no difference in plasma metabolite or hormone concentrations, linear body measurements, ultrasonically scanned fat depths, carcass conformation, dressing percentage or fat class between H-H and L-H steers. At slaughter, carcass weights were affected by diet with greater values for H-H compared to L-H steers. Genotype affected measures associated with body composition including pelvic width and both muscle and fat depths (P < 0.05). Overall, L-H had a CG (or recovery) index of 0.52 and did not make up for the loss of gains during the differential feeding period; however, M. longissimus thoracis et lumborum, a tissue of high economic value, recovered completely making it a target of interest for further investigation.
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Affiliation(s)
- S M Keady
- Animal and Bioscience Research Department, Animal and Grassland Research and Innovation Centre, Teagasc, Dunsany, Co. Meath, Ireland; Department of Biology, National University of Ireland Maynooth, Co. Kildare, Ireland
| | - M G Keane
- Teagasc, Animal & Grassland Research and Innovation Centre, Grange, Dunsany, Co. Meath, Ireland
| | - S M Waters
- Animal and Bioscience Research Department, Animal and Grassland Research and Innovation Centre, Teagasc, Dunsany, Co. Meath, Ireland
| | - A R Wylie
- Agri-Food and Biosciences Institute, Newforge Lane, Belfast BT9 5PX, Co. Antrim, Northern Ireland, United Kingdom
| | - E G O'Riordan
- Teagasc, Animal & Grassland Research and Innovation Centre, Grange, Dunsany, Co. Meath, Ireland
| | - K Keogh
- Animal and Bioscience Research Department, Animal and Grassland Research and Innovation Centre, Teagasc, Dunsany, Co. Meath, Ireland
| | - D A Kenny
- Animal and Bioscience Research Department, Animal and Grassland Research and Innovation Centre, Teagasc, Dunsany, Co. Meath, Ireland.
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Haddad A, Bocchese M, Garber R, O'Neill B, Yesenosky GA, Patil P, Keane MG, Islam S, Sherrer JM, Basil A, Gangireddy C, Cooper JM, Cronin EM, Whitman IR. Racial and ethnic differences in left atrial appendage occlusion wait time, complications, and periprocedural management. Pacing Clin Electrophysiol 2021; 44:1143-1150. [PMID: 33959994 DOI: 10.1111/pace.14255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/01/2021] [Accepted: 04/11/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE Non-white patients are underrepresented in left atrial appendage occlusion (LAAO) trials, and racial disparities in LAAO periprocedural management are unknown. METHODS We assessed sociodemographics and comorbidities of consecutive patients at our institution undergoing LAAO between 2015 and 2020, then in adjusted analyses, compared procedural wait time, procedural complications, and post-procedure oral anticoagulation (OAC) use in whites versus non-whites. RESULTS Among 109 patients undergoing LAAO (45% white), whites had lower CHA2 DS2 VASc scores, on average, than non-whites (4.0 vs. 4.8, p = .006). There was no difference in median time from index event (IE) or initial outpatient cardiology encounter to LAAO procedure (whites 10.5 vs. non-whites 13.7 months, p = .9; 1.9 vs. 1.8 months, p = .6, respectively), and there was no difference in procedural complications (whites 4% vs. non-whites 5%, p = .33). After adjusting for CHA2 DS2 VASc score, OAC use at discharge tended to be higher in whites (OR 2.4, 95% CI [0.9-6.0], p = .07). When restricting the analysis to those with prior gastrointestinal (GI) bleed, adjusting for CHA2 DS2 VASc score and GI bleed severity, whites had a nearly five-fold odds of being discharged on OAC (OR 4.6, 95% CI [1-21.8], p = 0.05). The association between race and discharge OAC was not mediated through income category (total mediation effect 19% 95% CI [-.04-0.11], p = .38). CONCLUSION Despite an increased prevalence of comorbidities amongst non-whites, wait time for LAAO and procedural complications were similar in whites versus non-whites. Among those with prior GI bleed, whites were nearly five-fold more likely to be discharged on OAC than non-whites, independent of income.
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Affiliation(s)
- Abdullah Haddad
- Sections of Cardiology, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Matthew Bocchese
- Department of Medicine, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Rebecca Garber
- Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Brian O'Neill
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan, USA
| | - George A Yesenosky
- Cardiac Electrophysiology, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Pravin Patil
- Sections of Cardiology, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Martin G Keane
- Sections of Cardiology, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Sabrina Islam
- Sections of Cardiology, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Jacqueline M Sherrer
- Sections of Cardiology, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Anuj Basil
- Cardiac Electrophysiology, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Chethan Gangireddy
- Cardiac Electrophysiology, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Joshua M Cooper
- Cardiac Electrophysiology, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Edmond M Cronin
- Cardiac Electrophysiology, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Isaac R Whitman
- Cardiac Electrophysiology, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
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8
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Lai WW, Galer BS, Wong PC, Farfel G, Pringsheim M, Keane MG, Agarwal A. Cardiovascular safety of fenfluramine in the treatment of Dravet syndrome: Analysis of an ongoing long-term open-label safety extension study. Epilepsia 2020; 61:2386-2395. [PMID: 32809271 PMCID: PMC7754414 DOI: 10.1111/epi.16638] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/16/2020] [Accepted: 07/16/2020] [Indexed: 01/03/2023]
Abstract
Objective Fenfluramine, which was previously approved as a weight loss drug, was withdrawn in 1997 when reports of cardiac valvulopathy emerged. The present study was conducted in part to characterize the cardiovascular safety profile of low‐dose fenfluramine when used in a pediatric population to reduce seizure frequency in patients with Dravet syndrome. Methods Patients 2‐ to 18‐years‐old with Dravet syndrome who had completed any of three randomized, placebo‐controlled clinical trials of fenfluramine were offered enrollment in this open‐label extension (OLE) study. All patients were treated with fenfluramine starting at a dose of 0.2 mg/kg/day (oral solution dosed twice per day), which was titrated to maximal effect with a dose limit of 0.7 mg/kg/day (maximum 26 mg/day) or 0.4 mg/kg/day (maximum 17 mg/day) in patients receiving concomitant stiripentol. Standardized echocardiographic examinations were conducted at Week 4 or 6 and then every 3 months during the OLE study to monitor cardiac valve function and structure and pulmonary artery pressure. The primary end point for the echocardiography analysis was the number of patients who developed valvular heart disease or pulmonary artery hypertension (PAH) during treatment. Results A total of 232 patients were enrolled in the study. The average age of patients was 9.1 ± 4.7 years, and 55.2% were male. The median duration of treatment with fenfluramine was 256 days (range = 58‐634 days), and the mean dose of fenfluramine was 0.41 mg/kg/day. No cases of valvular heart disease or PAH were observed. Significance Longitudinal echocardiography over a median 8.4 months of treatment with fenfluramine suggests a low risk of developing cardiac valvulopathy and PAH when used to treat pediatric patients with Dravet syndrome.
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Affiliation(s)
- Wyman W Lai
- Children's Hospital of Orange County, Orange, CA, USA
| | | | - Pierre C Wong
- Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Milka Pringsheim
- Department of Pediatric Cardiology, German Heart Centre Munich, Munich, Germany.,Pediatric Neurology, Schön Klinik Vogtareuth, Vogtareuth, Germany
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9
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Affiliation(s)
- Martin G Keane
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania.
| | - Susan E Wiegers
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
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10
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Chen CB, Sandhu HS, Keane MG, Dass C, Whitman IR. Dramatic Aneurysmal Atrial Septum Identified with Intracardiac Echo Complicating Transseptal Puncture. CASE 2020; 4:115-118. [PMID: 32577588 PMCID: PMC7303242 DOI: 10.1016/j.case.2019.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Atrial septal aneurysm is a largely underdiagnosed phenomenon. Septal anatomy is best delineated using intracardiac echocardiography. Septal anatomy is clinically relevant with procedures involving transseptal puncture. Atrial septal aneurysms may be associated with supraventricular tachycardias.
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11
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Delfiner MS, Dillane C, Kaoukis R, Haddad A, Schwartz DR, Keane MG. Echocardiographic Changes with Mineralocorticoid Antagonists in Heart Failure. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.07.116] [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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Keane MG, Shamali A, Nilsson LN, Antila A, Millastre Bocos J, Marijinissen Van Zanten M, Verdejo Gil C, Maisonneuve P, Vaalavuo Y, Hoskins T, Robinson S, Ceyhan GO, Abu Hilal M, Pereira SP, Laukkarinen J, Del Chiaro M. Risk of malignancy in resected pancreatic mucinous cystic neoplasms. Br J Surg 2018; 105:439-446. [PMID: 29488646 DOI: 10.1002/bjs.10787] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/12/2017] [Accepted: 11/16/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Pancreatic mucinous cystic neoplasms (MCNs) are rare mucin-producing cystic tumours defined by the presence of ovarian-type stroma. MCNs have a malignant potential and thus surgery is frequently performed. The aim of this cohort study was to define better the criteria for surgical resection in patients with MCN. METHODS This multicentre retrospective study included all resected MCNs between 2003 and 2015 in participating centres. Lesions without ovarian-type stroma were excluded. Patient characteristics, preoperative findings, histopathology findings and follow-up data were recorded. RESULTS The study included 211 patients; their median age was 53 (range 18-82) years, and 202 (95·7 per cent) were women. Median preoperative tumour size was 55 (range 12-230) mm. Thirty-four of the 211 (16·1 per cent) were malignant, and high-grade dysplasia (HGD) was found in a further 13 (6·2 per cent). One-third of MCNs in men were associated with invasive cancer, compared with 15·3 per cent in women. Five cases of malignant transformation occurred in MCNs smaller than 4 cm. All cases of malignancy or HGD were associated with symptoms or features of concern on preoperative cross-sectional imaging. In multivariable analysis, raised carbohydrate antigen 19-9 (odds ratio (OR) 10·54, 95 per cent c.i. 2·85 to 218·23; P < 0·001), tumour size (OR 4·23, 3·02 to 11·03; P = 0·001), mural nodules (OR 3·55, 1·31 to 20·55; P = 0·002) and weight loss (OR 3·40, 2·34 to 12·34; P = 0·034) were independent factors predictive of malignant transformation. CONCLUSIONS Small indeterminate MCNs with no symptoms or features of concern may safely be observed as they have a low risk of malignant transformation.
