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Ngo-Hamilton A, Agakishiev D, Maharaj V. Cardiac rehabilitation for heart failure: progress and gaps in evidence and policy. Curr Opin Cardiol 2024; 39:196-201. [PMID: 38391275 DOI: 10.1097/hco.0000000000001129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW This review synthesizes recent research on the efficacy, optimal design, and delivery methods of cardiac rehabilitation tailored to heart failure patients. Despite established benefits, cardiac rehabilitation referral and access disparities persist, necessitating elucidation of limitations and solutions. RECENT FINDINGS Exercise-based cardiac rehabilitation improves long-term mortality and hospitalization rates but not short-term mortality. cardiac rehabilitation further enhances quality of life and medical therapy adherence. However, cardiac rehabilitation relies on in-person delivery, presenting access barriers exacerbated during COVID-19. Significant geographic disparities exist, with analyses indicating current capacity only serves 45% of eligible US adults even if fully utilized. Referral rates also lag, disproportionately affecting women and minority groups. Research increasingly focuses on home-based and digital therapeutics modalities to expand reach, with evidence demonstrating comparable improvements across settings. Protocols and research center on heart failure with reduced ejection fraction (HFrEF), despite growing heart failure with preserved ejection fraction (HFpEF) prevalence. SUMMARY Increasing referrals through standardized procedures and addressing multifactorial geographic, economic, and capacity limitations are imperative to ensure equitable cardiac rehabilitation access. Broadening HFpEF rehabilitation research and care standards also constitutes a critical practice gap requiring alignment with projected epidemiologic shifts. Advancing patient-centered, evidence-based solutions can promote rehabilitation as essential secondary prevention for wider cardiac populations. VIDEO ABSTRACT http://links.lww.com/HCO/A97.
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Affiliation(s)
- Alfred Ngo-Hamilton
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Dzhalal Agakishiev
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Siems CB, Ji Z, Jedeon Z, Schultz J, Teigen L, Allen T, John R, Estep JD, Masotti M, Alexy T, Kamdar F, Maharaj V, Pritzker M, Garry D, Shaffer A, Cogswell R. Validation of the Minnesota Pectoralis Risk Score to predict mortality in the HeartMate 3 population. J Heart Lung Transplant 2024; 43:539-546. [PMID: 37956881 DOI: 10.1016/j.healun.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 10/20/2023] [Accepted: 11/05/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND The Minnesota Pectoralis Risk Score (MPRS) utilizes computed tomography-quantified thoracic muscle and clinical variables to predict survival after left ventricular assist device (LVAD) implantation. The model has not been prospectively tested in HeartMate 3 recipients. METHODS A single-center HeartMate 3 cohort from July 2016 to July 2021 (n = 108) was utilized for this analysis. Cohort subjects with complete covariates for MPRS calculation (pectoralis muscle measures, Black race, creatinine, total bilirubin, body mass index, bridge to transplant status, and presence/absence of contrast) implanted after MPRS development were included. MPRS were calculated on each subject. Receiver operating characteristic curves were generated to test model discrimination at 30-day, 90-day, and 1-year mortality post-LVAD. Next, the performance of the 1-year post-LVAD outcome was compared to the HeartMate 3 survival risk score (HM3RS). RESULTS The mean age was 58 (15 years), 80% (86/108) were male, and 26% (28/108) were destination therapy. The area under the curve (AUC) for the MPRS model to predict post-LVAD mortality was 0.73 at 30 days, 0.78 at 90 days, and 0.81 at 1 year. The AUC for the HM3RS for the 1-year outcome was 0.693. Each 1-unit point of the MPRS was associated with a significant increase in the hazard rate of death after LVAD (hazard ratio 2.1, 95% confidence interval 1.5-3.0, p < 0.0001). CONCLUSIONS The MPRS had high performance in this prospective validation, particularly with respect to 90-day and 1-year post-LVAD mortality. Such a tool can provide additional information regarding risk stratification to aid informed decision-making.
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Affiliation(s)
- Chesney B Siems
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota.
