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Forrest JK, Deeb GM, Yakubov SJ, Rovin JD, Mumtaz M, Gada H, O'Hair D, Bajwa T, Sorajja P, Heiser JC, Merhi W, Mangi A, Spriggs DJ, Kleiman NS, Chetcuti SJ, Teirstein PS, Zorn GL, Tadros P, Tchétché D, Resar JR, Walton A, Gleason TG, Ramlawi B, Iskander A, Caputo R, Oh JK, Huang J, Reardon MJ. 2-Year Outcomes After Transcatheter Versus Surgical Aortic Valve Replacement in Low-Risk Patients. J Am Coll Cardiol 2022; 79:882-896. [PMID: 35241222 DOI: 10.1016/j.jacc.2021.11.062] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/24/2021] [Accepted: 11/29/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND The Evolut Low Risk Trial (Medtronic Evolut Transcatheter Aortic Valve Replacement in Low Risk Patients) showed that transcatheter aortic valve replacement (TAVR) with a supra-annular, self-expanding valve was noninferior to surgery for the primary endpoint of all-cause mortality or disabling stroke at 2 years. This finding was based on a Bayesian analysis performed after 850 patients had reached 1 year of follow-up. OBJECTIVES The goal of this study was to report the full 2-year clinical and echocardiographic outcomes for patients enrolled in the Evolut Low Risk Trial. METHODS A total of 1,414 low-surgical risk patients with severe aortic stenosis were randomized to receive TAVR or surgical AVR. An independent clinical events committee adjudicated adverse events, and a central echocardiographic core laboratory assessed hemodynamic endpoints. RESULTS An attempted implant was performed in 730 TAVR and 684 surgical patients from March 2016 to May 2019. The Kaplan-Meier rates for the complete 2-year primary endpoint of death or disabling stroke were 4.3% in the TAVR group and 6.3% in the surgery group (P = 0.084). These rates were comparable to the interim Bayesian rates of 5.3% with TAVR and 6.7% with surgery (difference: -1.4%; 95% Bayesian credible interval: -4.9% to 2.1%). All-cause mortality rates were 3.5% vs 4.4% (P = 0.366), and disabling stroke rates were 1.5% vs 2.7% (P = 0.119), respectively. Between years 1 and 2, there was no convergence of the primary outcome curves. CONCLUSIONS The complete 2-year follow-up from the Evolut Low Risk Trial found that TAVR is noninferior to surgery for the primary endpoint of all-cause mortality or disabling stroke, with event rates that were slightly better than those predicted by using the Bayesian analysis. (Medtronic Evolut Transcatheter Aortic Valve Replacement in Low Risk Patients [Evolut Low Risk Trial]; NCT02701283).
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Affiliation(s)
- John K Forrest
- Department of Internal Medicine (Cardiology), Yale University School of Medicine, New Haven, Connecticut, USA; Department of Surgery (Cardiac Surgery), Yale University School of Medicine, New Haven, Connecticut, USA.