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Affiliation(s)
- M G Keane
- Institute for Liver and Digestive Health, University College London, London
| | - A Shamali
- Department of Surgery, Southampton University Hospital, Southampton, UK
| | - L N Nilsson
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - A Antila
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - J Millastre Bocos
- Department of Gastroenterology, Miguel Servet University Hospital, Zaragoza, Spain
| | | | - C Verdejo Gil
- Department of Gastroenterology, Ciudad Real University Hospital, Ciudad Real, Spain
| | | | - Y Vaalavuo
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - T Hoskins
- Department of Hepato-Pancreato-Biliary Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - S Robinson
- Department of Hepato-Pancreato-Biliary Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - G O Ceyhan
- Surgical Clinic, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - M Abu Hilal
- Department of Surgery, Southampton University Hospital, Southampton, UK
| | - S P Pereira
- Institute for Liver and Digestive Health, University College London, London
| | - J Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - M Del Chiaro
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
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13
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Bansal N, Roy J, Chen HY, Deo R, Dobre M, Fischer MJ, Foster E, Go AS, He J, Keane MG, Kusek JW, Mohler E, Navaneethan SD, Rahman M, Hsu CY. Evolution of Echocardiographic Measures of Cardiac Disease From CKD to ESRD and Risk of All-Cause Mortality: Findings From the CRIC Study. Am J Kidney Dis 2018; 72:390-399. [PMID: 29784617 DOI: 10.1053/j.ajkd.2018.02.363] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 02/24/2018] [Indexed: 12/21/2022]
Abstract
RATIONALE & OBJECTIVE Abnormal cardiac structure and function are common in chronic kidney disease (CKD) and end-stage renal disease (ESRD) and linked with mortality and heart failure. We examined changes in echocardiographic measures during the transition from CKD to ESRD and their associations with post-ESRD mortality. STUDY DESIGN Prospective study. SETTING & PARTICIPANTS We studied 417 participants with CKD in the Chronic Renal Insufficiency Cohort (CRIC) who had research echocardiograms during CKD and ESRD. PREDICTOR We measured change in left ventricular mass index, left ventricular ejection fraction (LVEF), diastolic relaxation (normal, mildly abnormal, and moderately/severely abnormal), left ventricular end-systolic (LVESV), end-diastolic (LVEDV) volume, and left atrial volume from CKD to ESRD. OUTCOMES All-cause mortality after dialysis therapy initiation. ANALYTICAL APPROACH Cox proportional hazard models were used to test the association of change in each echocardiographic measure with postdialysis mortality. RESULTS Over a mean of 2.9 years between pre- and postdialysis echocardiograms, there was worsening of mean LVEF (52.5% to 48.6%; P<0.001) and LVESV (18.6 to 20.2mL/m2.7; P<0.001). During this time, there was improvement in left ventricular mass index (60.4 to 58.4g/m2.7; P=0.005) and diastolic relaxation (11.11% to 4.94% with moderately/severely abnormal; P=0.02). Changes in left atrial volume (4.09 to 4.15mL/m2; P=0.08) or LVEDV (38.6 to 38.4mL/m2.7; P=0.8) were not significant. Worsening from CKD to ESRD of LVEF (adjusted HR for every 1% decline in LVEF, 1.03; 95% CI, 1.00-1.06) and LVESV (adjusted HR for every 1mL/m2.7 increase, 1.04; 95% CI, 1.02-1.07) were independently associated with greater risk for postdialysis mortality. LIMITATIONS Some missing or technically inadequate echocardiograms. CONCLUSIONS In a longitudinal study of patients with CKD who subsequently initiated dialysis therapy, LVEF and LVESV worsened and were significantly associated with greater risk for postdialysis mortality. There may be opportunities for intervention during this transition period to improve outcomes.
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Affiliation(s)
| | - Jason Roy
- University of Pennsylvania, Philadelphia, PA
| | | | - Rajat Deo
- University of Pennsylvania, Philadelphia, PA
| | - Mirela Dobre
- Case Western Reserve University, University Hospitals Cleveland Medical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH
| | - Michael J Fischer
- Center of Innovation for Complex Chronic Healthcare, Edward Hines VA Hospital and Jesse Brown VAMC And University of Illinois at Chicago, Chicago, IL
| | - Elyse Foster
- University of California, San Francisco, San Francisco, CA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland; University of California, San Francisco, San Francisco, CA
| | - Jiang He
- Tulane University, New Orleans, LA
| | | | - John W Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | | | - Mahboob Rahman
- Case Western Reserve University, University Hospitals Cleveland Medical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH
| | - Chi-Yuan Hsu
- Division of Research, Kaiser Permanente Northern California, Oakland; University of California, San Francisco, San Francisco, CA
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Schoonjans AS, Marchau F, Paelinck BP, Lagae L, Gammaitoni A, Pringsheim M, Keane MG, Ceulemans B. Cardiovascular safety of low-dose fenfluramine in Dravet syndrome: a review of its benefit-risk profile in a new patient population. Curr Med Res Opin 2017; 33:1773-1781. [PMID: 28704161 DOI: 10.1080/03007995.2017.1355781] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Dravet syndrome (DS) is a rare, treatment-resistant epilepsy syndrome for which current treatment regimens are often ineffective. Fenfluramine is currently in development for treatment of DS, based on reports in the 1980s and 1990s of its anti-epileptic activity in pediatric patients with intractable epilepsy. However, fenfluramine was withdrawn from global markets in 1997 following reports of its association with pulmonary hypertension and heart valve disease in adult patients treated for obesity. This review was conducted to assess cardiac safety of fenfluramine when used at lower doses for treatment of DS. METHODS Pubmed was searched for clinical studies of fenfluramine in obese adults who reported incidence of heart valve disease. These data were reviewed against published results from Belgian patients with DS who have been treated with low-dose fenfluramine for up to 28 years. RESULTS Nine controlled studies of fenfluramine and related compounds (dexfenfluramine and/or phentermine) which assessed incidence and severity of cardiac valve disease in 3,268 treated patients and 2,017 control subjects have been reported. Mild or greater aortic valve regurgitation was found in 9.6% of treated patients compared with 3.9% of control subjects, and moderate or greater mitral valve regurgitation was found in 3.1% of treated patients and 2.5% of control subjects. Nineteen DS patients have been treated for up to 28 years with 10-20 mg/day fenfluramine, with no clinical signs or symptoms of cardiac valve disease or pulmonary hypertension. Slight and clinically unimportant changes in valve structure have been seen on echocardiography in five patients at some time during the observation period. CONCLUSIONS A different benefit-risk relationship appears to be emerging when fenfluramine is used at low doses for extended periods in young patients with DS. Continued cardiac assessments during ongoing Phase 3 clinical trials will provide additional safety information for this potential new and effective treatment.
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Affiliation(s)
- An-Sofie Schoonjans
- a Department of Paediatric Neurology , Antwerp University Hospital, University of Antwerp , Antwerp , Belgium
| | - Fabienne Marchau
- b Department of Paediatric Cardiology , Antwerp University Hospital, University of Antwerp , Antwerp , Belgium
| | - Bernard P Paelinck
- c Department of Cardiology , Antwerp University Hospital, University of Antwerp , Antwerp , Belgium
| | - Lieven Lagae
- d Department of Development and Regeneration , Section of Paediatric Neurology, University Hospitals Gasthuisberg , Leuven , Belgium
| | | | - Milka Pringsheim
- f Department of Pediatric Cardiology , German Heart Centre Munich , Munich , Germany
- g Pediatric Neurology, Schön Klinik Vogtareuth , Vogtareuth , Germany
| | | | - Berten Ceulemans
- a Department of Paediatric Neurology , Antwerp University Hospital, University of Antwerp , Antwerp , Belgium
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15
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Raza F, Dillane C, Mirza A, Brailovsky Y, Weaver S, Keane MG, Forfia P. Differences in right ventricular morphology, not function, indicate the nature of increased afterload in pulmonary hypertensive subjects with normal left ventricular function. Echocardiography 2017; 34:1584-1592. [PMID: 28942616 DOI: 10.1111/echo.13699] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [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: 02/01/2023] Open
Abstract
BACKGROUND The aim of study was to assess whether a specific morphology of the right ventricle (RV) by 2D echo predicts the hemodynamic nature of pulmonary hypertension (PH). METHODS We reviewed clinical, 2D echo, and hemodynamic data of 100 patients with PH: divided into three groups: PH from pulmonary vascular disease (PHPVD ; n = 34) with pulmonary vascular resistance (PVR) > 3 mm Hg/L/min (Wood unit [WU]) and pulmonary artery wedge pressure (PAWP) ≤ 15 mm Hg, pulmonary venous hypertension (PVH; n = 33) with PVR < 3 WU and PAWP > 15 mm Hg and PHMIXED (n = 33) with PVR > 3 WU and PAWP > 15 mm Hg. We analyzed several two-dimensional parameters of right heart morphology and function, including the degree of tapering of the RV diameter from base (just above tricuspid annulus) to apex (level of moderator band) in the apical four-chamber view. P = <.05. RESULTS Baseline characteristics were similar in all three groups: age 62 ± 14.4 years, 69% females, 57% Caucasians. Hemodynamics and 2D echo data of PHPVD vs PVH vs PHMIXED were as follows: PVR 13 ± 6 vs 2 ± 1 vs 7 ± 2 WU, mean pulmonary artery pressure 53 ± 14 vs 34 ± 8 vs 49 ± 8 mm Hg and cardiac index 2.0 ± 0.5 vs 2.8 ± 0.7 vs 2.2 ± 0.7 L/m2 , RV base/apex ratio during systole (sRVb/a ) 1.3 ± 0.2 vs 2.6 ± 0.5 vs 1.5 ± 0.3. Thus, sRVb/a was twofold higher in the PVH vs PHPVD cohort. On ROC analysis, the AUC for sRVb/a for predicting PVR > 3 WU was 0.873, with optimal cutoff of 1.5. CONCLUSION Systolic RV base/apex ratio is a simple 2D index of RV shape that powerfully predicts a PVR > 3 WU and provides powerful discriminating ability between PVH and PHPVD .
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Affiliation(s)
- Farhan Raza
- Heart and Vascular Institute, Temple University Hospital, Philadelphia, PA, USA
| | - Catherine Dillane
- Heart and Vascular Institute, Temple University Hospital, Philadelphia, PA, USA
| | - Arslan Mirza
- Heart and Vascular Institute, Temple University Hospital, Philadelphia, PA, USA
| | - Yevgeniy Brailovsky
- Center for Heart and Vascular Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Sheila Weaver
- Temple Lung Center, Temple University Hospital, Philadelphia, PA, USA
| | - Martin G Keane
- Heart and Vascular Institute, Temple University Hospital, Philadelphia, PA, USA
| | - Paul Forfia
- Heart and Vascular Institute, Temple University Hospital, Philadelphia, PA, USA
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16
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Raza F, Vaidya A, Lacharite-Roberge AS, Lakhter V, Al-Maluli H, Ahsan I, Boodram P, Dass C, Rogers F, Keane MG, Weaver S, Bashir R, Toyoda Y, Forfia P. Initial clinical and hemodynamic results of a regional pulmonary thromboendarterectomy program. J Cardiovasc Surg (Torino) 2017; 59:428-437. [PMID: 28870062 DOI: 10.23736/s0021-9509.17.10188-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pulmonary thromboendarterectomy (PTE) is the treatment of choice for eligible patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, access to CTEPH and PTE care is limited. There is a paucity of published data on PTE efficacy and outcomes from alternative, regional centers of excellence in CTEPH and PTE care in the USA, outside a single national and international referral center. METHODS We performed a retrospective review of patients undergoing PTE at our institution from June 2013 to December 2016 (42 months), and collected clinical, echocardiographic and hemodynamic data on our patients pre- and post-PTE (N.=71). RESULTS Patients age ranged between 20-83 years (mean±SD: 56±16), with 54% of patients female and 61% Caucasians. The predominant symptom was shortness of breath with a median duration of symptoms of 17 months. Following PTE, clinical improvements included a reduction in NYHA class from 3.1±1.1 to 2.2±1.2. There were major improvements in hemodynamics and echocardiographic parameters pre- versus post-PTE: mean pulmonary artery pressure (mmHg) 45±11 to 24±8, cardiac index (L/min/m2) 2.1±0.5 to 2.8±0.5, pulmonary vascular resistance (mmHg/L/min) 8.9±4.5 to 2.8±1.8, ratio of right ventricle (RV): left ventricle (LV) 1.2±0.3 to 0.9±0.2, RV fractional area change (%) 23±14 to 44±13, reduction in the incidence of RV outflow tract Doppler notching and improved pulmonary artery acceleration time (96% to 30%, and 74±19 to 111±21). In-hospital mortality was 4.2% (3 patients). CONCLUSIONS Herein, we report for the first time, the improvements in patient functionality, hemodynamics, right heart function and outcomes at a major regional PTE program.