| | - Ziyu Ji
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota
| | - Zeina Jedeon
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Jessica Schultz
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Levi Teigen
- Department of Food Science and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Tadashi Allen
- Department of Diagnostic Radiology, University of Minnesota, Minneapolis, Minnesota
| | - Ranjit John
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Jerry D Estep
- Department of Cardiology, Cleveland Clinic Florida, Weston, Florida
| | - Maria Masotti
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Tamas Alexy
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Forum Kamdar
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Valmiki Maharaj
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Marc Pritzker
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Daniel Garry
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Andrew Shaffer
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Rebecca Cogswell
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Lerman JB, Green CL, Molina MR, Maharaj V, Ortega-Legaspi JM, Sen S, Flattery M, Maziarz EK, Shah KB, Martin CM, Alexy T, Shah P, Morris AA, DeVore AD, Cole RT. Multicenter study of universal prophylaxis versus pre-emptive therapy for patients at intermediate risk (R+) for CMV following heart transplantation. Clin Transplant 2023; 37:e15065. [PMID: 37392192 PMCID: PMC10592402 DOI: 10.1111/ctr.15065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/15/2023] [Accepted: 06/20/2023] [Indexed: 07/03/2023]
Abstract
INTRODUCTION Heart transplant (HT) recipients with prior exposure to cytomegalovirus (CMV R+) are considered intermediate risk for CMV-related complications. Consensus guidelines allow for either universal prophylaxis (UP) or preemptive therapy (PET) (serial CMV testing) approaches to CMV prevention in such patients. Whether an optimal approach to mitigate CMV related risks exists in this setting remains uncertain. We therefore assessed the utility of PET as compared to UP in CMV R+ HT recipients. METHODS Retrospective analysis of all CMV R+ HT recipients from 6 U.S. centers between 2010 and 2018 was performed. The primary outcome was the development of CMV DNAemia or end-organ disease resulting in the initiation/escalation of anti-CMV therapy. The secondary outcome was CMV-related hospitalization. Additional outcomes included incidence of acute cellular rejection (ACR) ≥ grade 2R, death, cardiac allograft vasculopathy (CAV), and leukopenia. RESULTS Of 563 CMV R+ HT recipients, 344 (61.1%) received UP. PET was associated with increased risk for the primary (adjusted HR 3.95, 95% CI: 2.65-5.88, p < .001) and secondary (adjusted HR 3.19, 95% CI: 1.47-6.94, p = .004) outcomes, and with increased ACR ≥ grade 2R (PET 59.4% vs. UP 34.4%, p < .001). Incidence of detectable CAV was similar at 1 year (PET 8.2% vs. UP 9.5%, p = .698). UP was associated with increased incidence of leukopenia within 6 months post-HT (PET 34.7% vs. UP 43.6%, p = .036). CONCLUSION The use of a PET CMV prophylaxis strategy in intermediate risk HT recipients associated with increased risk of CMV infection and CMV-related hospitalization, and may associate with worse post-HT graft outcomes.
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Affiliation(s)
- Joseph B. Lerman
- Division of Cardiology, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Cynthia L. Green
- Duke Clinical Research Institute, Durham, NC
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Maria R. Molina
- Department of Medicine, Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Valmiki Maharaj
- Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Juan M. Ortega-Legaspi
- Department of Medicine, Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Maureen Flattery
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | - Eileen K. Maziarz
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
| | - Keyur B. Shah
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | - Cindy M. Martin
- Department of Cardiovascular Medicine, Houston Methodist Hospital, Houston, TX
| | - Tamas Alexy
- Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Palak Shah
- Heart Failure, MCS and Transplant, Inova Heart and Vascular Institute, Falls Church, VA
| | - Alanna A. Morris
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Adam D. DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Robert T. Cole
- Samsky Advanced Heart Failure Center, Piedmont Heart Institute, Atlanta, GA
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DeFilippis EM, Ji Z, Masotti M, Maharaj V, Alexy T, Kittleson MM, Cogswell R. Association between calculated panel reactive antibody and waitlist outcomes in the 2018 heart allocation system. J Heart Lung Transplant 2023; 42:1469-1477. [PMID: 37268050 DOI: 10.1016/j.healun.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/09/2023] [Accepted: 05/25/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND The impact of heart transplant (HT) waitlist candidate sensitization on waitlist outcomes in the US is unknown. METHODS Adult waitlist outcomes in OPTN (October 2018-September 2022) by calculated panel reactive antibody (cPRA) were modeled to identify thresholds of clinical significance. The primary outcome was the rate of HT by cPRA category (low: 0-35, middle: >35-90, high: >90) assessed using multivariable competing risk analysis (compete: waitlist removal for death or clinical deterioration). The secondary outcome was waitlist removal for death or clinical deterioration. RESULTS The elevated cPRA categories were associated with lower rates of HT. Candidates in the middle (35-90) and high cPRA categories (>90) had an adjusted 24% lower rate (hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.80-0.92) and 61% lower rate (HR 0.39 95% CI. 0.33-0.47) of HT than the lowest category, respectively. Waitlist candidates in the high cPRA category listed in the top acuity strata (Statuses 1, 2) had increased rates of delisting for death or deterioration compared to those in the low cPRA category (adjusted HR 2.9, 95% CI 1.5-5.5), however, elevated cPRA (middle, high) was not associated with an increased rate of death and delisting when the cohort was considered as a whole. CONCLUSIONS Elevated cPRA was associated with reduced rates of HT across all waitlist acuity tiers. Among HT waitlist candidates listed at the top acuity strata, the high cPRA category was associated with increased rates of delisting due to death or deterioration. Elevated cPRA may require consideration for critically ill candidates under continuous allocation.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Ziyu Ji
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Maria Masotti
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Valmiki Maharaj
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Tamas Alexy
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rebecca Cogswell
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota.