| | - G Michael Deeb
- Department of Interventional Cardiology, University of Michigan Hospitals, Ann Arbor, Michigan, USA; Department of Cardiovascular Surgery, University of Michigan Hospitals, Ann Arbor, Michigan, USA
| | - Steven J Yakubov
- Department of Interventional Cardiology, Riverside Methodist-OhioHealth, Columbus, Ohio, USA
| | - Joshua D Rovin
- Department of Cardiac Surgery, Morton Plant Hospital, Clearwater, Florida, USA
| | - Mubashir Mumtaz
- Department of Interventional Cardiology, University of Pittsburgh Medical Center Pinnacle, Wormleyburg, Pennsylvania, USA; Department of Cardiovascular and Thoracic Surgery, University of Pittsburgh Medical Center Pinnacle, Wormleyburg, Pennsylvania, USA
| | - Hemal Gada
- Department of Interventional Cardiology, University of Pittsburgh Medical Center Pinnacle, Wormleyburg, Pennsylvania, USA; Department of Cardiovascular and Thoracic Surgery, University of Pittsburgh Medical Center Pinnacle, Wormleyburg, Pennsylvania, USA
| | - Daniel O'Hair
- Department of Interventional Cardiology, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, USA; Department of Cardiovascular Surgery, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, USA
| | - Tanvir Bajwa
- Department of Interventional Cardiology, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, USA; Department of Cardiovascular Surgery, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, USA
| | - Paul Sorajja
- Department of Interventional Cardiology, Minneapolis Heart Institute-Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - John C Heiser
- Department of Interventional Cardiology, Spectrum Health, Grand Rapids, Michigan, USA; Department of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Michigan, USA
| | - William Merhi
- Department of Interventional Cardiology, Spectrum Health, Grand Rapids, Michigan, USA; Department of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Michigan, USA
| | - Abeel Mangi
- Department of Internal Medicine (Cardiology), Yale University School of Medicine, New Haven, Connecticut, USA; Department of Surgery (Cardiac Surgery), Yale University School of Medicine, New Haven, Connecticut, USA
| | - Douglas J Spriggs
- Department of Cardiac Surgery, Morton Plant Hospital, Clearwater, Florida, USA
| | - Neal S Kleiman
- Department of Interventional Cardiology, Houston Methodist-DeBakey Heart and Vascular Center, Houston, Texas, USA; Department of Cardiothoracic Surgery, Houston Methodist-DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Stanley J Chetcuti
- Department of Interventional Cardiology, University of Michigan Hospitals, Ann Arbor, Michigan, USA; Department of Cardiovascular Surgery, University of Michigan Hospitals, Ann Arbor, Michigan, USA
| | - Paul S Teirstein
- Department of Interventional Cardiology, Scripps Clinic, La Jolla, California, USA
| | - George L Zorn
- Department of Interventional Cardiology, University of Kansas, Kansas City, Kansas, USA; Department of Cardiac Surgery, University of Kansas, Kansas City, Kansas, USA
| | - Peter Tadros
- Department of Interventional Cardiology, University of Kansas, Kansas City, Kansas, USA; Department of Cardiac Surgery, University of Kansas, Kansas City, Kansas, USA
| | - Didier Tchétché
- Department of Interventional Cardiology, Clinique Pasteur, Toulouse, France
| | - Jon R Resar
- Department of Interventional Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Antony Walton
- Department of Interventional Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Thomas G Gleason
- Department of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Basel Ramlawi
- Department of Cardiovascular Surgery, Valley Health System, Winchester, Virginia, USA
| | - Ayman Iskander
- Department of Interventional Cardiology, Saint Joseph's Hospital Health Center, Syracuse, New York, USA; Department of Cardiovascular Surgery, Saint Joseph's Hospital Health Center, Syracuse, New York, USA
| | - Ronald Caputo
- Department of Interventional Cardiology, Saint Joseph's Hospital Health Center, Syracuse, New York, USA; Department of Cardiovascular Surgery, Saint Joseph's Hospital Health Center, Syracuse, New York, USA
| | - Jae K Oh
- Division of Cardiovascular Ultrasound, Mayo Clinic, Rochester, Minnesota, USA
| | - Jian Huang
- Department of Statistics, Medtronic, Minneapolis, Minnesota, USA
| | - Michael J Reardon
- Department of Interventional Cardiology, Houston Methodist-DeBakey Heart and Vascular Center, Houston, Texas, USA; Department of Cardiothoracic Surgery, Houston Methodist-DeBakey Heart and Vascular Center, Houston, Texas, USA