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Affiliation(s)
- Farhan Raza
- Heart and Vascular Institute, Temple University Hospital, Philadelphia, PA, USA
| | - Anjali Vaidya
- Heart and Vascular Institute, Temple University Hospital, Philadelphia, PA, USA
| | | | - Vladimir Lakhter
- Heart and Vascular Institute, Temple University Hospital, Philadelphia, PA, USA
| | - Hayan Al-Maluli
- Heart and Vascular Institute, Temple University Hospital, Philadelphia, PA, USA
| | - Irfan Ahsan
- Department of Medicine, Abington Memorial Hospital, Philadelphia, PA, USA
| | - Pamela Boodram
- Temple University School of Medicine, Philadelphia, PA, USA
| | - Chandra Dass
- Department of Radiology, Temple University Hospital, Philadelphia, PA, USA
| | - Frances Rogers
- Heart and Vascular Institute, Temple University Hospital, Philadelphia, PA, USA
| | - Martin G Keane
- Heart and Vascular Institute, Temple University Hospital, Philadelphia, PA, USA
| | - Sheila Weaver
- Temple Lung Center, Temple University Hospital, Philadelphia, PA, USA
| | - Riyaz Bashir
- Heart and Vascular Institute, Temple University Hospital, Philadelphia, PA, USA
| | - Yoshiya Toyoda
- Department of Cardiovascular Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Paul Forfia
- Heart and Vascular Institute, Temple University Hospital, Philadelphia, PA, USA -
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Ahmad FS, Cai X, Kunkel K, Ricardo AC, Lash JP, Raj DS, He J, Anderson AH, Budoff MJ, Wright Nunes JA, Roy J, Wright JT, Go AS, St. John Sutton MG, Kusek JW, Isakova T, Wolf M, Keane MG. Racial/Ethnic Differences in Left Ventricular Structure and Function in Chronic Kidney Disease: The Chronic Renal Insufficiency Cohort. Am J Hypertens 2017; 30:822-829. [PMID: 28444108 DOI: 10.1093/ajh/hpx058] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 03/20/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is associated with increased risk of cardiovascular disease (CVD) and it is especially common among Blacks. Left ventricular hypertrophy (LVH) is an important subclinical marker of CVD, but there are limited data on racial variation in left ventricular structure and function among persons with CKD. METHODS In a cross-sectional analysis of the Chronic Renal Insufficiency Cohort Study, we compared the prevalence of different types of left ventricular remodeling (concentric hypertrophy, eccentric hypertrophy, and concentric remodeling) by race/ethnicity. We used multinomial logistic regression to test whether race/ethnicity associated with different types of left ventricular remodeling independently of potential confounding factors. RESULTS We identified 1,164 non-Hispanic Black and 1,155 non-Hispanic White participants who completed Year 1 visits with echocardiograms that had sufficient data to categorize left ventricular geometry type. Compared to non-Hispanic Whites, non-Hispanic Blacks had higher mean left ventricular mass index (54.7 ± 14.6 vs. 47.4 ± 12.2 g/m2.7; P < 0.0001) and prevalence of concentric LVH (45.8% vs. 24.9%). In addition to higher systolic blood pressure and treatment with >3 antihypertensive medications, Black race/ethnicity was independently associated with higher odds of concentric LVH compared to White race/ethnicity (odds ratio: 2.73; 95% confidence interval: 2.02, 3.69). CONCLUSION In a large, diverse cohort with CKD, we found significant differences in left ventricular mass and hypertrophic morphology between non-Hispanic Blacks and Whites. Future studies will evaluate whether higher prevalence of LVH contribute to racial/ethnic disparities in cardiovascular outcomes among CKD patients.
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Affiliation(s)
- Faraz S. Ahmad
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Xuan Cai
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Katherine Kunkel
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ana C. Ricardo
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - James P. Lash
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Dominic S. Raj
- Department of Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Los Angeles, USA
| | - Amanda H. Anderson
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Matthew J. Budoff
- Los Angeles Biomedical Research Institute, Torrance, California, USA
| | | | - Jason Roy
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jackson T. Wright
- Department of Medicine, Case Western University School of Medicine, Cleveland, Ohio, USA
| | - Alan S. Go
- Kaiser Permanente Northern California Division of Research, Oakland, California, USA
- Departments of Epidemiology and Biostatistics and Department of Medicine, University of California School of Medicine, San Francisco, San Francisco, California, USA
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California, USA
| | - Martin G. St. John Sutton
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - John W. Kusek
- Division of Kidney, Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Tamara Isakova
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Myles Wolf
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Martin G. Keane
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
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Bansal N, Xie D, Tao K, Chen J, Deo R, Horwitz E, Hsu CY, Kallem RK, Keane MG, Lora CM, Raj D, Soliman EZ, Strauss L, Wolf M, Go AS. Atrial Fibrillation and Risk of ESRD in Adults with CKD. Clin J Am Soc Nephrol 2016; 11:1189-1196. [PMID: 27073197 PMCID: PMC4934846 DOI: 10.2215/cjn.10921015] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [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: 10/14/2015] [Accepted: 03/08/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Atrial fibrillation frequently complicates CKD and is associated with adverse outcomes. Progression to ESRD is a major complication of CKD, but the link with atrial fibrillation has not been fully delineated. In this study, we examined the association of incident atrial fibrillation with the risk of ESRD in patients with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We studied participants in the prospective Chronic Renal Insufficiency Cohort Study without atrial fibrillation at entry. Incident atrial fibrillation was identified by study visit ECGs, self-report, and hospital discharge diagnostic codes, with confirmation by physician adjudication. ESRD through 2012 was ascertained by participant self-report, medical records, and linkage to the US Renal Data System. Data on potential confounders were obtained from self-report, study visits, and laboratory tests. Marginal structural models were used to study the potential association of incident atrial fibrillation with risk of ESRD after adjustment for time-dependent confounding. RESULTS Among 3091 participants, 172 (5.6%) developed incident atrial fibrillation during follow-up. During mean follow-up of 5.9 years, 43 patients had ESRD that occurred after development of incident atrial fibrillation (11.8/100 person-years) compared with 581 patients without incident atrial fibrillation (3.4/100 person-years). In marginal structural models with inverse probability weighting, incident atrial fibrillation was associated with a substantially higher rate of ESRD (hazard ratio, 3.2; 95% confidence interval, 1.9 to 5.2). This association was consistent across important subgroups by age, sex, race, diabetes status, and baseline eGFR. CONCLUSIONS Incident atrial fibrillation was associated with higher risk of developing ESRD in CKD. Additional study is needed to identify potentially modifiable pathways through which atrial fibrillation was associated with a higher risk of progression to ESRD. More aggressive monitoring and treatment of patients with CKD and atrial fibrillation may improve outcomes in this high-risk population.
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Affiliation(s)
- Nisha Bansal
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Mills KT, Chen J, Yang W, Appel LJ, Kusek JW, Alper A, Delafontaine P, Keane MG, Mohler E, Ojo A, Rahman M, Ricardo AC, Soliman EZ, Steigerwalt S, Townsend R, He J. Sodium Excretion and the Risk of Cardiovascular Disease in Patients With Chronic Kidney Disease. JAMA 2016; 315:2200-10. [PMID: 27218629 PMCID: PMC5087595 DOI: 10.1001/jama.2016.4447] [Citation(s) in RCA: 158] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Patients with chronic kidney disease (CKD) are at an increased risk of cardiovascular disease (CVD) compared with the general population. Prior studies have produced contradictory results on the association of dietary sodium intake with risk of CVD, and this relationship has not been investigated in patients with CKD. OBJECTIVE To evaluate the association between urinary sodium excretion and clinical CVD events among patients with CKD. DESIGN, SETTING, AND PARTICIPANTS A prospective cohort study of patients with CKD from 7 locations in the United States enrolled in the Chronic Renal Insufficiency Cohort Study and followed up from May 2003 to March 2013. EXPOSURES The cumulative mean of urinary sodium excretion from three 24-hour urinary measurements and calibrated to sex-specific mean 24-hour urinary creatinine excretion. MAIN OUTCOMES AND MEASURES A composite of CVD events defined as congestive heart failure, stroke, or myocardial infarction. Events were reported every 6 months and confirmed by medical record adjudication. RESULTS Among 3757 participants (mean age, 58 years; 45% women), 804 composite CVD events (575 heart failure, 305 myocardial infarction, and 148 stroke) occurred during a median 6.8 years of follow-up. From lowest (<2894 mg/24 hours) to highest (≥4548 mg/24 hours) quartile of calibrated sodium excretion, 174, 159, 198, and 273 composite CVD events occurred, and the cumulative incidence was 18.4%, 16.5%, 20.6%, and 29.8% at median follow-up. In addition, the cumulative incidence of CVD events in the highest quartile of calibrated sodium excretion compared with the lowest was 23.2% vs 13.3% for heart failure, 10.9% vs 7.8% for myocardial infarction, and 6.4% vs 2.7% for stroke at median follow-up. Hazard ratios of the highest quartile compared with the lowest quartile were 1.36 (95% CI, 1.09-1.70; P = .007) for composite CVD events, 1.34 (95% CI, 1.03-1.74; P = .03) for heart failure, and 1.81 (95% CI, 1.08-3.02; P = .02) for stroke after multivariable adjustment. Restricted cubic spline analyses of the association between sodium excretion and composite CVD provided no evidence of a nonlinear association (P = .11) and indicated a significant linear association (P < .001). CONCLUSIONS AND RELEVANCE Among patients with CKD, higher urinary sodium excretion was associated with increased risk of CVD.
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Affiliation(s)
- Katherine T Mills
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Jing Chen
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana2Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | - Wei Yang
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Lawrence J Appel
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
| | - John W Kusek
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Arnold Alper
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | - Patrice Delafontaine
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | - Martin G Keane
- Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Emile Mohler
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Akinlolu Ojo
- Department of Medicine, University of Michigan, Ann Arbor
| | - Mahboob Rahman
- Division of Nephrology and Hypertension, Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, Ohio10Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
| | - Ana C Ricardo
- Department of Medicine, University of Illinois at Chicago, Chicago
| | - Elsayed Z Soliman
- Department of Internal Medicine-Cardiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | - Raymond Townsend
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana2Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
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20
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Drawz PE, Alper AB, Anderson AH, Brecklin CS, Charleston J, Chen J, Deo R, Fischer MJ, He J, Hsu CY, Huan Y, Keane MG, Kusek JW, Makos GK, Miller ER, Soliman EZ, Steigerwalt SP, Taliercio JJ, Townsend RR, Weir MR, Wright JT, Xie D, Rahman M. Masked Hypertension and Elevated Nighttime Blood Pressure in CKD: Prevalence and Association with Target Organ Damage. Clin J Am Soc Nephrol 2016; 11:642-52. [PMID: 26912547 DOI: 10.2215/cjn.08530815] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 01/04/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Masked hypertension and elevated nighttime BP are associated with increased risk of hypertensive target organ damage and adverse cardiovascular and renal outcomes in patients with normal kidney function. The significance of masked hypertension for these risks in patients with CKD is less well defined. The objective of this study was to evaluate the association between masked hypertension and kidney function and markers of cardiovascular target organ damage, and to determine whether this relationship was consistent among those with and without elevated nighttime BP. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This was a cross-sectional study. We performed 24-hour ambulatory BP in 1492 men and women with CKD enrolled in the Chronic Renal Insufficiency Cohort Study. We categorized participants into controlled BP, white-coat, masked, and sustained hypertension on the basis of clinic and 24-hour ambulatory BP. We obtained echocardiograms and measured pulse wave velocity in 1278 and 1394 participants, respectively. RESULTS The percentages of participants with controlled BP, white-coat, masked, and sustained hypertension were 49.3%, 4.1%, 27.8%, and 18.8%, respectively. Compared with controlled BP, masked hypertension independently associated with low eGFR (-3.2 ml/min per 1.73 m(2); 95% confidence interval, -5.5 to -0.9), higher proteinuria (+0.9 unit higher in log2 urine protein; 95% confidence interval, 0.7 to 1.1), and higher left ventricular mass index (+2.52 g/m(2.7); 95% confidence interval, 0.9 to 4.1), and pulse wave velocity (+0.92 m/s; 95% confidence interval, 0.5 to 1.3). Participants with masked hypertension had lower eGFR only in the presence of elevated nighttime BP (-3.6 ml/min per 1.73 m(2); 95% confidence interval, -6.1 to -1.1; versus -1.4 ml/min per 1.73 m(2); 95% confidence interval, -6.9 to 4.0, among those with nighttime BP <120/70 mmHg; P value for interaction with nighttime systolic BP 0.002). CONCLUSIONS Masked hypertension is common in patients with CKD and associated with lower eGFR, proteinuria, and cardiovascular target organ damage. In patients with CKD, ambulatory BP characterizes the relationship between BP and target organ damage better than BP measured in the clinic alone.