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Agdamag AC, Riad S, Maharaj V, Jackson S, Fraser M, Charpentier V, Nzemenoh B, Martin CM, Alexy T. Temporary Mechanical Circulatory Support Use and Clinical Outcomes of Simultaneous Heart/Kidney Transplant Recipients in the Pre- and Post-heart Allocation Policy Change Eras. Transplantation 2023; 107:1605-1614. [PMID: 36706061 DOI: 10.1097/tp.0000000000004518] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The use of temporary mechanical circulatory support (tMCS) devices (intra-aortic balloon pump; Impella 2.5, CP, 5.0; venoarterial extracorporeal membrane oxygenation) increased significantly across the United States for heart transplant candidates after the allocation policy change. Whether this practice change also affected simultaneous heart-kidney (SHK) candidates and recipient survival is understudied. METHODS We used the Scientific Registry of Transplant Recipients database to identify adult SHK recipients between January 2010 and March 2022. The population was stratified into pre- and post-heart allocation change cohorts. Kaplan-Meier curves were generated to compare 1-y survival rates. A Cox proportional hazards model was used to investigate the effect of allocation period on patient survival. Recipient outcomes bridged with eligible tMCS devices were compared in the post-heart allocation era. In a separate analysis, SHK waitlist mortality was evaluated between the allocation eras. RESULTS A total of 1548 SHK recipients were identified, and 1102 were included in the final cohort (534 pre-allocation and 568 post-allocation change). tMCS utilization increased from 17.9% to 51.6% after the allocation change, with venoarterial extracorporeal membrane oxygenation use rising most significantly. However, 1-y post-SHK survival remained unchanged in the full cohort (log-rank P = 0.154) and those supported with any of the eligible tMCS devices. In a separate analysis (using a larger cohort of all SHK listings), SHK waitlist mortality at 1 y was significantly lower in the current allocation era ( P = 0.002). CONCLUSIONS Despite the remarkable increase in tMCS use in SHK candidates after the heart allocation change, 1 y posttransplant survival remained unchanged. Further studies with larger cohorts and longer follow-ups are needed to confirm these findings.
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Affiliation(s)
- Arianne C Agdamag
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Samy Riad
- Division of Nephrology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Valmiki Maharaj
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Scott Jackson
- Complex Care Analytics, Fairview Health Services, Minneapolis, MN
| | - Meg Fraser
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | | | - Bellony Nzemenoh
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Cindy M Martin
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
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6
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DeFilippis EM, Masotti M, Blumer V, Maharaj V, Cogswell R. Sex-Specific Outcomes of Candidates Listed as the Highest Priority Status for Heart Transplantation. Circ Heart Fail 2023:e009946. [PMID: 37232180 DOI: 10.1161/circheartfailure.122.009946] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND While sex differences in heart transplantation (HT) waitlist mortality have been previously described, waitlist and HT outcomes by sex of patients in the highest urgency strata (Status 1) since implementation of the 2018 allocation system change in the United States are unknown. We hypothesized that women listed as Status 1 may have worse outcomes due to adverse events on temporary mechanical circulatory support. METHODS The analysis included adult, single-organ HT waitlist candidates listed as Status 1 at any time while listed, after the HT allocation system change (from October 18, 2018 through March 31, 2022). The primary outcome was the rate of HT by sex, assessed using multivariable competing risk analysis where waitlist removal for death or clinical deterioration was the competing event. Post-HT survival by sex of waitlist candidates transplanted as a Status 1 was also compared. RESULTS Of 1120 Status 1 waitlist candidates (23.8% women), women had a lower rate of HT compared to men (adjusted hazard ratio, 0.74 [95% CI, 0.62-0.88]; P<0.001) and a higher rate of delisting for death or medical unsuitability (adjusted hazard ratio, 1.48 [95% CI, 1.05-2.09]; P=0.026). Calculated panel reactive antibody did not account for all the harm observed. Post-HT survival of Status 1 candidates by sex was similar (adjusted hazard ratio, 1.13 [95% CI, 0.62-2.06]; P=0.70). CONCLUSIONS Women have a lower rate of HT and higher rate of delisting for death or clinical deterioration at the highest urgent status, which appears to be mediated but not fully explained by calculated panel reactive antibody levels. Further investigation into the safety profile of temporary mechanical circulatory support devices in women is needed.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY (E.M.D.)
| | - Maria Masotti
- Division of Cardiology, University of Minnesota, Minneapolis (M.M., V.M., R.C.)
| | - Vanessa Blumer
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, OH (V.B.)
| | - Valmiki Maharaj
- Division of Cardiology, University of Minnesota, Minneapolis (M.M., V.M., R.C.)
| | - Rebecca Cogswell
- Division of Cardiology, University of Minnesota, Minneapolis (M.M., V.M., R.C.)
