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Coniglio AC, Segar MW, Loungani RS, Savla JJ, Grodin JL, Fox ER, Garg S, de Lemos JA, Berry JD, Drazner MH, Shah S, Hall ME, Shah A, Khan SS, Mentz RJ, Pandey A. Transthyretin V142I Genetic Variant and Cardiac Remodeling, Injury, and Heart Failure Risk in Black Adults. JACC Heart Fail 2022; 10:129-138. [PMID: 35115086 DOI: 10.1016/j.jchf.2021.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 09/07/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study evaluated the association of transthyretin (TTR) gene variant, in which isoleucine substitutes for valine at position 122 (V142I), with cardiac structure, function, and heart failure (HF) risk among middle-aged Black adults. BACKGROUND The valine-to-isoleucine substitution in the TTR protein is prevalent in Black individuals and causes cardiac amyloidosis. METHODS Jackson Heart Study participants without HF at baseline who had available data on the TTR V142I variant were included. The association of the TTR V142I variant with baseline echocardiographic parameters and repeated measures of high-sensitivity cardiac troponin-I (hs-cTnI) was assessed using adjusted linear regression models and linear mixed models, respectively. Adjusted Cox models, restricted mean survival time analysis, and Anderson-Gill models were constructed to determine the association of TTR V142I variant with the risk of incident HF, survival free of HF, and total HF hospitalizations. RESULTS A total of 119 of 2,960 participants (4%) were heterozygous carriers of the TTR V142I variant. The TTR V142I variant was not associated with measures of cardiac parameters at baseline but was associated with a greater increase in high-sensitivity troponin I (hs-TnI) levels over time. In adjusted Cox models, TTR V142I variant carriers had significantly higher risk of incident HF (HR: 1.80; 95% CI: 1.07-3.05; P = 0.03), lower survival free of HF (mean difference: 4.0 year; 95% CI: 0.6-6.2 years); P = 0.02), and higher risk of overall HF hospitalizations (HR: 2.12; 95% CI: 1.23-3.63; P = 0.007). CONCLUSIONS The TTR V142I variant in middle-aged Black adults is not associated with adverse cardiac remodeling but was associated with a significantly higher burden of chronic myocardial injury, and greater risk of incident HF and overall HF hospitalizations.
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Affiliation(s)
- Amanda C Coniglio
- Department of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matthew W Segar
- Department of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Rahul S Loungani
- Department of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jainy J Savla
- Division of Cardiology, Department of Internal Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Justin L Grodin
- Department of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ervin R Fox
- Department of Internal Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Sonia Garg
- Department of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - James A de Lemos
- Department of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jarett D Berry
- Department of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mark H Drazner
- Department of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sanjiv Shah
- Division of Cardiology, Department of Internal Medicine, Northwestern University School of Medicine, Chicago, Illinois, USA
| | - Michael E Hall
- Department of Internal Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Amil Shah
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sadiya S Khan
- Division of Cardiovascular Medicine, Department of Internal Medicine, Northwestern University School of Medicine, Chicago, Illinois, USA
| | - Robert J Mentz
- Department of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ambarish Pandey
- Department of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Barac YD, Loungani RS, Sabulsky R, Carr K, Zwischenberger B, Glower DD. Sustained results of robotic mitral repair in a lower volume center with extensive minimally invasive mitral repair experience. J Robot Surg 2021; 16:199-206. [PMID: 33761097 DOI: 10.1007/s11701-021-01214-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 02/17/2021] [Indexed: 10/21/2022]
Abstract
The literature for robotic mitral repair is dominated by a small number of large volume institutions, and intermediate-term outcomes out to 5 years are rare. Whether and under what circumstances a lower volume institution could obtain durable outcomes is not known. A retrospective review was performed on all 133 patients undergoing robotically assisted mitral repair from 2011 to 2019 at a single institution. Mean volume of robotic mitral repair was 16 ± 7 cases per year, while mean institutional total volume of mitral repair was 116 ± 16 cases per year. Mean age was 58 ± 12 years, 77% were men, and mitral etiology was prolapse in 90%. Comorbidity was infrequent with atrial fibrillation in 20% and moderate tricuspid regurgitation in 14%. Central aortic cannulation was used in 97% with concurrent tricuspid operation in 5% and concurrent maze in 14%. Median clamp time, pump time, and length of stay were 146 min, 265 min, and 5 days, respectively, but none improved with experience. There were no deaths or stroke. At 5 years, the cumulative incidence of moderate mitral regurgitation was 18 ± 6% (prolapse patients 11 ± 5%), severe regurgitation 4 ± 3%, and mitral replacement 9 ± 5% (prolapse patients 5 ± 3%). 5-year survival was 96 ± 3%. At centers with significant mitral repair volume, a volume of 16 robotic mitral cases/year can yield good clinical outcomes durable out to 5 years. A case volume of 16 cases per year was not sufficient to improve pump time or length of stay over time.