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Jais B, Rebours V, Malleo G, Salvia R, Fontana M, Maggino L, Bassi C, Manfredi R, Moran R, Lennon AM, Zaheer A, Wolfgang C, Hruban R, Marchegiani G, Fernández Del Castillo C, Brugge W, Ha Y, Kim MH, Oh D, Hirai I, Kimura W, Jang JY, Kim SW, Jung W, Kang H, Song SY, Kang CM, Lee WJ, Crippa S, Falconi M, Gomatos I, Neoptolemos J, Milanetto AC, Sperti C, Ricci C, Casadei R, Bissolati M, Balzano G, Frigerio I, Girelli R, Delhaye M, Bernier B, Wang H, Jang KT, Song DH, Huggett MT, Oppong KW, Pererva L, Kopchak KV, Del Chiaro M, Segersvard R, Lee LS, Conwell D, Osvaldt A, Campos V, Aguero Garcete G, Napoleon B, Matsumoto I, Shinzeki M, Bolado F, Fernandez JMU, Keane MG, Pereira SP, Acuna IA, Vaquero EC, Angiolini MR, Zerbi A, Tang J, Leong RW, Faccinetto A, Morana G, Petrone MC, Arcidiacono PG, Moon JH, Choi HJ, Gill RS, Pavey D, Ouaïssi M, Sastre B, Spandre M, De Angelis CG, Rios-Vives MA, Concepcion-Martin M, Ikeura T, Okazaki K, Frulloni L, Messina O, Lévy P. Serous cystic neoplasm of the pancreas: a multinational study of 2622 patients under the auspices of the International Association of Pancreatology and European Pancreatic Club (European Study Group on Cystic Tumors of the Pancreas). Gut 2016; 65:305-12. [PMID: 26045140 DOI: 10.1136/gutjnl-2015-309638] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 05/11/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Serous cystic neoplasm (SCN) is a cystic neoplasm of the pancreas whose natural history is poorly known. The purpose of the study was to attempt to describe the natural history of SCN, including the specific mortality. DESIGN Retrospective multinational study including SCN diagnosed between 1990 and 2014. RESULTS 2622 patients were included. Seventy-four per cent were women, and median age at diagnosis was 58 years (16-99). Patients presented with non-specific abdominal pain (27%), pancreaticobiliary symptoms (9%), diabetes mellitus (5%), other symptoms (4%) and/or were asymptomatic (61%). Fifty-two per cent of patients were operated on during the first year after diagnosis (median size: 40 mm (2-200)), 9% had resection beyond 1 year of follow-up (3 years (1-20), size at diagnosis: 25 mm (4-140)) and 39% had no surgery (3.6 years (1-23), 25.5 mm (1-200)). Surgical indications were (not exclusive) uncertain diagnosis (60%), symptoms (23%), size increase (12%), large size (6%) and adjacent organ compression (5%). In patients followed beyond 1 year (n=1271), size increased in 37% (growth rate: 4 mm/year), was stable in 57% and decreased in 6%. Three serous cystadenocarcinomas were recorded. Postoperative mortality was 0.6% (n=10), and SCN's related mortality was 0.1% (n=1). CONCLUSIONS After a 3-year follow-up, clinical relevant symptoms occurred in a very small proportion of patients and size slowly increased in less than half. Surgical treatment should be proposed only for diagnosis remaining uncertain after complete workup, significant and related symptoms or exceptionally when exists concern with malignancy. This study supports an initial conservative management in the majority of patients with SCN. TRIAL REGISTRATION NUMBER IRB 00006477.
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Affiliation(s)
- B Jais
- Department of Gastroenterology and Pancreatology, Beaujon Hospital, AP-HP, Clichy, France
| | - V Rebours
- Department of Gastroenterology and Pancreatology, Beaujon Hospital, AP-HP, Clichy, France
| | - G Malleo
- The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - R Salvia
- The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - M Fontana
- The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - L Maggino
- The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - C Bassi
- The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - R Manfredi
- The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, Verona, Italy
| | - R Moran
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Division of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A M Lennon
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Division of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A Zaheer
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Division of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - C Wolfgang
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Division of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - R Hruban
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Division of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - G Marchegiani
- Departments of Surgery and Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - C Fernández Del Castillo
- Departments of Surgery and Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - W Brugge
- Departments of Surgery and Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Y Ha
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - M H Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - D Oh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - I Hirai
- First Department of Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - W Kimura
- First Department of Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - J Y Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - S W Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - W Jung
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - H Kang
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - S Y Song
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - C M Kang
- Department of Surgery, Yonsei University College of Medicine, Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - W J Lee
- Department of Surgery, Yonsei University College of Medicine, Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - S Crippa
- Pancreatic Surgery Unit, Department of Surgery, Polytechnic University of Marche Region, Ancona-Torrette, Italy
| | - M Falconi
- Pancreatic Surgery Unit, Department of Surgery, Polytechnic University of Marche Region, Ancona-Torrette, Italy
| | - I Gomatos
- NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, Royal Liverpool University Hospital, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - J Neoptolemos
- NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, Royal Liverpool University Hospital, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - A C Milanetto
- Department of Surgery, Oncology and Gastroenterology, 3rd Surgical Clinic, University of Padua, Padua, Italy
| | - C Sperti
- Department of Surgery, Oncology and Gastroenterology, 3rd Surgical Clinic, University of Padua, Padua, Italy
| | - C Ricci
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - R Casadei
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - M Bissolati
- Pancreatic Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - G Balzano
- Pancreatic Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - I Frigerio
- Hepato-Pancreato-Biliary Unit, Pederzoli Hospital, Peschiera del Garda, Italy
| | - R Girelli
- Hepato-Pancreato-Biliary Unit, Pederzoli Hospital, Peschiera del Garda, Italy
| | - M Delhaye
- Department of Gastroenterology, Hepatopancreatology and GI Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - B Bernier
- Department of Gastroenterology, Hepatopancreatology and GI Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - H Wang
- Institute of Hepatopancreatobiliary Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - K T Jang
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - D H Song
- Department of Pathology, Gyeongsang National University School of Medicine, Jinju, Korea
| | - M T Huggett
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - K W Oppong
- Hepato-Pancreato-Biliary Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - L Pererva
- National Institute of Surgery and Transplantology named after Shalimov, Kiev, Ukraine
| | - K V Kopchak
- National Institute of Surgery and Transplantology named after Shalimov, Kiev, Ukraine
| | - M Del Chiaro
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - R Segersvard
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - L S Lee
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - D Conwell
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - A Osvaldt
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - V Campos
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - B Napoleon
- Hôpital Privé Mermoz, Gastroentérologie, Lyon, France
| | - I Matsumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - M Shinzeki
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - F Bolado
- Gastroenterology Department, Hospital de Navarra, Pamplona, Spain
| | | | - M G Keane
- Department of Gastroenterology and Hepatology, University College Hospital, London, UK
| | - S P Pereira
- Department of Gastroenterology and Hepatology, University College Hospital, London, UK
| | - I Araujo Acuna
- Department of Gastroenterology, Hospital Clinic, CIBEREHD, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - E C Vaquero
- Department of Gastroenterology, Hospital Clinic, CIBEREHD, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - M R Angiolini
- Department of Pancreatic Surgery, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - A Zerbi
- Department of Pancreatic Surgery, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - J Tang
- Gastroenterology and Liver Services, Concord Hospital, Sydney, New South Wales, Australia
| | - R W Leong
- Gastroenterology and Liver Services, Concord Hospital, Sydney, New South Wales, Australia
| | - A Faccinetto
- Radiological Department, General Hospital Cá Foncello, Treviso, Italy
| | - G Morana
- Radiological Department, General Hospital Cá Foncello, Treviso, Italy
| | - M C Petrone
- Division of Gastroenterology and Gastrointestinal Endoscopy, San Raffaele Scientific Institute, Milan, Italy
| | - P G Arcidiacono
- Division of Gastroenterology and Gastrointestinal Endoscopy, San Raffaele Scientific Institute, Milan, Italy
| | - J H Moon
- Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - H J Choi
- Department of Internal Medicine, Digestive Disease Center and Research Institute, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - R S Gill
- Department of Gastroenterology, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
| | - D Pavey
- Department of Gastroenterology, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
| | - M Ouaïssi
- Department of Digestive Surgery, Timone Hospital, Marseille, France
| | - B Sastre
- Department of Digestive Surgery, Timone Hospital, Marseille, France
| | - M Spandre
- Gastrohepatology Department, San Giovanni Battista Molinette Hospital, University of Turin, Turin, Italy
| | - C G De Angelis
- Gastrohepatology Department, San Giovanni Battista Molinette Hospital, University of Turin, Turin, Italy
| | - M A Rios-Vives
- Gastroenterology Department, Hospital de la Santa Creu i Sant Pau, Institut de Reçerca-IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M Concepcion-Martin
- Gastroenterology Department, Hospital de la Santa Creu i Sant Pau, Institut de Reçerca-IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - T Ikeura
- The Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - K Okazaki
- The Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - L Frulloni
- Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - O Messina
- Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - P Lévy
- Department of Gastroenterology and Pancreatology, Beaujon Hospital, AP-HP, Clichy, France
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Al Maluli H, Mathur M, Keane MG, Guy TS, Dries D, Edmundowicz D. Multiple Septal Coronary-Cameral Fistulae after Septal Myectomy. Echocardiography 2015; 32:1736-7. [PMID: 26059090 DOI: 10.1111/echo.12989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Hayan Al Maluli
- Department of Medicine, Section of Cardiology, Temple University Hospital, Philadelphia, Pennsylvania
| | - Moses Mathur
- Department of Medicine, Section of Cardiology, Temple University Hospital, Philadelphia, Pennsylvania
| | - Martin G Keane
- Department of Medicine, Section of Cardiology, Temple University Hospital, Philadelphia, Pennsylvania
| | - T Sloane Guy
- Department of Surgery, Division of Cardiovascular Surgery, Temple University Hospital, Philadelphia, Pennsylvania
| | - Daniel Dries
- Department of Medicine, Section of Cardiology, Temple University Hospital, Philadelphia, Pennsylvania
| | - Daniel Edmundowicz
- Department of Medicine, Section of Cardiology, Temple University Hospital, Philadelphia, Pennsylvania
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Guerraty MA, Chai B, Hsu JY, Ojo AO, Gao Y, Yang W, Keane MG, Budoff MJ, Mohler ER. Relation of aortic valve calcium to chronic kidney disease (from the Chronic Renal Insufficiency Cohort Study). Am J Cardiol 2015; 115:1281-6. [PMID: 25791240 DOI: 10.1016/j.amjcard.2015.02.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 02/03/2015] [Accepted: 02/03/2015] [Indexed: 10/24/2022]
Abstract
Although subjects with chronic kidney disease (CKD) are at markedly increased risk for cardiovascular mortality, the relation between CKD and aortic valve calcification has not been fully elucidated. Also, few data are available on the relation of aortic valve calcification and earlier stages of CKD. We sought to assess the relation of aortic valve calcium (AVC) with estimated glomerular filtration rate (eGFR), traditional and novel cardiovascular risk factors, and markers of bone metabolism in the Chronic Renal Insufficiency Cohort (CRIC) Study. All patients who underwent aortic valve scanning in the CRIC study were included. The relation between AVC and eGFR, traditional and novel cardiovascular risk factors, and markers of calcium metabolism were analyzed using both unadjusted and adjusted regression models. A total of 1,964 CRIC participants underwent computed tomography for AVC quantification. Decreased renal function was independently associated with increased levels of AVC (eGFR 47.11, 44.17, and 39 ml/min/1.73 m2, respectively, p<0.001). This association persisted after adjusting for traditional, but not novel, AVC risk factors. Adjusted regression models identified several traditional and novel risk factors for AVC in patients with CKD. There was a difference in AVC risk factors between black and nonblack patients. In conclusion, our study shows that eGFR is associated in a dose-dependent manner with AVC in patients with CKD, and this association is independent of traditional cardiovascular risk factors.