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Alexy T, Patel S, Rochlani Y, Saeed O, Gjelaj C, Madan S, Shin J, Maharaj V, Goldstein D, Jorde U, Vukelic S. Risk of Acute Rejection in Heart Transplant Patients Treated with M-TOR Inhibitors. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.177] [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: 04/05/2023] Open
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Maharaj V, Alexy T, Agdamag AC, Kalra R, Nzemenoh BN, Charpentier V, Bartos JA, Brunsvold ME, Yannopoulos D. Response to "Right Ventricular Dysfunction is Associated With Increased Mortality in Patients Requiring VV ECMO: Issues With the Method". ASAIO J 2023; 69:e110-e111. [PMID: 35609186 PMCID: PMC9684345 DOI: 10.1097/mat.0000000000001770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Valmiki Maharaj
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Tamas Alexy
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Arianne C. Agdamag
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Rajat Kalra
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | | | | | - Jason A. Bartos
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
- Center for Resuscitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Melissa E. Brunsvold
- Division of Critical Care/Acute Care Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Demetris Yannopoulos
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
- Center for Resuscitation Medicine, University of Minnesota, Minneapolis, MN, USA
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Jedeon Z, Masotti M, Schultz J, Vest AR, Alexy T, Pritzker M, Maharaj V, Kamdar F, Knopper R, Shaffer A, John R, Cogswell R. Overestimation of Renal Function Using Serum Creatinine in the Advanced Heart Failure Population: A Call for Alternative Measures. J Card Fail 2023; 29:116-118. [PMID: 36336141 DOI: 10.1016/j.cardfail.2022.10.428] [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] [Received: 07/25/2022] [Revised: 09/23/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Zeina Jedeon
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Maria Masotti
- University of Minnesota School of Public Health, Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota
| | - Jessica Schultz
- University of Minnesota School of Public Health, Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota
| | - Amanda R Vest
- Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Tamas Alexy
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Marc Pritzker
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Valmiki Maharaj
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Forum Kamdar
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Ryan Knopper
- Department of Surgery, Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Andrew Shaffer
- Department of Surgery, Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Ranjit John
- Department of Surgery, Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Rebecca Cogswell
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota.
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Maharaj V, Agdamag AC, Duval S, Edmiston J, Charpentier V, Fraser M, Hall A, Schultz J, John R, Shaffer A, Martin CM, Thenappan T, Francis GS, Cogswell R, Alexy T. Hypotension on cardiopulmonary stress test predicts 90 day mortality after LVAD implantation in INTERMACS 3-6 patients. ESC Heart Fail 2022; 9:3496-3504. [PMID: 35883259 DOI: 10.1002/ehf2.14099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 06/04/2022] [Accepted: 07/20/2022] [Indexed: 11/10/2022] Open
Abstract
AIMS Cardiopulmonary stress test (CPX) is routinely performed when evaluating patient candidacy for left ventricular assist device (LVAD) implantation. The predictive value of hypotensive systolic blood pressure (SBP) response during CPX on clinical outcomes is unknown. This study aims to determine the effect of hypotensive SBP response during to clinical outcomes among patients who underwent LVAD implantation. METHODS AND RESULTS This was a retrospective single center study enrolling consecutive patients implanted with a continuous flow LVAD between 2011 and 2022. Hypotensive SBP response was defined as peak exercise SBP below the resting value. Multivariable Cox-regression analysis was performed to evaluate the relationship between hypotensive SBP response and all-cause mortality within 30 and 90 days of LVAD implantation. A subgroup analysis was performed for patients implanted with a HeartMate III (HM III) device. Four hundred thirty-two patients underwent LVAD implantation during the pre-defined period and 156 with INTERMACS profiles 3-6 met our inclusion criteria. The median age was 63 years (IQR 54-69), and 52% had ischaemic cardiomyopathy. Hypotensive SBP response was present in 35% of patients and was associated with increased 90 day all-cause mortality (unadjusted HR 9.16, 95% CI 1.98-42; P = 0.0046). Hazard ratio remained significant after adjusting for age, INTERMACS profile, serum creatinine, and total bilirubin. Findings were similar in the HM III subgroup. CONCLUSIONS Hypotensive SBP response on pre-LVAD CPX is associated with increased perioperative and 90 day mortality after LVAD implantation. Additional studies are needed to determine the mechanism of increased mortality observed.