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Hameed I, Oakley CT, Hameed NUF, Ahmed A, Naeem N, Singh S, Rizwana K, Brackett A, Forrest JK, Kaple R, Mangi A, Salemi A, Geirsson A, Gaudino M, Vallabhajosyula P. Alternate accesses for transcatheter aortic valve replacement: A network meta-analysis. J Card Surg 2021; 36:4308-4319. [PMID: 34494307 DOI: 10.1111/jocs.15961] [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: 07/04/2021] [Accepted: 08/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND When transfemoral (TF) access is contraindicated in patients undergoing transcatheter aortic valve replacement (TAVR), alternate access strategies are considered. The choice of one alternate access over the other remains controversial. METHODS Following a comprehensive literature search, studies comparing any combination of TF, transapical (TA), transaortic (TAo), transcarotid (TC), and trans-subclavian (TS) TAVR were identified. Data were pooled using fixed- and random-effects network meta-analysis. Rank scores with probability ranks of different treatment groups were calculated. RESULTS Eighty-four studies (26,449 patients) were included. Compared to TF access, TA and TAo accesses were associated with higher 30-day mortality (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.31-1.94; OR 1.79, 95% CI 1.21-2.66, respectively), while the TC and TS showed no difference (OR 1.12, 95% CI 0.64-1.95; OR 1.23, 95% CI 0.67-2.27, respectively); TF access ranked best followed by TC. There was no significant difference in 30-day stroke; TC access ranked best followed by TS. At a weighted mean follow-up of 1.6 years, TA and TAo accesses were associated with higher long-term mortality versus TF (incidence rate ratio [IRR] 1.31, 95% CI 1.18-1.45; IRR 1.41, 95% CI 1.11-1.79, respectively); there was no difference between TC and TS versus TF access (IRR 1.02, 95% CI 0.70-1.47; IRR 1.16, 95% CI 0.82-1.66, respectively); TF access ranked best followed by TC. At a weighted mean follow-up of 1.4 years, only TA access was associated with higher long-term stroke compared to TF (IRR 3.01, 95% CI 1.15-7.87); TF access ranked as the best strategy followed by TAo. CONCLUSION TC and TS approaches are associated with superior postoperative outcomes compared to other TAVR alternate access strategies. Randomized trials definitively assessing the safety and efficacy of alternate access strategies are needed.
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Affiliation(s)
- Irbaz Hameed
- Department of Surgery, Section of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Christian T Oakley
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - N U Farrukh Hameed
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Adham Ahmed
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Nyla Naeem
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Saket Singh
- Department of Surgery, Section of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kaniz Rizwana
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Alexandria Brackett
- Cushing/Whitney Medical Library, Yale School of Medicine, New Haven, Connecticut, USA
| | - John K Forrest
- Department of Internal Medicine, Division of Cardiology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ryan Kaple
- Department of Internal Medicine, Division of Cardiology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Abeel Mangi
- Department of Surgery, Section of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Arash Salemi
- Department of Cardiothoracic Surgery, Robert Wood Johnson/Barnabas Health, West Orange, New Jersey, USA
| | - Arnar Geirsson
- Department of Surgery, Section of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Prashanth Vallabhajosyula
- Department of Surgery, Section of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
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Chen JF, Mangi A, Vallabhajosyula P, Nassiri N. Snare-assisted thoracic endovascular aortic repair for redirection of a false lumen elephant trunk. Journal of Vascular Surgery Cases, Innovations and Techniques 2020; 6:566-570. [PMID: 33134644 PMCID: PMC7588806 DOI: 10.1016/j.jvscit.2020.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 08/05/2020] [Indexed: 11/25/2022]
Abstract
In recent years, a hybrid approach to the classic two-stage elephant trunk technique has come into favor for treatment of thoracic aortic dissection. During the first stage, inadvertent intraoperative placement of the elephant trunk into the false lumen can occur on rare occasions, resulting in untoward difficulties during the second stage of the procedure. We describe here a snare-assisted technique for endovascular salvage of an elephant trunk that had inadvertently been placed in the false lumen of a chronic aortic dissection.