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Gupta J, Dominic EA, Fink JC, Ojo AO, Barrows IR, Reilly MP, Townsend RR, Joffe MM, Rosas SE, Wolman M, Patel SS, Keane MG, Feldman HI, Kusek JW, Raj DS. Association between Inflammation and Cardiac Geometry in Chronic Kidney Disease: Findings from the CRIC Study. PLoS One 2015; 10:e0124772. [PMID: 25909952 PMCID: PMC4409366 DOI: 10.1371/journal.pone.0124772] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 03/08/2015] [Indexed: 01/27/2023] Open
Abstract
Background Left ventricular hypertrophy (LVH) and myocardial contractile dysfunction are independent predictors of mortality in patients with chronic kidney disease (CKD). The association between inflammatory biomarkers and cardiac geometry has not yet been studied in a large cohort of CKD patients with a wide range of kidney function. Methods Plasma levels of interleukin (IL)-1β, IL-1 receptor antagonist (IL-1RA), IL-6, tumor necrosis factor (TNF)-α, transforming growth factor (TGF)-β, high-sensitivity C-Reactive protein (hs-CRP), fibrinogen and serum albumin were measured in 3,939 Chronic Renal Insufficiency Cohort study participants. Echocardiography was performed according to the recommendations of the American Society of Echocardiography and interpreted at a centralized core laboratory. Results LVH, systolic dysfunction and diastolic dysfunction were present in 52.3%, 11.8% and 76.3% of the study subjects, respectively. In logistic regression analysis adjusted for age, sex, race/ethnicity, diabetic status, current smoking status, systolic blood pressure, urinary albumin- creatinine ratio and estimated glomerular filtration rate, hs-CRP (OR 1.26 [95% CI 1.16, 1.37], p<0.001), IL-1RA (1.23 [1.13, 1.34], p<0.0001), IL-6 (1.25 [1.14, 1.36], p<0.001) and TNF-α (1.14 [1.04, 1.25], p = 0.004) were associated with LVH. The odds for systolic dysfunction were greater for subjects with elevated levels of hs-CRP (1.32 [1.18, 1.48], p<0.001) and IL-6 (1.34 [1.21, 1.49], p<0.001). Only hs-CRP was associated with diastolic dysfunction (1.14 [1.04, 1.26], p = 0.005). Conclusion In patients with CKD, elevated plasma levels of hs-CRP and IL-6 are associated with LVH and systolic dysfunction.
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Affiliation(s)
- Jayanta Gupta
- Department of Biomedical Sciences, Texas Tech University Health Sciences Center, El Paso, Texas, United States of America
| | - Elizabeth A. Dominic
- The George Washington University School of Medicine, Washington, DC, United States of America
| | - Jeffrey C. Fink
- Division of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Akinlolu O. Ojo
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Ian R. Barrows
- The George Washington University School of Medicine, Washington, DC, United States of America
| | - Muredach P. Reilly
- Cardiovascular Institute, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Raymond R. Townsend
- Renal and Electrolyte Division, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Marshall M. Joffe
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Sylvia E. Rosas
- Joslyn Diabetic Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Melanie Wolman
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Samir S. Patel
- Division of Renal Diseases and Hypertension, The George Washington University, Washington, DC, United States of America
| | - Martin G. Keane
- Department of Medicine, Temple University, Philadelphia, Pennsylvania, United States of America
| | - Harold I. Feldman
- Renal and Electrolyte Division, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - John W. Kusek
- Division of Kidney, Urologic, and Hematologic Diseases, The National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, United States of America
| | - Dominic S. Raj
- Division of Renal Diseases and Hypertension, The George Washington University, Washington, DC, United States of America
- * E-mail:
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Douglas PS, Hahn RT, Pibarot P, Weissman NJ, Stewart WJ, Xu K, Wang Z, Lerakis S, Siegel R, Thompson C, Gopal D, Keane MG, Svensson LG, Tuzcu EM, Smith CR, Leon MB. Hemodynamic Outcomes of Transcatheter Aortic Valve Replacement and Medical Management in Severe, Inoperable Aortic Stenosis: A Longitudinal Echocardiographic Study of Cohort B of the PARTNER Trial. J Am Soc Echocardiogr 2015; 28:210-7.e1-9. [DOI: 10.1016/j.echo.2014.10.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Indexed: 10/24/2022]
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Abstract
OBJECTIVES Pancreatic ductal adenocarcinoma (PDAC) and biliary tract cancers (BTC) are often diagnosed late and at an advanced stage. Population-based screening programmes do not exist and diagnosis is primarily dependent on symptom recognition. Recently symptom-based cancer decision support tools (CDSTs) have been introduced into primary care practices throughout the UK to support general practitioners (GPs) in identifying patients with suspected PDAC. However, future refinement of these tools to improve their diagnostic accuracy is likely to be necessary. SETTING The Health Improvement Network (THIN) is a primary care database, which includes more than 11 million electronic patient records, from 562 GP practices in the UK. PARTICIPANTS All patients with a diagnosis of PDAC or BTC between 2000 and 2010 were included in the study along with six matched controls; 2773 patients with PDAC, 848 patients with BTC and 15,395 controls. PRIMARY AND SECONDARY OUTCOME MEASURES The primary aim of this study was to determine the early symptom profiles of PDAC and BTC. Secondary aims included comparing early symptom trends between BTC and PDAC, defining symptom onset in PDAC and evaluating trends in routine blood tests nearest to the time of diagnosis. RESULTS In the year prior to diagnosis, patients with PDAC visited their GP on a median of 18 (IQR 11-27) occasions. PDAC was associated with 11 alarm symptoms and BTC with 8. Back pain (OR 1.33 (95% CI 1.18 to 1.49) p<0.001), lethargy (1.42 (95% CI 1.25 to 1.62) p<0.001) and new onset diabetes (OR 2.46 (95% CI 2.16 to 2.80)) were identified as unique features of PDAC. CONCLUSIONS PDAC and BTC are associated with numerous early alarm symptoms. CDSTs are therefore likely to be useful in identifying these tumours at an early stage. Inclusion of unique symptoms, symptoms with an early onset and routinely performed blood tests is likely to further improve the sensitivity of these tools.
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Affiliation(s)
- M G Keane
- Institute for Liver and Digestive Health, University College London, London, UK
| | - L Horsfall
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - G Rait
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - S P Pereira
- Institute for Liver and Digestive Health, University College London, London, UK
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Deo R, Yang W, Khan AM, Bansal N, Zhang X, Leonard MB, Keane MG, Soliman EZ, Steigerwalt S, Townsend RR, Shlipak MG, Feldman HI. Serum aldosterone and death, end-stage renal disease, and cardiovascular events in blacks and whites: findings from the Chronic Renal Insufficiency Cohort (CRIC) Study. Hypertension 2014; 64:103-10. [PMID: 24752431 DOI: 10.1161/hypertensionaha.114.03311] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [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: 01/13/2023]
Abstract
Prior studies have demonstrated that elevated aldosterone concentrations are an independent risk factor for death in patients with cardiovascular disease. Limited studies, however, have evaluated systematically the association between serum aldosterone and adverse events in the setting of chronic kidney disease. We investigated the association between serum aldosterone and death and end-stage renal disease in 3866 participants from the Chronic Renal Insufficiency Cohort. We also evaluated the association between aldosterone and incident congestive heart failure and atherosclerotic events in participants without baseline cardiovascular disease. Cox proportional hazards models were used to evaluate independent associations between elevated aldosterone concentrations and each outcome. Interactions were hypothesized and explored between aldosterone and sex, race, and the use of loop diuretics and renin-angiotensin-aldosterone system inhibitors. During a median follow-up period of 5.4 years, 587 participants died, 743 developed end-stage renal disease, 187 developed congestive heart failure, and 177 experienced an atherosclerotic event. Aldosterone concentrations (per SD of the log-transformed aldosterone) were not an independent risk factor for death (adjusted hazard ratio, 1.00; 95% confidence interval, 0.93-1.12), end-stage renal disease (adjusted hazard ratio, 1.07; 95% confidence interval, 0.99-1.17), or atherosclerotic events (adjusted hazard ratio, 1.04; 95% confidence interval, 0.85-1.18). Aldosterone was associated with congestive heart failure (adjusted hazard ratio, 1.21; 95% confidence interval, 1.02-1.35). Among participants with chronic kidney disease, higher aldosterone concentrations were independently associated with the development of congestive heart failure but not for death, end-stage renal disease, or atherosclerotic events. Further studies should evaluate whether mineralocorticoid receptor antagonists may reduce adverse events in individuals with chronic kidney disease because elevated cortisol levels may activate the mineralocorticoid receptor.
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Affiliation(s)
- Rajat Deo
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.).
| | - Wei Yang
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Abigail M Khan
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Nisha Bansal
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Xiaoming Zhang
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Mary B Leonard
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Martin G Keane
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Elsayed Z Soliman
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Susan Steigerwalt
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Raymond R Townsend
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Michael G Shlipak
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
| | - Harold I Feldman
- From the Department of Medicine, Division of Cardiovascular Medicine (R.D., A.M.K.) and Department of Medicine, The Renal Electrolyte and Hypertension Division (R.R.T.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Clinical Epidemiology and Biostatistics and the Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.Y., X.Z., M.B.L., H.I.F.); Department of Medicine, Division of Nephrology, University of Washington, Seattle (N.B.); Division of Nephrology, The Children's Hospital of Philadelphia, PA (M.B.L.); Division of Cardiovascular Medicine, Temple University, Philadelphia, PA (M.G.K.); Epidemiological Cardiology Research Center (E.Z.S.), Department of Epidemiology and Prevention (E.Z.S.), and Department of Internal Medicine, Cardiology Section (E.Z.S.), Wake Forest University School of Medicine, Winston Salem, NC; Division of Nephrology and Hypertension, St John Hospital and Medical Center, Detroit, MI (S.S.); Department of Medicine, Epidemiology and Biostatistics, University of California, San Francisco (M.G.S.); and Department of General Internal Medicine, San Francisco VA Medical Center, CA (M.G.S.)
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Abstract
Cholangiocarcinoma (CC) is a rare cancer arising from the epithelium of the biliary tree, anywhere from the small peripheral hepatic ducts to the distal common bile duct. Classification systems for CC typically group tumours by anatomical location into intrahepatic, hilar or extrahepatic subtypes. Surgical resection or liver transplantation remains the only curative therapy for CC, but up to 80% of patients present with advanced, irresectable disease. Unresectable CC remains resistant to many chemotherapeutic agents, although gemcitabine, particularly in combination with other agents, has been shown to improve overall survival. Ongoing investigation of biological agents has also yielded some promising results. Several novel interventional and endoscopic techniques for the diagnosis and management of non-operable CC have been developed: initial results show improvements in symptoms and progression-free survival, but further randomised studies are required to establish their role in the management of CC.