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Affiliation(s)
- Valmiki Maharaj
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Arianne C Agdamag
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Sue Duval
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Jonathan Edmiston
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | - Meg Fraser
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Alexandra Hall
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Jessica Schultz
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Ranjit John
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Andrew Shaffer
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Cindy M Martin
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Thenappan Thenappan
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Gary S Francis
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Rebecca Cogswell
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Tamas Alexy
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
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11
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Maharaj V, Alexy T, Agdamag AC, Kalra R, Nzemenoh BN, Charpentier V, Bartos JA, Brunsvold ME, Yannopoulos D. Right Ventricular Dysfunction is Associated with Increased Mortality in Patients Requiring Venovenous Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019. ASAIO J 2022; 68:772-778. [PMID: 35649224 PMCID: PMC9148640 DOI: 10.1097/mat.0000000000001666] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Respiratory failure caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is associated with mortality. Patients unresponsive to conventional therapy may benefit from temporary venovenous extracorporeal membrane oxygenation (VV-ECMO). We investigated clinical and echocardiographic characteristics, particularly, right ventricular dysfunction, with survival in patients with respiratory failure caused by SARS-CoV-2. We performed a single-center retrospective cohort study of patients requiring VV-ECMO for respiratory failure from COVID-19 infection between January 2020 and December 2020. Demographics, comorbidities, laboratory parameters, and echocardiographic features of left and right ventricular (LV/RV) function were compared between patients who survived and those who could not be weaned from VV-ECMO. In addition, we evaluated outcomes in a separate population managed with venoarterial extracorporeal membrane oxygenation (VA-ECMO). In total, 10/17 patients failed to wean from VV-ECMO and died in the hospital on average 41.5 ± 10.9 days post admission. Seven were decannulated (41%) and survived to hospital discharge. There were no significant differences in demographics, comorbidities, and laboratory parameters between groups. Moderate to severe RV dysfunction was significantly more in those who died (8/10, 80%) compared to survivors (0/7, 0%) (p = 0.002). Patients supported with VA-ECMO had superior survival with 5/9 patients (56%) decannulated and discharged. Moderate to severe RV dysfunction is associated with increased mortality in patients with respiratory failure requiring VV-ECMO for COVID-19.
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Affiliation(s)
- Valmiki Maharaj
- From the Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Tamas Alexy
- From the Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Arianne C. Agdamag
- From the Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Rajat Kalra
- From the Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | | | | | - Jason A. Bartos
- From the Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
- Center for Resuscitation Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Melissa E. Brunsvold
- Division of Critical Care/Acute Care Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Demetris Yannopoulos
- From the Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
- Center for Resuscitation Medicine, University of Minnesota, Minneapolis, Minnesota
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12
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Agdamag A, Maharaj V, Charpentier V, Jackson S, Martin C, Riad S, Alexy T. Simultaneous Heart-Kidney Transplant Outcomes Pre- and Post-Heart Allocation System Change: Impact of Temporary Mechanical Circulatory Support. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.197] [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: 11/16/2022] Open
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13
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Agdamag ACC, Gonzalez D, Carlson K, Konety S, McDonald WC, Martin CM, Maharaj V, Alexy T. Fulminant myocarditis following coronavirus disease 2019 vaccination: a case report. Eur Heart J Case Rep 2022; 6:ytac007. [PMID: 35088026 PMCID: PMC8790078 DOI: 10.1093/ehjcr/ytac007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/27/2021] [Accepted: 01/04/2022] [Indexed: 01/07/2023]
Abstract
Background The BNT162b2 vaccine received emergency use authorization from the U.S. Food and Drug Administration for the prevention of severe coronavirus disease 2019 (COVID-19) infection. We report a case of biopsy and magnetic resonance imaging (MRI)-proven severe myocarditis that developed in a previously healthy individual within days of receiving the first dose of the BNT162b2 COVID-19 vaccine. Case Summary An 80-year-old female with no significant cardiac history presented with cardiogenic shock and biopsy-proven fulminant myocarditis within 12 days of receiving the BNT162b2 COVID-19 vaccine. She required temporary mechanical circulatory support, inotropic agents, and high-dose steroids for stabilization and management. Ultimately, her cardiac function recovered, and she was discharged in stable condition after 2 weeks of hospitalization. A repeat cardiac MRI 3 months after her initial presentation demonstrated stable biventricular function and continued improvement in myocardial inflammation. Discussion Fulminant myocarditis is a rare complication of vaccination. Clinicians should stay vigilant to recognize this rare, but potentially deadly complication. Due to the high morbidity and mortality associated with COVID-19 infection, the clinical benefits of the BNT162b2 vaccine greatly outweighs the risks of complications.