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Affiliation(s)
- Yaron D Barac
- The Sackler Faculty of Medicine, Rabin Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Rahul S Loungani
- Duke University Medical Center, Box 3851, Durham, NC, 27710, USA
| | - Richard Sabulsky
- Duke University Medical Center, Box 3851, Durham, NC, 27710, USA
| | - Keith Carr
- Duke University Medical Center, Box 3851, Durham, NC, 27710, USA
| | | | - Donald D Glower
- Duke University Medical Center, Box 3851, Durham, NC, 27710, USA.
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3
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Barac YD, Loungani RS, Sabulsky R, Zwischenberger B, Gaca J, Carr K, Glower DD. Robotic versus port-access mitral repair: A propensity score analysis. J Card Surg 2021; 36:1219-1225. [PMID: 33462900 DOI: 10.1111/jocs.15342] [Citation(s) in RCA: 4] [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: 10/08/2020] [Revised: 12/02/2020] [Accepted: 12/04/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Port-access (PORT) and robotic (ROBO) mitral repair are well established, but differences in patient selection and outcomes are not well documented. METHODS A retrospective analysis was performed on 129 ROBO and 628 PORT mitral repairs at one institution. ROBO patients had 4 cm nonrib spreading incisions with robotic assistance, while PORT patients had 6-8 cm rib spreading incisions with thoracoscopic assistance. Propensity score analysis matched patients for differences in baseline characteristics. RESULTS Unmatched ROBO patients were younger (58 ± 11 vs. 61 ± 13, p = .05), had a higher percentage of males (77% vs. 63%, p = .003) and had less NYHA Class 3-4 symptoms (11% vs. 21%, p < .01), less atrial fibrillation (19% vs. 29%, p = .02) and less tricuspid regurgitation (14% vs. 24%, p = .01). Propensity score analysis of matched patients showed that pump time (275 ± 57 vs. 207 ± 55, p < .0001) and clamp time (152 ± 38 vs. 130 ± 34, p < .0001) were longer for ROBO patients. However, length of stay, postoperative morbidity, and 5-year survival (97 ± 1% vs. 96 ± 3%, p = .7) were not different. For matched patients with degenerative valve disease, 5-year incidence of mitral reoperation (3 ± 2% vs. 1 ± 1%), severe mitral regurgitation (MR) (6 ± 4% vs. 1 ± 1%), or ≥2 + MR (12 ± 5% vs. 12 ± 4%), were not significantly different between ROBO versus PORT approaches. Predictors of recurrent moderate MR were connective tissue disease, functional etiology, and non-White race, but not surgical approach. CONCLUSIONS In this first comparison out to 5 years, robotic versus port-access approach to mitral repair had longer pump and clamp times. Perioperative morbidity, 5-year survival, and 5-year repair durability were otherwise similar.