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Affiliation(s)
- Julia Fayanne Chen
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn.,Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Abeel Mangi
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Prashanth Vallabhajosyula
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, Conn.,Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Naiem Nassiri
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn.,Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, Conn
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Stawiarski K, Agboola O, Park J, Mangi A, Geirsson A, Bellumkonda L, Lee F, Chen M, Jacoby D, Chou J, Ahmad T, Testani J, McCloskey G, Bonde P. The Effects of Less Invasive Extra-Pericardial Placement of Left Ventricular Assist Devices on Right Ventricular Failure in the Early Postoperative Period. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.1087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Stawiarski K, Agboola O, Park J, Mangi A, Geirsson A, Lee F, Jacoby D, Bellumkonda L, Ahmad T, Chou J, Testani J, Chen M, McCloskey G, Bonde P. Blood Conservation Strategy at Time of Left Ventricular Assist Device Placement Improves Survival. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.1086] [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: 12/01/2022] Open
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Knudson KA, Gustafson CM, Sadler LS, Whittemore R, Redeker NS, Andrews LK, Mangi A, Funk M. Long-term health-related quality of life of adult patients treated with extracorporeal membrane oxygenation (ECMO): An integrative review. Heart Lung 2019; 48:538-552. [DOI: 10.1016/j.hrtlng.2019.08.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 08/09/2019] [Accepted: 08/12/2019] [Indexed: 12/13/2022]
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Søndergaard L, Popma JJ, Reardon MJ, Van Mieghem NM, Deeb GM, Kodali S, George I, Williams MR, Yakubov SJ, Kappetein AP, Serruys PW, Grube E, Schiltgen MB, Chang Y, Engstrøm T, Sorajja P, Sun B, Agarwal H, Langdon T, den Heijer P, Bentala M, O’Hair D, Bajwa T, Byrne T, Caskey M, Paulus B, Garrett E, Stoler R, Hebeler R, Khabbaz K, Scott Lim D, Bladergroen M, Fail P, Feinberg E, Rinaldi M, Skipper E, Chawla A, Hockmuth D, Makkar R, Cheng W, Aji J, Bowen F, Schreiber T, Henry S, Hengstenberg C, Bleiziffer S, Harrison JK, Hughes C, Joye J, Gaudiani V, Babaliaros V, Thourani V, Dauerman H, Schmoker J, Skelding K, Casale A, Kovac J, Spyt T, Seshiah P, Smith JM, McKay R, Hagberg R, Matthews R, Starnes V, O’Neill W, Paone G, García JMH, Such M, de la Tassa CM, Cortina JCL, Windecker S, Carrel T, Whisenant B, Doty J, Resar J, Conte J, Aharonian V, Pfeffer T, Rück A, Corbascio M, Blackman D, Kaul P, Kliger C, Brinster D, Teefy P, Kiaii B, Leya F, Bakhos M, Sandhu G, Pochettino A, Piazza N, de Varennes B, van Boven A, Boonstra P, Waksman R, Bafi A, Asgar A, Cartier R, Kipperman R, Brown J, Lin L, Rovin J, Sharma S, Adams D, Katz S, Hartman A, Al-Jilaihawi H, Crestanello J, Lilly S, Ghani M, Bodenhamer RM, Rajagopal V, Kauten J, Mumtaz M, Bachinsky W, Nickenig G, Welz A, Olsen P, Watson D, Chhatriwalla A, Allen K, Teirstein P, Tyner J, Mahoney P, Newton J, Merhi W, Keiser J, Yeung A, Miller C, Berg JT, Heijmen R, Petrossian G, Robinson N, Brecker S, Jahangiri M, Davis T, Batra S, Hermiller J, Heimansohn D, Radhakrishnan S, Fremes S, Maini B, Bethea B, Brown D, Ryan W, Kleiman N, Spies C, Lau J, Herrmann H, Bavaria J, Horlick E, Feindel C, Neumann FJ, Beyersdorf F, Binder R, Maisano F, Costa M, Markowitz A, Tadros P, Zorn G, de Marchena E, Salerno T, Chetcuti S, Labinz M, Ruel M, Lee JS, Gleason T, Ling F, Knight P, Robbins M, Ball S, Giacomini J, Burdon T, Applegate R, Kon N, Schwartz R, Schubach S, Forrest J, Mangi A. Comparison of a Complete Percutaneous Versus Surgical Approach to Aortic Valve Replacement and Revascularization in Patients at Intermediate Surgical Risk: Results From the Randomized SURTAVI Trial. Circulation 2019; 140:1296-1305. [PMID: 31476897 DOI: 10.1161/circulationaha.118.039564] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [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