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Affiliation(s)
- Arianne Clare C Agdamag
- Division of Cardiology, Department of Medicine, University of Minnesota, 420 Delaware St., Minneapolis, MN 55455, USA
| | - Daniel Gonzalez
- Division of Cardiology, Department of Medicine, University of Minnesota, 420 Delaware St., Minneapolis, MN 55455, USA
| | - Katie Carlson
- Department of Cardiology, Metropolitan Heart and Vascular Institute, Mercy Hospital, Coon Rapids, MN 55433, USA
| | - Suma Konety
- Division of Cardiology, Department of Medicine, University of Minnesota, 420 Delaware St., Minneapolis, MN 55455, USA
| | - William C McDonald
- Department of Pathology, Abbott Northwestern Hospital, Minneapolis, MN 55407, USA
| | - Cindy M Martin
- Division of Cardiology, Department of Medicine, University of Minnesota, 420 Delaware St., Minneapolis, MN 55455, USA
| | - Valmiki Maharaj
- Division of Cardiology, Department of Medicine, University of Minnesota, 420 Delaware St., Minneapolis, MN 55455, USA
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, 420 Delaware St., Minneapolis, MN 55455, USA
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Maharaj V, Steiner M, Boyle B, Kazmirczak F, Markowitz J, Alexy T, Shaffer A, John R, Martin CM, Cogswell R, Kamdar F. Rapidly Progressive Left Ventricular Assist Device Outflow Graft Thrombosis Associated With COVID-19 Infection. Circ Heart Fail 2021; 14:e008334. [PMID: 34775782 DOI: 10.1161/circheartfailure.121.008334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Valmiki Maharaj
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis. (V.M., B.B., F. Kazmirczak, J.M., T.A., C.M.M., R.C., F. Kamdar)
| | - Marie Steiner
- Divisions of Hematology and Oncology and Critical Care, University of Minnesota, Minneapolis. (M.S.)
| | - Brenden Boyle
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis. (V.M., B.B., F. Kazmirczak, J.M., T.A., C.M.M., R.C., F. Kamdar)
| | - Felipe Kazmirczak
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis. (V.M., B.B., F. Kazmirczak, J.M., T.A., C.M.M., R.C., F. Kamdar)
| | - Jeremy Markowitz
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis. (V.M., B.B., F. Kazmirczak, J.M., T.A., C.M.M., R.C., F. Kamdar)
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis. (V.M., B.B., F. Kazmirczak, J.M., T.A., C.M.M., R.C., F. Kamdar)
| | - Andrew Shaffer
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis. (A.S., R.J.)
| | - Ranjit John
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis. (A.S., R.J.)
| | - Cindy M Martin
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis. (V.M., B.B., F. Kazmirczak, J.M., T.A., C.M.M., R.C., F. Kamdar)
| | - Rebecca Cogswell
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis. (V.M., B.B., F. Kazmirczak, J.M., T.A., C.M.M., R.C., F. Kamdar)
| | - Forum Kamdar
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis. (V.M., B.B., F. Kazmirczak, J.M., T.A., C.M.M., R.C., F. Kamdar)
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15
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Shah H, Fraser M, Agdamag AC, Maharaj V, Nzemenoh B, Martin CM, Alexy T, Garry DJ. Cardiac Transplantation and the Use of Cannabis. Life (Basel) 2021; 11:life11101063. [PMID: 34685434 PMCID: PMC8539629 DOI: 10.3390/life11101063] [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: 09/01/2021] [Revised: 09/30/2021] [Accepted: 10/05/2021] [Indexed: 11/16/2022] Open
Abstract
Cardiac transplantation requires the careful allocation of a limited number of precious organs. Therefore, it is critical to select candidates that will receive the greatest anticipated medical benefit but will also serve as the best stewards of the organ. Individual transplant teams have established prerequisites pertaining to recreational drug, tobacco, alcohol, and controlled substance use in potential organ recipients and post-transplantation. Legalization of cannabis and implementation of its prescription-based use for the management of patients with chronic conditions have been increasing over the past years. Center requirements regarding abstinence from recreational and medical cannabis use vary due to rapidly changing state regulations, as well as the lack of clinical safety data in this population. This is evident by the results of the multicenter survey presented in this paper. Developing uniform guidelines around cannabis use will be imperative not only for providers but also for patients.
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Affiliation(s)
- Hirak Shah
- Lillehei Heart Institute and Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA; (H.S.); (A.C.A.); (V.M.); (C.M.M.)
- Advanced Heart Failure Program, Mechanical Circulatory Support Service and Cardiac Transplant Program, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Meg Fraser
- Advanced Heart Failure Program, Mechanical Circulatory Support Service and Cardiac Transplant Program, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Arianne C. Agdamag
- Lillehei Heart Institute and Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA; (H.S.); (A.C.A.); (V.M.); (C.M.M.)
- Advanced Heart Failure Program, Mechanical Circulatory Support Service and Cardiac Transplant Program, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Valmiki Maharaj
- Lillehei Heart Institute and Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA; (H.S.); (A.C.A.); (V.M.); (C.M.M.)
- Advanced Heart Failure Program, Mechanical Circulatory Support Service and Cardiac Transplant Program, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Bellony Nzemenoh
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Cindy M. Martin
- Lillehei Heart Institute and Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA; (H.S.); (A.C.A.); (V.M.); (C.M.M.)