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Affiliation(s)
- Yaron D Barac
- Rabin Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | | | - Jeffrey Gaca
- Duke University Medical Center, Durham, North Carolina, USA
| | - Keith Carr
- Duke University Medical Center, Durham, North Carolina, USA
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Loungani RS, Fudim M, Ranney D, Kochar A, Samsky MD, Bonadonna D, Itoh A, Takayama H, Takeda K, Wojdyla D, DeVore AD, Daneshmand M. Contemporary Use of Venoarterial Extracorporeal Membrane Oxygenation: Insights from the Multicenter RESCUE Registry. J Card Fail 2021; 27:327-337. [PMID: 33347997 DOI: 10.1016/j.cardfail.2020.11.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 05/01/2020] [Revised: 11/24/2020] [Accepted: 11/27/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a life-saving therapy for patients with cardiovascular collapse, but identifying patients unlikely to benefit remains a challenge. METHODS AND RESULTS We created the RESCUE registry, a retrospective, observational registry of adult patients treated with VA-ECMO between January 2007 and June 2017 at 3 high-volume centers (Columbia University, Duke University, and Washington University) to describe short-term patient outcomes. In 723 patients treated with VA-ECMO, the most common indications for deployment were postcardiotomy shock (31%), cardiomyopathy (including acute heart failure) (26%), and myocardial infarction (17%). Patients frequently suffered in-hospital complications, including acute renal dysfunction (45%), major bleeding (41%), and infection (33%). Only 40% of patients (n = 290) survived to discharge, with a minority receiving durable cardiac support (left ventricular assist device [n = 48] or heart transplantation [n = 7]). Multivariable regression analysis identified risk factors for mortality on ECMO as older age (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.12-1.42) and female sex (OR, 1.44; 95% CI, 1.02-2.02) and risk factors for mortality after decannulation as higher body mass index (OR 1.17; 95% CI, 1.01-1.35) and major bleeding while on ECMO support (OR, 1.92; 95% CI, 1.23-2.99). CONCLUSIONS Despite contemporary care at high-volume centers, patients treated with VA-ECMO continue to have significant in-hospital morbidity and mortality. The optimization of outcomes will require refinements in patient selection and improvement of care delivery.
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Affiliation(s)
- Rahul S Loungani
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina.
| | - Marat Fudim
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Dave Ranney
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Ajar Kochar
- Division of Cardiology, Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Marc D Samsky
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Desiree Bonadonna
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Akinobu Itoh
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Hiroo Takayama
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - Koji Takeda
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - Daniel Wojdyla
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Adam D DeVore
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Mani Daneshmand
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
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Loungani RS, Teerlink JR, Metra M, Allen LA, Butler J, Carson PE, Chen CW, Cotter G, Davison BA, Eapen ZJ, Filippatos GS, Gimpelewicz C, Greenberg B, Holbro T, Januzzi JL, Lanfear DE, Pang PS, Piña IL, Ponikowski P, Miller AB, Voors AA, Felker GM. Cause of Death in Patients With Acute Heart Failure: Insights From RELAX-AHF-2. JACC Heart Fail 2020; 8:999-1008. [PMID: 33189635 DOI: 10.1016/j.jchf.2020.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/27/2020] [Accepted: 09/15/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This study sought to better understand the discrepant results of 2 trials of serelaxin on acute heart failure (AHF) and short-term mortality after AHF by analyzing causes of death of patients in the RELAX-AHF-2 (Efficacy, Safety and Tolerability of Serelaxin When Added to Standard Therapy in AHF-2) trial. BACKGROUND Patients with AHF continue to suffer significant short-term mortality, but limited systematic analyses of causes of death in this patient population are available. METHODS Adjudicated cause of death of patients in RELAX-AHF-2, a randomized, double-blind, placebo-controlled trial of serelaxin in patients with AHF across the spectrum of ejection fraction (EF), was analyzed. RESULTS By 180 days of follow-up, 11.5% of patients in RELAX-AHF-2 died, primarily due to heart failure (HF) (38% of all deaths). Unlike RELAX-AHF, there was no apparent effect of treatment with serelaxin on any category of cause of death. Older patients (≥75 years) had higher rates of mortality (14.2% vs. 8.8%) and noncardiovascular (CV) death (27% vs. 19%) compared to younger patients. Patients with preserved EF (≥50%) had lower rates of HF-related mortality (30% vs. 40%) but higher non-CV mortality (36% vs. 20%) compared to patients with reduced EF. CONCLUSIONS Despite previous data suggesting benefit of serelaxin in AHF, treatment with serelaxin was not found to improve overall mortality or have an effect on any category of cause of death in RELAX-AHF-2. Careful adjudication of events in the serelaxin trials showed that older patients and those with preserved EF had fewer deaths from HF or sudden death and more deaths from other CV causes and from noncardiac causes. (Efficacy, Safety and Tolerability of Serelaxin When Added to Standard Therapy in AHF [RELAX-AHF-2]; NCT01870778).