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Affiliation(s)
- J R A Skipworth
- Department of Surgery and Interventional Science, University College London, London, UK
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Ky B, Shults J, Keane MG, Sutton MSJ, Wolf M, Feldman HI, Reese PP, Anderson CA, Townsend RR, Deo R, Lo J, Gadegbeku C, Carlow D, Sulik MJ, Leonard MB. FGF23 modifies the relationship between vitamin D and cardiac remodeling. Circ Heart Fail 2013; 6:817-24. [PMID: 23748358 DOI: 10.1161/circheartfailure.112.000105] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND There is growing evidence to support an important role for vitamin D and related hormones, parathyroid hormone and fibroblast growth factor 23 (FGF23), on cardiac remodeling in chronic kidney disease. Our objective was to determine the relationships between vitamin D and cardiac remodeling in chronic kidney disease and the effects of parathyroid hormone and FGF23 on these associations. METHODS AND RESULTS In 1431 participants from the Chronic Renal Insufficiency Cohort study, we measured 25-hydroxyvitamin D (25(OH)D), 1,25-dihydroxyvitamin D (1,25(OH)2D), FGF23, and parathyroid hormone and performed quantitative echocardiography. Using linear regression methods, we determined significant negative interactions between 25(OH)D and FGF23 on left ventricular (LV) mass (P=0.016), end-diastolic volume (P=0.029), and end-systolic volumes (P=0.021). In participants with an FGF23 level greater than the median of 123.5 RU/mL, each doubling of 25(OH)D was associated with a 2.5% (95% confidence interval, -4.8, -0.2) lower LV mass. This association was less pronounced with FGF23 levels less than the median (0.4%; 95% confidence interval, -1.9, 2.7). Conversely, in participants with deficient 25(OH)D levels <20 ng/mL, each doubling of FGF23 was associated with a 3.4% (95% confidence interval, 1.2, 5.6) greater LV mass compared with only a 1.6% (95% confidence interval, -0.2, 3.5) difference in participants with sufficient 25(OH)D. Similar findings were observed with 25(OH)D and volumes (P<0.05), and 1,25(OH)2D and LV mass and volumes (P<0.005). There was no effect modification by parathyroid hormone. CONCLUSIONS We identified significant interactions among 25(OH)D, 1,25(OH)2D, and FGF23 on cardiac remodeling. Increased LV mass and cavity dilatation were observed with low 25(OH)D and high FGF23. Our findings suggest that consideration of both hormones is crucial to understanding the role of either in cardiac remodeling, and may have important therapeutic implications.
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Affiliation(s)
- Bonnie Ky
- Renal Division, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Hahn RT, Pibarot P, Stewart WJ, Weissman NJ, Gopalakrishnan D, Keane MG, Anwaruddin S, Wang Z, Bilsker M, Lindman BR, Herrmann HC, Kodali SK, Makkar R, Thourani VH, Svensson LG, Akin JJ, Anderson WN, Leon MB, Douglas PS. Comparison of transcatheter and surgical aortic valve replacement in severe aortic stenosis: a longitudinal study of echocardiography parameters in cohort A of the PARTNER trial (placement of aortic transcatheter valves). J Am Coll Cardiol 2013; 61:2514-21. [PMID: 23623915 DOI: 10.1016/j.jacc.2013.02.087] [Citation(s) in RCA: 182] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 02/14/2013] [Accepted: 02/18/2013] [Indexed: 01/16/2023]
Abstract
OBJECTIVES This study sought to compare echocardiographic findings in patients with critical aortic stenosis following surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). BACKGROUND The PARTNER (Placement of Aortic Transcatheter Valves) trial randomized patients 1:1 to SAVR or TAVR. METHODS Echocardiograms were obtained at baseline, discharge, 30 days, 6 months, 1 year, and 2 years after the procedure and analyzed in a core laboratory. For the analysis of post-implantation variables, the first interpretable study (≤6 months) was used. RESULTS Both groups showed a decrease in aortic valve gradients and increase in effective orifice area (EOA) (p < 0.0001), which remained stable over 2 years. Compared with SAVR, TAVR resulted in larger indexed EOA (p = 0.038), less prosthesis-patient mismatch (p = 0.019), and more total and paravalvular aortic regurgitation (p < 0.0001). Baseline echocardiographic univariate predictors of death were lower peak transaortic gradient in TAVR patients, and low left ventricular diastolic volume, low stroke volume, and greater severity of mitral regurgitation in SAVR patients. Post-implantation echocardiographic univariate predictors of death were: larger left ventricular diastolic volume, left ventricular systolic volume and EOA, decreased ejection fraction, and greater aortic regurgitation in TAVR patients; and smaller left ventricular systolic and diastolic volumes, low stroke volume, smaller EOA, and prosthesis-patient mismatch in SAVR patients. CONCLUSIONS Patients randomized to either SAVR or TAVR experience enduring, significant reductions in transaortic gradients and increase in EOA. Compared with SAVR, TAVR patients had higher indexed EOA, lower prosthesis-patient mismatch, and more aortic regurgitation. Univariate predictors of death for the TAVR and SAVR groups differed and might allow future refinement in patient selection. (THE PARTNER TRIAL: Placement of AoRTic TraNscathetER Valve Trial; NCT00530894).
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Affiliation(s)
- Rebecca T Hahn
- NYP Columbia Heart Valve Center, Columbia University Medical Center, New York, New York 10032, USA.
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Keady SM, Kenny DA, Ohlendieck K, Doyle S, Keane MG, Waters SM. Proteomic profiling of bovine M. longissimus lumborum from Crossbred Aberdeen Angus and Belgian Blue sired steers varying in genetic merit for carcass weight. J Anim Sci 2013; 91:654-65. [PMID: 23307841 DOI: 10.2527/jas.2012-5850] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Bovine skeletal muscle is a tissue of significant value to the beef industry and global economy. Proteomic analyses offer the opportunity to detect molecular mechanisms regulating muscle growth and intramuscular fat accumulation. The current study aimed to investigate differences in protein abundance in skeletal muscle tissue of cattle from two breeds of contrasting maturity (early vs. late maturing), adiposity, and muscle growth potential, namely, Belgian Blue (BB) × Holstein Friesian and Aberdeen Angus (AA) × Holstein Friesian. Twenty AA (n = 10) and BB (n = 10) sired steers, the progeny of sires of either high or low genetic merit, expressed as expected progeny difference for carcass weight (EPDcwt), and bred through AI, were evaluated as 4 genetic groups, BB-High, BB-Low, AA-High, and AA-Low (n = 5 per treatment). Chemical composition analysis of M. longissimus lumborum showed greater protein and moisture and decreased lipid concentrations for BB-sired compared with AA-sired steers. To investigate the effects of both sire breed and EPDcwt on M. longissimus lumborum, proteomic analysis was performed using 2-dimensional difference gel electrophoresis followed by mass spectrometry. Proteins were identified from their peptide sequences, using the National Center for Biotechnology Information (NCBI) and Swiss-prot databases. Metabolic enzymes involved in glycolysis (glycogen phosphorylase, phosphoglycerate mutase) and the citric acid cycle (aconitase 2, oxoglutarate dehydrogenase) were increased in AA- vs. BB-sired steers. Expression of proteins involved in cell structure, such as myosin light chain isoforms and troponins I and T, were also altered due to sire breed. Furthermore, heat shock protein β-1 and peroxiredoxin 6, involved in cell defense, had increased abundance in muscle of AA-sired relative to BB-sired steers. Protein abundance of glucose-6-phosphate isomerase, enolase-3, and pyruvate kinase was greater in AA-sired animals of High compared with Low EPDcwt. Changes in the expression of these proteins were supported by gene expression analysis using quantitative real-time PCR. This information will aid in our understanding of genetic influences controlling muscle growth and fat accumulation and could contribute to future breeding programs to increase lean tissue gain of beef cattle.
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Affiliation(s)
- Sarah M Keady
- Animal and Bioscience Research Department, Animal and Grassland Research and Innovation Centre, Teagasc, Dunsany, Co. Meath, Ireland
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Ky B, Plappert T, Kirkpatrick J, Silvestry FE, Ferrari VA, Keane MG, Wiegers SE, Chirinos JA, St. John Sutton M. Continuing Medical Education Activity in Echocardiography. Echocardiography 2012. [DOI: 10.1111/j.1540-8175.2012.01805.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
| | - Ted Plappert
- Division of Cardiovascular Medicine; University of Pennsylvania School of Medicine; Philadelphia; Pennsylvania
| | - James Kirkpatrick
- Division of Cardiovascular Medicine; University of Pennsylvania School of Medicine; Philadelphia; Pennsylvania
| | - Frank E. Silvestry
- Division of Cardiovascular Medicine; University of Pennsylvania School of Medicine; Philadelphia; Pennsylvania
| | - Victor A. Ferrari
- Division of Cardiovascular Medicine; University of Pennsylvania School of Medicine; Philadelphia; Pennsylvania
| | - Martin G. Keane
- Division of Cardiovascular Medicine; University of Pennsylvania School of Medicine; Philadelphia; Pennsylvania
| | - Susan E. Wiegers
- Division of Cardiovascular Medicine; University of Pennsylvania School of Medicine; Philadelphia; Pennsylvania
| | - Julio A. Chirinos
- Division of Cardiovascular Medicine; University of Pennsylvania School of Medicine; Philadelphia; Pennsylvania
| | - Martin St. John Sutton
- Division of Cardiovascular Medicine; University of Pennsylvania School of Medicine; Philadelphia; Pennsylvania
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Ky B, Plappert T, Kirkpatrick J, Silvestry FE, Ferrari VA, Keane MG, Wiegers SE, Chirinos JA, St John Sutton M. Left ventricular remodeling in human heart failure: quantitative echocardiographic assessment of 1,794 patients. Echocardiography 2012; 29:758-65. [PMID: 22497559 DOI: 10.1111/j.1540-8175.2012.01701.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The left ventricle (LV) undergoes significant architectural remodeling in heart failure (HF). However, the fundamental associations between cardiac function and LV size and performance have not been thoroughly characterized in this population. We sought to define the adaptive remodeling that occurs in chronic human HF through the detailed analyses of a large quantitative echocardiography database. METHODS Baseline echocardiograms were performed in 1,794 patients with HF across a broad range of ejection fraction (EF), from less than 10% to greater than 70%. Core lab measurements of LV volumes and length were made, from which EF, mass, sphericity indices, stroke volume (SV), and stroke work were derived. Spearman correlation coefficients and linear regression methods were used to determine the relationships between remodeling parameters. RESULTS The median EF was 28.6% (IQR 21.9-37.0). Across a multitude of parameters of cardiac structure and function, indexed end-systolic volumes (ESVs) explained the greatest proportion of the variance in EF (R =-0.87, P < 0.0001). Systolic sphericity index and LV mass were also strongly correlated with EF (R =-0.62 and -0.63, P < 0.0001), reflective of the alterations in LV shape and size that occur as EF declines. SV was rigorously maintained across a broad spectrum of EF, until the EF fell below 20%, at which point SV decreased significantly (P < 0.0001). CONCLUSIONS In chronic HF, the LV undergoes extensive structural adaptive remodeling in order to maintain SV across a broad range of EF. However, when the EF falls below 20%, further modulation of SV is no longer possible through alterations in ventricular architecture.