- Advanced Heart Failure Program, Mechanical Circulatory Support Service and Cardiac Transplant Program, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Tamas Alexy
- Lillehei Heart Institute and Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA; (H.S.); (A.C.A.); (V.M.); (C.M.M.)
- Advanced Heart Failure Program, Mechanical Circulatory Support Service and Cardiac Transplant Program, University of Minnesota, Minneapolis, MN 55455, USA;
- Correspondence: (T.A.); (D.J.G.)
| | - Daniel J. Garry
- Lillehei Heart Institute and Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA; (H.S.); (A.C.A.); (V.M.); (C.M.M.)
- Advanced Heart Failure Program, Mechanical Circulatory Support Service and Cardiac Transplant Program, University of Minnesota, Minneapolis, MN 55455, USA;
- Paul and Sheila Wellstone Muscular Dystrophy Center, University of Minnesota, Minneapolis, MN 55455, USA
- Correspondence: (T.A.); (D.J.G.)
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Maharaj V, Masotti M, Schultz J, Martin C, John R, Alexy T, Thenappan T, Knoper R, Shaffer A, Cogswell R. Trends in Renal Function Prior to and after LVAD Placement and Association with Post LVAD Mortality. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1181] [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: 11/17/2022] Open
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El Rafei A, Schultz J, Masotti M, Maharaj V, Fraser M, Mutschler M, Martin C, Alexy T, Kamdar F, Knoper R, Shaffer A, John R, Cogswell R. Risk Factors and Clinical Significance of Vasoplegia after LVAD Implantation. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Cogswell R, Masotti M, Schultz J, Maharaj V, El Rafei A, Fraser M, Mutschler M, Martin C, Thenappan T, Pritzker M, Knoper R, John R, Shaffer A. A New Hemodynamic Profile Signaling Early Death on Left Ventricular Assist Device. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.506] [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: 11/16/2022] Open
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Maharaj V, Agdamag A, Edmiston J, Charpentier V, Schultz J, John R, Shaffer A, Duval S, Martin CM, Francis GS, Cogswell R, Alexy T. Hypotensive Response on Cardiopulmonary Stress Test Predicts Elevated Pulmonary Capillary Wedge Pressure and Reduced Cardiac Output in Patients Undergoing Evaluation for Left Ventricular Assist Device. J Card Fail 2020. [DOI: 10.1016/j.cardfail.2020.09.425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Velangi P, Maharaj V, Athwal S, Bartos J, Markowitz J, Duval S, Nijjar P. CT Coronary Plaque Characteristics Predict Ischemia Detected By Invasive Fractional Flow Reserve. J Cardiovasc Comput Tomogr 2020. [DOI: 10.1016/j.jcct.2020.06.148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Maharaj V, Masotti M, Schultz J, Murray T, Teigen L, Shah H, Shaffer A, Alexy T, John R, Cogswell R. Worsening Creatinine Trend in the Year Prior to LVAD Implantation is Associated with Lower Pectoralis Muscle Measures and Increased Post LVAD Mortality. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.223] [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: 11/29/2022] Open
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22
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Maharaj V, Schultz J, Charpentier V, Duval S, John R, Shaffer A, Pritzker M, Martin C, Thenappan T, Cogswell R, Alexy T. Higher Body Mass Index is Associated with End Stage Renal Failure after Left Ventricular Assist Device Implantation. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.170] [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: 10/24/2022] Open
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Abstract
Computed tomography angiography is frequently used for double rule out of obstructive coronary artery disease and pulmonary embolism in patients presenting to the emergency department with acute chest pain, but it is rare to see concomitant acute coronary occlusion and pulmonary embolism on the same computed tomography angiography scan. (Level of Difficulty: Beginner.)