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Affiliation(s)
- Rahul S Loungani
- Division of Cardiology and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, California, USA
| | - Marco Metra
- Cardiology, ASST Civil Hospitals, and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| | - Peter E Carson
- Department of Cardiology, Washington VA Medical Center, Washington, DC, USA
| | - Chien-Wei Chen
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Gad Cotter
- Momentum Research, Durham, North Carolina, USA
| | | | | | - Gerasimos S Filippatos
- School of Medicine, University of Cyprus, Nicosia, Cyprus, Greece; Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Barry Greenberg
- University of California San Diego Health, Cardiovascular Institute, La Jolla, California, USA
| | | | - James L Januzzi
- Division of Cardiology, Department of Medicine, Harvard Medical School, and Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - David E Lanfear
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ileana L Piña
- Division of Cardiology, Wayne State University, Detroit, Michigan, USA
| | - Piotr Ponikowski
- Department of Cardiology, Wroclaw Medical University, Wroclaw, Poland
| | - Alan B Miller
- Department of Cardiology, University of Florida, Jacksonville, Florida, USA
| | - Adriaan A Voors
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - G Michael Felker
- Division of Cardiology and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA.
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6
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Loungani RS, Fudim M, Ranney D, Kochar A, Samsky M, Bonadonna D, Itoh A, Takayama H, Takeda K, Wojdyla D, DeVore A, Daneshmand M. Contemporary Use of Veno-arterial Extracorporeal Membrane Oxygenation: Insights from the Multicenter Rescue Registry. J Card Fail 2020. [DOI: 10.1016/j.cardfail.2020.09.404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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7
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Rehorn MR, Loungani RS, Black-Maier E, Coniglio AC, Karra R, Pokorney SD, Khouri MG. Cardiac Implantable Electronic Devices: A Window Into the Evolution of Conduction Disease in Cardiac Amyloidosis. JACC Clin Electrophysiol 2020; 6:1144-1154. [PMID: 32972550 DOI: 10.1016/j.jacep.2020.04.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/30/2020] [Accepted: 04/17/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVES This study characterized the relationship between conduction disease and cardiac amyloidosis (CA) through longitudinal analysis of cardiac implantable electronic device (CIED) data. BACKGROUND Bradyarrhythmias and tachyarrhythmias are commonly reported in CA and may precede a CA diagnosis, although the natural history of conduction disease in CA is not well-described. METHODS Patients with CA (transthyretin amyloidosis cardiomyopathy [ATTR-CM] and light-chain amyloidosis [AL-CA]) and a CIED were identified within the Duke University Health System. Patient characteristics at the time of implantation, including demographics and data relevant to CA diagnosis, cardiac imaging, and CIED were recorded. CIED interrogations were analyzed for pacing and atrial fibrillation (AF) burden, activity level, lead parameters, and ventricular arrhythmia incidence and/or therapy. RESULTS Thirty-four patients with CA (7 with AL-CA, 27 with ATTR-CM [78% with wild-type]; 82% men) with median age of 75 years and a mean ejection fraction of 42 ± 13% had a CIED implanted for bradycardia (65%) or prevention of sudden cardiac death (35%). CIED implantation preceded CA diagnosis in 14 patients (41%). Over a mean follow-up of 3.1 ± 4.0 years, right ventricular sensing amplitudes decreased but did not result in device malfunction; lead impedances and capture thresholds remained stable. Between post-implantation years 1 and 5, mean ventricular pacing increased from 56 ± 9% to 96 ± 1% (p = 0.003) and AF burden increased from 2 ± 1.3 to 17 ± 3 h/day (p = 0.0002). Ventricular arrhythmias were common (mean episodes per patient per year: 6.7 ± 2.3 [ATTR-CM] and 5.1 ± 3.2 [AL-CA]) but predominately nonsustained; only 1 patient with AL-CA required implantable cardioverter-defibrillator therapy. CONCLUSIONS Longitudinal analysis of CIED data in patients with CA revealed progressive conduction disease, with high AF burden and eventual dependence on ventricular pacing, although lead parameters remained stable. Ventricular arrhythmias were common but predominantly nonsustained, particularly in ATTR-CM.