BACKGROUND For patients with severe aortic stenosis and coronary artery disease, the completely percutaneous approach to aortic valve replacement and revascularization has not been compared with the standard surgical approach. METHODS The prospective SURTAVI trial (Safety and Efficiency Study of the Medtronic CoreValve System in the Treatment of Severe, Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement) enrolled intermediate-risk patients with severe aortic stenosis from 87 centers in the United States, Canada, and Europe between June 2012 and June 2016. Complex coronary artery disease with SYNTAX score (Synergy Between PCI with Taxus and Cardiac Surgery Trial) >22 was an exclusion criterion. Patients were stratified according to the need for revascularization and then randomly assigned to treatment with transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). Patients assigned to revascularization in the TAVR group underwent percutaneous coronary intervention, whereas those in the SAVR group had coronary artery bypass grafting. The primary end point was the rate of all-cause mortality or disabling stroke at 2 years. RESULTS Of 1660 subjects with attempted aortic valve implants, 332 (20%) were assigned to revascularization. They had a higher Society of Thoracic Surgeons risk score for mortality (4.8±1.7% versus 4.4±1.5%; P<0.01) and were more likely to be male (65.1% versus 54.2%; P<0.01) than the 1328 patients not assigned to revascularization. After randomization to treatment, there were 169 patients undergoing TAVR and percutaneous coronary intervention, 163 patients undergoing SAVR and coronary artery bypass grafting, 695 patients undergoing TAVR, and 633 patients undergoing SAVR. No significant difference in the rate of the primary end point was found between TAVR and percutaneous coronary intervention and SAVR and coronary artery bypass grafting (16.0%; 95% CI, 11.1-22.9 versus 14.0%; 95% CI, 9.2-21.1; P=0.62), or between TAVR and SAVR (11.9%; 95% CI, 9.5-14.7 versus 12.3%; 95% CI, 9.8-15.4; P=0.76). CONCLUSIONS For patients at intermediate surgical risk with severe aortic stenosis and noncomplex coronary artery disease (SYNTAX score ≤22), a complete percutaneous approach of TAVR and percutaneous coronary intervention is a reasonable alternative to SAVR and coronary artery bypass grafting. CLINICAL TRIAL REGISTRATION URL: https://www. CLINICALTRIALS gov. Unique identifier: NCT01586910.
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Affiliation(s)
- Lars Søndergaard
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Denmark (L.S., T.E.)
| | - Jeffrey J. Popma
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA (J.J.P.)
| | - Michael J. Reardon
- Department of Cardiovascular Surgery, Methodist DeBakey Heart and Vascular Center, Houston, TX (M.J.R.)
| | - Nicolas M. Van Mieghem
- Departments of Cardiology and Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands (N.M.V.M., A.P.K.)
| | - G. Michael Deeb
- Department of Cardiac Surgery, University of Michigan, Ann Arbor (G.M.D.)
| | - Susheel Kodali
- Department of Surgery, Columbia University Medical Center, New York (S.K., I.G.)
| | - Isaac George
- Department of Surgery, Columbia University Medical Center, New York (S.K., I.G.)
| | - Mathew R. Williams
- Departments of Medicine (Cardiology) and Cardiothoracic Surgery, NYU-Langone Medical Center, New York (M.R.W.)
| | - Steven J. Yakubov
- Department of Cardiology, OhioHealth Riverside Methodist Hospital, Columbus (S.J.Y.)
| | - Arie P. Kappetein
- Departments of Cardiology and Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands (N.M.V.M., A.P.K.)