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Affiliation(s)
- Valmiki Maharaj
- Division of Cardiology, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Pratik S Velangi
- Division of Cardiology, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Kurt Prins
- Division of Cardiology, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Pal Satyajit Singh Athwal
- Division of Cardiology, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Prabhjot S Nijjar
- Division of Cardiology, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
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Maharaj V, Cogswell R, Schultz J, John R, Martin C, Thenappan T, Alexy T. Poor Left Ventricular Unloading is Associated with Increased Mortality after Continuous Flow Left Ventricular Assist Device Implantation. J Heart Lung Transplant 2019. [DOI: 10.1016/j.healun.2019.01.179] [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: 11/29/2022] Open
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25
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Maharaj V, Fitz M, Ding X. Drug-Induced Liver Injury in the Setting of Glycogenic Hepatopathy. J Gen Intern Med 2017; 32:714-717. [PMID: 28224373 PMCID: PMC5442014 DOI: 10.1007/s11606-017-3996-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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] [Received: 03/16/2016] [Revised: 07/11/2016] [Accepted: 01/13/2017] [Indexed: 12/12/2022]
Abstract
Glycogenic hepatopathy (GH) is an underdiagnosed complication of uncontrolled type 1 diabetes mellitus (T1DM). It appears as an acute relapsing hepatitis with reversible transaminase elevations secondary to excessive hepatic glycogen accumulation. Patients are often asymptomatic but can present with abdominal pain, nausea and vomiting. Physical examination shows hepatomegaly without splenomegaly. GH is diagnosed by biopsy as it is clinically indistinguishable from non-alcoholic fatty liver disease (NAFLD), a more common cause of hepatic dysfunction in diabetics. Here we describe a case of GH in a patient with uncontrolled type 1 diabetes whose clinical course was complicated by drug-induced liver injury. The patient initially presented with diabetic ketoacidosis and had a mild transaminitis, thought to be due to NAFLD. She developed profound transaminase elevations while receiving treatment with newer antipsychotic medications for her bipolar disorder. Liver biopsy showed evidence of resolving glycogenic hepatopathy with signs of drug-induced liver injury. This case report reviews the pathology and pathogenesis of GH and reminds the clinician to keep GH within the differential diagnosis for severe transaminitis in a patient with type 1 diabetes mellitus.
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Affiliation(s)
- Valmiki Maharaj
- Department of Medicine, Loyola University Stritch School of Medicine, Room 7612, 2160 S 1st Avenue, Maywood, IL, 60153, USA.
| | - Matthew Fitz
- Department of Medicine, Loyola University Stritch School of Medicine, Room 7612, 2160 S 1st Avenue, Maywood, IL, 60153, USA
| | - Xianzdong Ding
- Department of Pathology, Loyola University Stritch School of Medicine, Room 7612, 2160 S 1st Avenue, Maywood, IL, 60153, USA
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Maharaj V, Rahman F, Adamson L. Tackling child health inequalities due to deprivation: using health equity audit to improve and monitor access to a community paediatric service. Child Care Health Dev 2014; 40:223-30. [PMID: 23121388 DOI: 10.1111/cch.12011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Deprived children constitute a large population with high levels of ill health, and difficulty with access to healthcare contributes to their poor health outcomes. There is debate on how best to engage deprived families and the literature on differential access to paediatric care based on deprivation is limited. AIMS To demonstrate that community paediatrics can contribute to reduction of health inequalities by providing services that are accessible to and preferentially used by children whose health is likely to be affected by deprivation. To provide a template for others to improve and monitor equity in their services. METHOD Long-term service reconfiguration and health equity audit. We used routinely collected activity data and the Indices of Multiple Deprivation to construct equity profiles of the children using our service, and compared these with the profile of the population aged 0-16 years in the geographical area covered by the service. RESULTS The new patient contact rate for the most deprived children in the population was more than three times that of the least deprived [odds ratio (OR) 3.29, 95% confidence interval (CI) 2.76-3.93]. Deprived children were more than twice as likely to require multi-agency meetings as part of their medical care (OR 2.28, 95% CI 1.94-2.69). Seventy per cent (3693/5312) of our total contacts were with children in the two most deprived quintiles. There was a marked socio-economic gradient in all types of contact. CONCLUSIONS The model of care used by our community paediatric service successfully engages deprived families, thereby reducing health inequalities due to poor access. Key features are multi-agency working, removing barriers to access, raising staff awareness and use of health equity audit. Our findings provide support for tackling health inequalities via health services that are available to all, but capable of responding proportionately according to level of need, a model recently described as proportionate universalism.
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Affiliation(s)
- V Maharaj
- Derbyshire Healthcare NHS Foundation Trust, Derbyshire, UK
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Kalra A, Maharaj V, Johannsen RA, Hollenberg SM. Catheterization laboratory activation during mechanical cardiopulmonary resuscitation: When should we say “No?”. Catheter Cardiovasc Interv 2013; 83:58-64. [DOI: 10.1002/ccd.25167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 08/22/2013] [Indexed: 11/07/2022]
Affiliation(s)
- Ankur Kalra
- Department of Medicine; Section of Cardiology, Hennepin County Medical Center; Minneapolis Minnesota
| | - Valmiki Maharaj
- University of Minnesota Medical School; Minneapolis Minnesota
| | - Ronald A. Johannsen
- Department of Medicine; Section of Cardiology, Hennepin County Medical Center; Minneapolis Minnesota
- University of Minnesota Medical School; Minneapolis Minnesota
| | - Steven M. Hollenberg
- Department of Medicine; Section of Cardiology and Critical Care Medicine, Cooper University Hospital, Cooper Medical School of Rowan University; Camden New Jersey
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Maharaj V, Rauk A, van de Sande J, Wieser H. Infrared absorption and vibrational circular dichroism spectra of selected deoxyoctanucleotides complexed with daunorubicin. J Mol Struct 1997. [DOI: 10.1016/s0022-2860(96)09668-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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