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Affiliation(s)
- Michael R Rehorn
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - Rahul S Loungani
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - Eric Black-Maier
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - Amanda C Coniglio
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - Ravi Karra
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - Sean D Pokorney
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - Michel G Khouri
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA.
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8
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Loungani RS, Sekar S, Rehorn MR, Black-Maier E, Vemulapalli S, Shah SH, Harrison RW. Cardiac Arrest in the Setting of Diffuse Coronary Ectasia: Perspectives on a Unique Ischemic Insult. JACC Case Rep 2020; 2:1662-1666. [PMID: 34317029 PMCID: PMC8312123 DOI: 10.1016/j.jaccas.2020.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/17/2020] [Indexed: 11/17/2022]
Abstract
A 69-year-old man with a history of coronary artery ectasia, potentially resulting from an underlying heritable connective tissue disorder, presented with ventricular fibrillation. Despite medical management of ischemia, he developed recurrent ventricular tachycardia with poor neurological recovery. We highlight challenges in the management of coronary artery ectasia. (Level of Difficulty: Beginner.).
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Affiliation(s)
- Rahul S. Loungani
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Sitharthan Sekar
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Michael R. Rehorn
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Eric Black-Maier
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | | | - Svati H. Shah
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Robert W. Harrison
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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9
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Loungani RS, Mentz RJ, Agarwal R, DeVore AD, Patel CB, Rogers JG, Russell SD, Felker GM. Biomarkers in Advanced Heart Failure: Implications for Managing Patients With Mechanical Circulatory Support and Cardiac Transplantation. Circ Heart Fail 2020; 13:e006840. [PMID: 32660322 DOI: 10.1161/circheartfailure.119.006840] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Biomarkers have a well-defined role in the diagnosis and management of chronic heart failure, but their role in patients with left ventricular assist devices and cardiac transplant is uncertain. In this review, we summarize the available literature in this patient population, with a focus on clinical application. Some ubiquitous biomarkers, for example, natriuretic peptides and cardiac troponin, may assist in the diagnosis of left ventricular assist device complications and transplant rejection. Novel biomarkers focused on specific pathological processes, such as left ventricular assist device thrombosis and profiling of leukocyte activation, continue to be developed and show promise in altering the management of the advanced heart failure patient. Few biomarkers at this time have been assessed with sufficient scrutiny to warrant broad, universal application, but encouraging limited data and large potential for impact should prompt ongoing investigation.