- Structural Heart, Medtronic plc, Minneapolis, MN (A.P.K., M.B.S., Y.C.)
| | - Patrick W. Serruys
- International Centre for Circulatory Health, NHLI, Imperial College London, United Kingdom (P.W.S.)
| | - Eberhard Grube
- Department of Medicine II, Heart Center Bonn, Germany (E.G.)
| | | | - Yanping Chang
- Structural Heart, Medtronic plc, Minneapolis, MN (A.P.K., M.B.S., Y.C.)
| | - Thomas Engstrøm
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Denmark (L.S., T.E.)
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Nguemeni Tiako MJ, Hong S, Bin Mahmood SU, Darr U, Mangi A, Jutthani-Mehta M, Geirsson A. Abstract 255: Patterns of Addiction Treatment for Patients Undergoing Cardiac Surgery for Infective Endocarditis Associated with Intravenous Drug Use. Circ Cardiovasc Qual Outcomes 2019. [DOI: 10.1161/hcq.12.suppl_1.255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Over the last decade, the U.S. has seen an increase in the number of infective endocarditis (IE) cases requiring surgical intervention. Infective endocarditis is often caused by intravenous drug use (IVDU). Given the complexity of these cases, the association with IVDU and the current opioid epidemic, we sought to characterize the nature of addiction interventions for these patients peri-operatively.
Methods:
This is a retrospective review of patients who underwent cardiac surgery for IE associated with a history of IVDU from 2009 to 2016 at a tertiary care center in New Haven, Connecticut. Data was collected including which drugs patients used, consultations by social work and psychiatry, initiation of medical therapy for addiction (methadone, buprenorphine, naltrexone), harm reduction initiative (naloxone), and evidence of enrollment in a drug rehabilitation program in the post-operative period.
Results:
This study observed 56 patients with a history of IVDU who underwent surgical intervention for IE. Thirty patients had active drug use at the time of their surgery, and the rest was labeled as having a history of IVDU. Among the 30, 22 used at least heroin, including 8 who used heroin and cocaine, and 5 who used heroin along with 2 or more other drugs (benzodiazepine, PCP, street suboxone, cocaine, Percocet, marijuana). In terms of psychosocial interventions, 41 (73.2%) were seen by a social worker, and 38 (67.9%) were seen by a psychiatrist during their hospitalization. Fourteen patients (25%) were neither seen by a social worker nor a psychiatrist. Medical therapy was defined as the administration of methadone, buprenorphine, naltrexone or naloxone during the hospitalization. Twenty-one patients (37.5%) were prescribed methadone, 6 patients (10.7%) were prescribed buprenorphine, 14 (25%) were prescribed naloxone, and 1 (0.02%) was prescribed naltrexone. Twenty-six patients (46.4%) were not prescribed any of the aforementioned medications. A total of 15 patients went to a drug rehabilitation program (26.8%) upon discharge, 13 of whom had been seen by a social worker (86.7%), and 8 by a psychiatrist (53.3%). Conversely, among those who did not go to a rehabilitation program, only 23% were seen by a psychiatrist, and 67.5% were seen by a social worker. The programs described included 12-step group rehabilitation, narcotics anonymous and adherence to daily methadone programs.
Conclusion:
This study highlights the inconsistency in addiction interventions in patients with IVDU-associated IE. Some patients receive medical therapy and are consulted upon for their psychosocial factors, but this practice is inconsistent. Given than recidivism (relapse in drug use or recurrent endocarditis) is the leading cause of death in this population, standardized protocols for addiction interventions in these patients are of utmost importance with the aim to improve long-term survival.