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Affiliation(s)
- Bonnie Ky
- Division of Cardiovascular Medicine Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Ricardo AC, Lash JP, Fischer MJ, Lora CM, Budoff M, Keane MG, Kusek JW, Martinez M, Nessel L, Stamos T, Ojo A, Rahman M, Soliman EZ, Yang W, Feldman HI, Go AS. Cardiovascular disease among hispanics and non-hispanics in the chronic renal insufficiency cohort (CRIC) study. Clin J Am Soc Nephrol 2012; 6:2121-31. [PMID: 21896829 DOI: 10.2215/cjn.11341210] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Hispanics are the largest minority group in the United States. The leading cause of death in patients with chronic kidney disease (CKD) is cardiovascular disease (CVD), yet little is known about its prevalence among Hispanics with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted cross-sectional analyses of prevalent self-reported clinical and subclinical measures of CVD among 497 Hispanics, 1638 non-Hispanic Caucasians, and 1650 non-Hispanic African Americans, aged 21 to 74 years, with mild-to-moderate CKD at enrollment in the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic CRIC (HCRIC) studies. Measures of subclinical CVD included left ventricular hypertrophy (LVH), coronary artery calcification (CAC), and ankle-brachial index. RESULTS Self-reported coronary heart disease (CHD) was lower in Hispanics compared with non-Hispanic Caucasians (18% versus 23%, P = 0.02). Compared with non-Hispanic Caucasians, Hispanics had a lower prevalence of CAC >100 (41% versus 34%, P = 0.03) and CAC >400 (26% versus 19%, P = 0.02). However, after adjusting for sociodemographic factors, these differences were no longer significant. In adjusted analyses, Hispanics had a higher odds of LVH compared with non-Hispanic Caucasians (odds ratio 1.97, 95% confidence interval, 1.22 to 3.17, P = 0.005), and a higher odds of CAC >400 compared with non-Hispanic African Americans (odds ratio, 2.49, 95% confidence interval, 1.11 to 5.58, P = 0.03). Hispanic ethnicity was not independently associated with any other CVD measures. CONCLUSIONS Prevalent LVH was more common among Hispanics than non-Hispanic Caucasians, and elevated CAC score was more common among Hispanics than non-Hispanic African Americans. Understanding reasons for these racial/ethnic differences and their association with long-term clinical outcomes is needed.
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Affiliation(s)
- Ana C Ricardo
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
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Faul C, Amaral AP, Oskouei B, Hu MC, Sloan A, Isakova T, Gutiérrez OM, Aguillon-Prada R, Lincoln J, Hare JM, Mundel P, Morales A, Scialla J, Fischer M, Soliman EZ, Chen J, Go AS, Rosas SE, Nessel L, Townsend RR, Feldman HI, St John Sutton M, Ojo A, Gadegbeku C, Di Marco GS, Reuter S, Kentrup D, Tiemann K, Brand M, Hill JA, Moe OW, Kuro-O M, Kusek JW, Keane MG, Wolf M. FGF23 induces left ventricular hypertrophy. J Clin Invest 2011; 121:4393-408. [PMID: 21985788 DOI: 10.1172/jci46122] [Citation(s) in RCA: 1441] [Impact Index Per Article: 110.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 08/25/2011] [Indexed: 12/11/2022] Open
Abstract
Chronic kidney disease (CKD) is a public health epidemic that increases risk of death due to cardiovascular disease. Left ventricular hypertrophy (LVH) is an important mechanism of cardiovascular disease in individuals with CKD. Elevated levels of FGF23 have been linked to greater risks of LVH and mortality in patients with CKD, but whether these risks represent causal effects of FGF23 is unknown. Here, we report that elevated FGF23 levels are independently associated with LVH in a large, racially diverse CKD cohort. FGF23 caused pathological hypertrophy of isolated rat cardiomyocytes via FGF receptor-dependent activation of the calcineurin-NFAT signaling pathway, but this effect was independent of klotho, the coreceptor for FGF23 in the kidney and parathyroid glands. Intramyocardial or intravenous injection of FGF23 in wild-type mice resulted in LVH, and klotho-deficient mice demonstrated elevated FGF23 levels and LVH. In an established animal model of CKD, treatment with an FGF-receptor blocker attenuated LVH, although no change in blood pressure was observed. These results unveil a klotho-independent, causal role for FGF23 in the pathogenesis of LVH and suggest that chronically elevated FGF23 levels contribute directly to high rates of LVH and mortality in individuals with CKD.
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Affiliation(s)
- Christian Faul
- Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA.
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Llano R, Winsor-Hines D, Patel DB, Seifert PS, Hamamdzic D, Wilson GJ, Wang H, Keane MG, Huibregtse BA, Wilensky RL. Vascular responses to drug-eluting and bare metal stents in diabetic/hypercholesterolemic and nonatherosclerotic porcine coronary arteries. Circ Cardiovasc Interv 2011; 4:438-46. [PMID: 21972400 DOI: 10.1161/circinterventions.110.959957] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Animal models used to gain insight into the vascular response to drug-eluting stents are generally juvenile and nonatherosclerotic, whereas stents are placed in patients with complex atherosclerosis and comorbidities. Hence, models reflecting these complexities are needed to help elucidate the vascular effects of drug-eluting stents. We compared the vascular responses with bare metal stent (BMS) and paclitaxel-eluting stent (PES) implantation in a diabetic/hypercholesterolemic (DM/HC) porcine model of advanced coronary atherosclerosis with the standard juvenile porcine model. METHODS AND RESULTS Two studies using similar stent procedural protocols were performed in either DM/HC (n=20) or domestic swine (non-DM/HC, n=20). Animals pretreated with dual-antiplatelet therapy, underwent BMS or PES implantation (1/artery, 2 stents per animal) and were euthanized 30 or 90 days later. DM/HC resulted in a 24% increase in platelet aggregation (P=0.05 versus baseline), whereas dual-antiplatelet therapy reduced platelet aggregation in both groups (P<0.0001). DM/HC pigs developed substantially greater neointimal area versus non-DM/HC pigs, regardless of stent type, (P=0.004 for BMS at 30 days and P=0.002 at 90 days, P=0.005 for PES at 30 days, P=0.002 at 90 days). Compared with non-DM/HC pigs, reendothelialization was delayed in DM/HC pigs, more so after PES implantation. Increased para-strut leukocytes were observed for PES compared with BMS in the DM/HC pigs at both 30 days (P=0.023) and 90 days (P=0.04). As well, increased T-lymphocyte infiltration was seen in the DM/HC pigs. CONCLUSIONS Stent implantation in a DM/HC swine model provides a metabolic environment closer to human disease, including hyperglycemia, hypercholesterolemia, and increased platelet aggregation. This model augmented differences in the vascular response between PES and BMS that are not as clearly evident in the non-DM/HC swine, including increased neointimal area, delayed reendothelialization, and greater, persistent vascular inflammation.
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Affiliation(s)
- Raul Llano
- Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA 19104, USA
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Zamorano JL, Badano LP, Bruce C, Chan KL, Gonçalves A, Hahn RT, Keane MG, La Canna G, Monaghan MJ, Nihoyannopoulos P, Silvestry FE, Vanoverschelde JL, Gillam LD. EAE/ASE Recommendations for the Use of Echocardiography in New Transcatheter Interventions for Valvular Heart Disease. J Am Soc Echocardiogr 2011; 24:937-65. [DOI: 10.1016/j.echo.2011.07.003] [Citation(s) in RCA: 167] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Zamorano JL, Badano LP, Bruce C, Chan KL, Gonçalves A, Hahn RT, Keane MG, La Canna G, Monaghan MJ, Nihoyannopoulos P, Silvestry FE, Vanoverschelde JL, Gillam LD. EAE/ASE recommendations for the use of echocardiography in new transcatheter interventions for valvular heart disease. Eur Heart J 2011; 32:2189-214. [PMID: 21885465 DOI: 10.1093/eurheartj/ehr259] [Citation(s) in RCA: 245] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Keady SM, Kenny DA, Keane MG, Waters SM. Effect of sire breed and genetic merit for carcass weight on the transcriptional regulation of the somatotropic axis in longissimus dorsi of crossbred steers. J Anim Sci 2011; 89:4007-16. [PMID: 21724946 DOI: 10.2527/jas.2011-4032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The somatotropic axis plays an important role in postnatal growth, development, and differentiation of skeletal muscle. The aim of this study was to examine the effect of sire breed and sire EPD for carcass weight (EPD(cwt)) on the expression of components of the somatotropic axis in LM of beef cattle at slaughter. Crossbred Aberdeen Angus (AA; n = 17) and Belgian Blue (BB; n = 16) steers born to Holstein-Friesian dams and sired by bulls with either high (H) or low (L) EPD(cwt) were used in the study. Thus, there were 4 genetic groups [i.e., BBH (n = 8), BBL (n = 8), AAH (n = 8), and AAL (n = 9)]. Blood samples were collected via jugular venipuncture at regular intervals for analysis of plasma concentrations of IGF-1 and insulin. Total RNA was isolated from LM collected at slaughter, and the mRNA expression of IGF-1, IGF-2, their receptors (IGF-1R; IGF-2R), 6 IGFBP, acid labile subunit (ALS), and GH receptor (GHR) was measured by real-time reverse-transcription quantitative PCR. There was no effect of either sire breed or EPD(cwt) on concentrations of circulating IGF or insulin (P > 0.05). Gene expression of IGF-1R and IGFBP3 was upregulated in AA (P < 0.001) compared with BB, whereas IGF-1 was upregulated in H compared with L animals (P < 0.01). Correlation analysis indicated moderate positive associations between gene expression of IGFBP3 and IGF-1 (r = 0.54; P < 0.001) and IGF-1R (r = 0.48; P < 0.01). In addition, correlation analysis revealed that mRNA expression of IGFBP3 was moderately negatively associated with LM area per kilogram of carcass weight (r = -0.40; P < 0.05). Greater gene expression of IGF-1 and reduced transcript abundance of IGFBP3 in muscle may have a role in increased muscle growth potential in steers during the finishing period. These data will contribute to a better understanding of the molecular control of muscle growth at a tissue level in cattle.
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Affiliation(s)
- S M Keady
- Animal and Bioscience Research Department, Animal and Grassland Research and Innovation Centre, Teagasc, Dunsany, Co. Meath, Ireland
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Ogbara J, Logani S, Ky B, Chirinos JA, Silvestry FE, Eberman K, Moss JD, Ferrari VA, Keane MG, John Sutton MS, Wiegers SE, Kirkpatrick JN. The Utility of Prescreening Transesophageal Echocardiograms: A Prospective Study. Echocardiography 2011; 28:767-73. [DOI: 10.1111/j.1540-8175.2011.01421.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Hamamdzic D, Fenning RS, Patel D, Mohler ER, Orlova KA, Wright AC, Llano R, Keane MG, Shannon RP, Birnbaum MJ, Wilensky RL. Akt pathway is hypoactivated by synergistic actions of diabetes mellitus and hypercholesterolemia resulting in advanced coronary artery disease. Am J Physiol Heart Circ Physiol 2010; 299:H699-706. [PMID: 20601459 DOI: 10.1152/ajpheart.00071.2010] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [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: 12/31/2022]
Abstract
Atherosclerosis is an inflammatory process leading to enhanced cellular proliferation, apoptosis, and vasa vasorum (VV) neovascularization. While both diabetes mellitus (DM) and hypercholesterolemia (HC) predispose to atherosclerosis, the precise interaction of these risk factors is unclear. Akt is a central node in signaling pathways important for inflammation, and we hypothesized that DM/HC would lead to aberrant Akt signaling and advanced, complex atherosclerosis. DM was induced in pigs by streptozotocin and HC by a high-fat diet. Animals were randomized to control (non-DM, non-HC), DM only, HC only, and DM/HC groups. Coronary artery homogenates were analyzed by immunoblotting for proteins involved in the Akt pathway, including phosphorylated (p)-Akt (Ser473), p-GSK-3beta (Ser9), activated NF-kappaB p65, and VEGF. Immunohistochemical staining for Ki67 (cell proliferation), terminal deoxynucleotidyltransferase-mediated dUTP nick end labeling (TUNEL) (apoptosis), and von Willebrand factor (vWF) (neovascularization) was performed. Neovascularization was visualized with micro-computerized tomography (CT). Only DM/HC animals developed advanced atherosclerosis and showed decreased p-Akt (Ser473) and p-GSK-3beta (Ser9) levels (P < 0.01 and P < 0.05, respectively). DM/HC arteries demonstrated increased cellular proliferation (P < 0.001), apoptosis (P < 0.01), and activation of NF-kappaB p65 (P < 0.05). Induction of DM/HC also resulted in significant VV neovascularization by enhanced VEGF expression (P < 0.05), increased vWF staining (P < 0.01), and increased density by micro-CT. In conclusion, DM and HC synergistically resulted in complex atherosclerosis associated with attenuated p-Akt (Ser473) levels. Aberrant Akt signaling correlated with increased inflammation, cellular proliferation, apoptosis, and VV neovascularization. Our results revealed a synergistic effect of DM and HC in triggering abnormal Akt signaling, resulting in advanced atherosclerosis.