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Affiliation(s)
- Rahul S Loungani
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Richa Agarwal
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Adam D DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Chetan B Patel
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Joseph G Rogers
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Stuart D Russell
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, NC
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10
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Loungani RS, Rehorn MR, Newby LK, Katz JN, Klem I, Mentz RJ, Jones WS, Vemulapalli S, Kelsey AM, Blazing MA, Piccini JP, Patel MR. A care pathway for the cardiovascular complications of COVID-19: Insights from an institutional response. Am Heart J 2020; 225:3-9. [PMID: 32417526 PMCID: PMC7252188 DOI: 10.1016/j.ahj.2020.04.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/28/2020] [Indexed: 12/28/2022]
Abstract
The infection caused by severe acute respiratory syndrome coronavirus-2, or COVID-19, can result in myocardial injury, heart failure, and arrhythmias. In addition to the viral infection itself, investigational therapies for the infection can interact with the cardiovascular system. As cardiologists and cardiovascular service lines will be heavily involved in the care of patients with COVID-19, our division organized an approach to manage these complications, attempting to balance resource utilization and risk to personnel with optimal cardiovascular care. The model presented can provide a framework for other institutions to organize their own approaches and can be adapted to local constraints, resource availability, and emerging knowledge.
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Affiliation(s)
- Rahul S Loungani
- Division of Cardiology and Duke Heart Center, Duke University Medical Center, Durham, NC.
| | - Michael R Rehorn
- Division of Cardiology and Duke Heart Center, Duke University Medical Center, Durham, NC
| | - L Kristin Newby
- Division of Cardiology and Duke Heart Center, Duke University Medical Center, Durham, NC
| | - Jason N Katz
- Division of Cardiology and Duke Heart Center, Duke University Medical Center, Durham, NC
| | - Igor Klem
- Division of Cardiology and Duke Heart Center, Duke University Medical Center, Durham, NC
| | - Robert J Mentz
- Division of Cardiology and Duke Heart Center, Duke University Medical Center, Durham, NC
| | - W Schuyler Jones
- Division of Cardiology and Duke Heart Center, Duke University Medical Center, Durham, NC
| | - Sreekanth Vemulapalli
- Division of Cardiology and Duke Heart Center, Duke University Medical Center, Durham, NC
| | - Anita M Kelsey
- Division of Cardiology and Duke Heart Center, Duke University Medical Center, Durham, NC
| | - Michael A Blazing
- Division of Cardiology and Duke Heart Center, Duke University Medical Center, Durham, NC
| | - Jonathan P Piccini
- Division of Cardiology and Duke Heart Center, Duke University Medical Center, Durham, NC
| | - Manesh R Patel
- Division of Cardiology and Duke Heart Center, Duke University Medical Center, Durham, NC
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11
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Loungani RS, Rehorn MR, Geurink KR, Coniglio AC, Black-Maier E, Pokorney SD, Khouri MG. Outcomes following cardioversion for patients with cardiac amyloidosis and atrial fibrillation or atrial flutter. Am Heart J 2020; 222:26-29. [PMID: 32004797 DOI: 10.1016/j.ahj.2020.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 01/02/2020] [Indexed: 12/20/2022]
Abstract
Atrial arrhythmias commonly occur in patients with cardiac amyloidosis (CA), but there is limited data on safety or efficacy of cardioversion (DCCV) for management of these rhythms in CA. We identified 25 patients with CA (20 with transthyretin (TTR) and 5 with light-chain (AL) amyloidosis) at Duke University who underwent DCCV for atrial arrhythmias and documented procedural success, complications, and long-term morbidity and mortality. While DCCV successfully restored sinus rhythm in 96% of patients, 36% of patients experienced immediate procedural complications (primarily bradycardia and hypotension), 80% had recurrence of atrial arrhythmias at 1 year, and 52% died at 3 years, highlighting short-term safety concerns, long-term inefficacy, and poor prognosis associated with symptomatic atrial arrhythmias requiring DCCV in CA.