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Affiliation(s)
- Damir Hamamdzic
- Cardiovascular Division, Hospital of University of Pennsylvania and Cardiovascular Institute, University of Pennsylvania 19104, USA
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Testani JM, Khera AV, St. John Sutton MG, Keane MG, Wiegers SE, Shannon RP, Kirkpatrick JN. Effect of right ventricular function and venous congestion on cardiorenal interactions during the treatment of decompensated heart failure. Am J Cardiol 2010; 105:511-6. [PMID: 20152246 DOI: 10.1016/j.amjcard.2009.10.020] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Revised: 10/11/2009] [Accepted: 10/11/2009] [Indexed: 02/09/2023]
Abstract
Recent reports have demonstrated the adverse effects of venous congestion on renal function (RF) and challenged the assumption that worsening RF is driven by decreased cardiac output (CO). We hypothesized that diuresis in patients with right ventricular (RV) dysfunction, despite decreased CO, would lead to a decrease in venous congestion and resultant improvement in RF. We reviewed consecutive admissions with a discharge diagnosis of heart failure. RV function was assessed by multiple echocardiographic methods and those with >or=2 measurements of RV dysfunction were considered to have significant RV dysfunction. Worsening RF was defined as an increase in creatinine of >or=0.3 mg/dl and improved RF as improvement in glomerular filtration rate >or=25%. A total of 141 admissions met eligibility criteria; 34% developed worsening RF. Venous congestion was more common in those with RV dysfunction (odds ratio [OR] 3.3, p = 0.009). All measurements of RV dysfunction excluding RV dilation correlated with CO (p <0.05). Significant RV dysfunction predicted a lower incidence of worsening RF (OR 0.21, p <0.001) and a higher incidence of improved RF (OR 6.4, p <0.001). CO emerged as a significant predictor of change in glomerular filtration rate during hospitalization in those without significant RV dysfunction (r = 0.38, p <0.001). In conclusion, RV dysfunction is a strong predictor of improved renal outcomes in patients with acute decompensated heart failure, an effect likely mediated by relief of venous congestion.
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Chirinos JA, Segers P, Raina A, Saif H, Swillens A, Gupta AK, Townsend R, Emmi AG, Kirkpatrick JN, Keane MG, Ferrari VA, Wiegers SE, St John Sutton MG. Arterial pulsatile hemodynamic load induced by isometric exercise strongly predicts left ventricular mass in hypertension. Am J Physiol Heart Circ Physiol 2009; 298:H320-30. [PMID: 19966060 DOI: 10.1152/ajpheart.00334.2009] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Although resting hemodynamic load has been extensively investigated as a determinant of left ventricular (LV) hypertrophy, little is known about the relationship between provoked hemodynamic load and the risk of LV hypertrophy. We studied central pressure-flow relations among 40 hypertensive and 19 normotensive adults using carotid applanation tonometry and Doppler echocardiography at rest and during a 40% maximal voluntary forearm contraction (handgrip) maneuver. Carotid-femoral pulse wave velocity (CF-PWV) was measured at rest. Hypertensive subjects demonstrated various abnormalities in resting and induced pulsatile load. Isometric exercise significantly increased systemic vascular resistance, aortic characteristic impedance (Zc), induced earlier wave reflections, increased augmentation index, and decreased total arterial compliance (TAC; all P < or = 0.01). In hypertensive subjects, CF-PWV was the strongest resting predictor of LV mass index (LVMI) and remained an independent predictor after adjustment for age, gender, systemic vascular resistance, reflection magnitude, aortic Zc, and TAC (beta = 2.52 m/s; P < 0.0001). Age, sex, CF-PWV, and resting hemodynamic indexes explained 48% of the interindividual variability in LVMI. In stepwise regression, TAC (beta = -17.85; P < 0.0001) during handgrip, Zc during handgrip (beta = -150; P < 0.0001), and the change in the timing of wave reflections during handgrip (beta = -0.63; P = 0.03) were independent predictors of LVMI. A model that included indexes of provoked hemodynamic load explained 68% of the interindividual variability in LVMI. Hemodynamic load provoked by isometric exercise strongly predicts LVMI in hypertension. The magnitude of this association is far greater than for resting hemodynamic load, suggesting that provoked testing captures important arterial properties that are not apparent at rest and is advantageous to assess dynamic arterial load in hypertension.
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Affiliation(s)
- Julio A Chirinos
- University of Pennsylvania, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA 19104, USA.
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Affiliation(s)
- M G Keane
- Gastroenterology Department, Charing Cross Hospital, London, UK.
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Llano R, Epstein S, Zhou R, Zhang H, Hamamdzic D, Keane MG, Freyman T, Wilensky RL. Intracoronary delivery of mesenchymal stem cells at high flow rates after myocardial infarction improves distal coronary blood flow and decreases mortality in pigs. Catheter Cardiovasc Interv 2009; 73:251-7. [PMID: 19085935 DOI: 10.1002/ccd.21781] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Evaluate the effects of pressure and duration of intracoronary (IC) infusion of mesenchymal stem cells (MSCs) on delivery efficiency and safety after myocardial infarction (MI). BACKGROUND Standard IC delivery of MSCs can lead to intravascular plugging and reduced coronary blood flow. The optimal delivery pressure and duration is unknown. METHODS Immediately after MI pigs were randomized to 1 of 3 delivery protocols of 5 x 10(7) iron-fluorescent microspheres labeled MSCs, control received 2 ml infusions at 1 ml/min (five times), very high flow rate (VHFR) a single 10 ml infusion at 60 ml/min and the high flow rate (HFR) group a single 10 ml infusion at 20 ml/min. TIMI grade flow was assessed throughout the procedure and at sacrifice (day 14). MSCs distribution was analyzed in isolated hearts by 4.7T MRI. Delivery efficiency was quantified via fluorescent microsphere recovery using a magnetic separation technique and by light microscopy. RESULTS TIMI grade flow did not change following MI (all groups TIMI 3). However, following MSCs delivery only 18% (2/11) of control animals had TIMI 3 blood flow vs. 56% (5/9) in VHFR and 67% (4/6) in HFR (P = 0.03). As a consequence, 63% of control animals died within 24 hr, 33% in VHFR and none in HFR (P = 0.02). MSCs delivery in the infarct tissue did not differ between the groups (P = 0.06). CONCLUSIONS A single MSCs infusion at 20 ml/min resulted in improved coronary blood flow and decreased mortality, without sacrificing delivery efficiency.
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Affiliation(s)
- Raul Llano
- Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Kirkpatrick JN, Ky B, Rahmouni HW, Chirinos JA, Farmer SA, Fields AV, Ogbara J, Eberman KM, Ferrari VA, Silvestry FE, Keane MG, Opotowsky AR, Sutton MSJ, Wiegers SE. Application of appropriateness criteria in outpatient transthoracic echocardiography. J Am Soc Echocardiogr 2009; 22:53-9. [PMID: 19131002 DOI: 10.1016/j.echo.2008.10.020] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2008] [Indexed: 11/15/2022]
Abstract
BACKGROUND Appropriateness criteria were applied to outpatient transthoracic echocardiographic (TTE) studies. METHODS Indications were rated as appropriate, inappropriate, or unclassifiable, considering provider-stated indications, previous TTE studies, symptom changes, and patient-stated indications. Clinically important new or unexpected findings were recorded. RESULTS Of 368 TTE studies, 206 (56%) were appropriate, 31 (8%) were inappropriate, and 131 (35%) were unclassifiable. Appropriateness was not correlated with patient or provider demographics. In 288 cases with prior TTE studies, there were 92 (32%) important new findings and 63 (22%) unexpected findings, of which 20% were from inappropriately ordered and 31% from unclassifiable TTE studies. Appropriateness was not associated with new (odds ratio, 1.23; 95% confidence interval, 0.48-3.18) or unexpected (odds ratio, 1.15; 95% confidence interval, 0.38-3.52) findings. Provider type and level of training were not correlated with new or unexpected findings. CONCLUSIONS Many indications for TTE studies were unclassifiable. A high percentage of inappropriately ordered TTE studies yielded important information. Care must be taken in judging the value of TTE studies solely on the basis of appropriateness criteria.
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Affiliation(s)
- James N Kirkpatrick
- Department of Medicine, Cardiovascular Division, Echocardiography Laboratory, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Keane MG, Kapoor R. Study of the ability of ICU staff to set a bed to the semi-recumbent position. Crit Care 2009. [PMCID: PMC4084370 DOI: 10.1186/cc7648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Affiliation(s)
- Martin G. Keane
- From the Departments of Medicine (M.G.K., R.E.P.) and Genetics (R.E.P.) and the Institute for Cardiovascular Medicine (M.G.K., R.E.P.), University of Pennsylvania School of Medicine, Philadelphia
| | - Reed E. Pyeritz
- From the Departments of Medicine (M.G.K., R.E.P.) and Genetics (R.E.P.) and the Institute for Cardiovascular Medicine (M.G.K., R.E.P.), University of Pennsylvania School of Medicine, Philadelphia
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Kirkpatrick JN, Keane MG. Future potential of echocardiography in heart failure. Future Cardiol 2008; 4:299-319. [PMID: 19804334 DOI: 10.2217/14796678.4.3.299] [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] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Echocardiography represents a convenient, portable and noninvasive method to provide important anatomic and physiologic information to inform the management of heart failure patients. Traditional echo assessments include diagnostic, etiologic and prognostic data from ventricular size, geometry and performance. Newer echocardiographic techniques are receiving greater utilization, however, and promise to further enhance diagnostic abilities in heart failure. This article reviews traditional anatomic assessments, echo-based cardiac hemodynamics, 3D echocardiography, quantification of myocardial tissue mechanics and hand-carried echocardiography. These developments in echocardiography underlie future trends toward echo objectivity, improved imaging of patients with poor acoustic windows, miniaturization and simplicity in focused exams and the expanded application of old and new techniques.
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Affiliation(s)
- James N Kirkpatrick
- Hospital of the University of Pennsylvania, 9th Floor, Gates Pavilion, 3400 Spruce St, Philadelphia, PA 19104, USA.
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Rahmouni HW, Keane MG, Silvestry FE, St. John Sutton MG, Ferrari VA, Scott CH, Wiegers SE. Failure of digital echocardiography to accurately diagnose intracardiac shunts. Am Heart J 2008; 155:161-5. [PMID: 18082508 DOI: 10.1016/j.ahj.2007.08.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2007] [Accepted: 08/30/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intravenous agitated saline injection during transthoracic echocardiography assists in the detection of right to left intracardiac and intrapulmonary shunts. Whether digital echocardiography offers comparable sensitivity and specificity to analog tape recording to assess shunts is unknown. Technical differences between methods could lead to significant differences in shunt detection. METHODS Agitated saline was injected intravenously at rest and with Valsalva in 189 consecutive patient studies (406 injections). Echocardiographers assessed presence and degree of left ventricle contrast on simultaneously recorded analog tape and digital echocardiography images in blinded fashion. RESULTS Digital echocardiography had low overall sensitivity (rest 0.50, valsalva 0.63, late 0.39) compared to analog tape. Longer clip lengths improved sensitivity for detection of late contrast passage (rest 0.50, valsalva 0.67, late 0.46). CONCLUSION Digital echocardiography saline contrast studies have poor sensitivity for assessment of intracardiac shunts versus analog tape, and increasing clip length only modestly increases sensitivity. Joint Photographic Experts Group digital compression losses may be an important cause of failure to detect intracardiac shunts, including patent foramen ovale.
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