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Affiliation(s)
- Rahul S Loungani
- Division of Cardiovascular Disease, Duke University Medical Center, Durham, NC
| | - Michael R Rehorn
- Division of Cardiovascular Disease, Duke University Medical Center, Durham, NC
| | - Kyle R Geurink
- Division of Cardiovascular Disease, Duke University Medical Center, Durham, NC
| | - Amanda C Coniglio
- Division of Cardiovascular Disease, Duke University Medical Center, Durham, NC
| | - Eric Black-Maier
- Division of Cardiovascular Disease, Duke University Medical Center, Durham, NC
| | - Sean D Pokorney
- Division of Cardiovascular Disease, Duke University Medical Center, Durham, NC; Electrophysiology Section, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Michel G Khouri
- Division of Cardiovascular Disease, Duke University Medical Center, Durham, NC.
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12
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Loungani RS, Felker GM. Is Resistance Futile?: Addressing Diuretic Resistance During Hospitalization for Heart Failure. JACC Heart Fail 2020; 8:169-171. [PMID: 31926852 DOI: 10.1016/j.jchf.2019.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/22/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Rahul S Loungani
- Division of Cardiology, Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina
| | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina.
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13
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Feng KY, Loungani RS, Rao VN, Patel CB, Khouri MG, Felker GM, DeVore AD. Best Practices for Prognostic Evaluation of a Patient With Transthyretin Amyloid Cardiomyopathy. JACC CardioOncol 2019; 1:273-279. [PMID: 34396189 PMCID: PMC8352120 DOI: 10.1016/j.jaccao.2019.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/30/2019] [Accepted: 11/04/2019] [Indexed: 11/28/2022]
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) has emerged as an increasingly identified etiology of heart failure. Fortunately, the disease now has an approved therapy, with many others under development. Assessment of prognosis in ATTR-CM is critical to inform patients about the disease course and guide clinical decisions. This review discusses the evidence behind clinical, biomarker, and imaging findings that inform prognosis in patients with ATTR-CM and can assist providers in the shared decision-making process during management of this disease. Prognostic factors for ATTR-CM can guide patient expectations and inform clinical decisions. Clinical features, blood biomarkers, and imaging obtained during workup for ATTR-CM convey prognostic information. Further studies in determining the incremental value of prognostic factors are warranted.
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Key Words
- 99mTc-PYP, 99mTc-pyrophosphate
- AF, atrial fibrillation
- ATTR-CM, transthyretin amyloid cardiomyopathy
- CMR, cardiac magnetic resonance
- H/CL, heart to contralateral
- HF, heart failure
- LGE, late gadolinium enhancement
- MCF, myocardial contraction fraction
- NT-proBNP, N-terminal pro-B-type natriuretic peptide
- NYHA, New York Heart Association
- SVI, stroke volume index
- TTR, transthyretin
- V122I, valine-122-isoleucine
- amyloidosis
- biomarkers
- cardiac magnetic resonance
- cardiomyopathy
- eGFR, estimated glomerular filtration rate
- echocardiography
- nuclear imaging
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Affiliation(s)
- Kent Y Feng
- Stanford Center for Clinical Research, Stanford University School of Medicine, Stanford, California, USA
| | - Rahul S Loungani
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Vishal N Rao
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Chetan B Patel
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Michel G Khouri
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - G Michael Felker
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Adam D DeVore
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
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14
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Morgan BP, Gilliard RJ, Loungani RS, Smith RC. Macromol. Rapid Commun. 16/2009. Macromol Rapid Commun 2009. [DOI: 10.1002/marc.200990039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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15
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Morgan BP, Gilliard RJ, Loungani RS, Smith RC. Poly(p
-phenylene ethynylene) Incorporating Sterically Enshrouding m
-Terphenyl Oxacyclophane Canopies. Macromol Rapid Commun 2009; 30:1399-405. [DOI: 10.1002/marc.200900160] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 04/08/2009] [Accepted: 04/15/2009] [Indexed: 11/07/2022]
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