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Mori M, Brown K, Mahmood SUB, Geirsson A, Mangi A. TRENDS IN INFECTIVE ENDOCARDITIS INCIDENCE, CHARACTERISTICS, AND VALVE REPLACEMENT IN PATIENTS WITH OPIOID USE DISORDERS IN THE UNITED STATES FROM 2005 TO 2014. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)32574-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nguemeni Tiako MJ, Mori M, Bin Mahmood SU, Shioda K, Mangi A, Yun J, Geirsson A. Recidivism Is the Leading Cause of Death Among Intravenous Drug Users Who Underwent Cardiac Surgery for Infective Endocarditis. Semin Thorac Cardiovasc Surg 2019; 31:40-45. [DOI: 10.1053/j.semtcvs.2018.07.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 07/24/2018] [Indexed: 02/06/2023]
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Kleiman NS, Maini BJ, Reardon MJ, Conte J, Katz S, Rajagopal V, Kauten J, Hartman A, McKay R, Hagberg R, Huang J, Popma J, Ad N, Aharonian V, Anderson WD, Applegate R, Bafi A, Bajwa T, Bakhos M, Ball S, Batra S, Beohar N, Brachinsky W, Brinster D, Brown J, Byrne J, Byrne T, Casale A, Caskey M, Chawla A, Cohen H, Coselli J, Costa M, Cheatham J, Chetcuti SJ, Crestanello J, Davis T, Michael Deeb G, Diez J, Dauerman H, Elefteriades J, Fail P, Feinberg E, Fontana G, Forrest JL, Galloway A, Giacomini J, Gleason TG, Guadiani V, Harrison JK, Hebeler R, Heimansohn D, Heiser J, Heller L, Henry S, Hermiller J, Hockmuth D, Hughes GC, Joye J, Kafi A, Kar B, Khabbaz K, Kipperman R, Kliger C, Kon N, Lamelas J, Lee JS, Leya F, Londono JC, Macheers S, Mangi A, de Marchena E, Markowitz A, Matthews R, Merhi W, Mumtaz M, O’Hair D, Petrossian G, Pfeffer T, Raybuck B, Resar J, Robbins M, Robbins R, Robinson N, Ring M, Salerno T, Schreiber T, Schmoker J, Sharma S, Siwek L, Skelding K, Slater J, Starnes V, Stoler R, Subramanian V, Tadros P, Thompson C, Waksman R, Watson D, Yakubov S, Zhao D, Zorn GL. Neurological Events Following Transcatheter Aortic Valve Replacement and Their Predictors: A Report From the CoreValve Trials. Circ Cardiovasc Interv 2017; 9:CIRCINTERVENTIONS.115.003551. [PMID: 27601429 DOI: 10.1161/circinterventions.115.003551] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 07/15/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The risk for stroke after transcatheter aortic valve replacement (TAVR) is an important concern. Identification of predictors for stroke is likely to be a critical factor aiding patient selection and management as TAVR use becomes widespread. METHODS AND RESULTS Patients enrolled in the CoreValve US Extreme Risk and High Risk Pivotal Trials or Continued Access Study treated with the self-expanding CoreValve bioprosthesis were included in this analysis. The 1-year stroke rate after TAVR was 8.4%. Analysis of the stroke hazard rate identified an early phase (0-10 days; 4.1% of strokes) and a late phase (11-365 days; 4.3% of strokes). Baseline predictors of early stroke included National Institutes of Health stroke scale score >0, prior stroke, prior transient ischemic attack, peripheral vascular disease, absence of prior coronary artery bypass surgery, angina, low body mass index (<21 kg/m(2)), and falls within the past 6 months. Significant procedural predictors were total time in the catheterization laboratory or operating room, delivery catheter in the body time, rapid pacing used during valvuloplasty, and repositioning of the prosthesis. Predictors of stroke between 11 and 365 days were small body surface area, severe aortic calcification, and falls within the past 6 months. There were no significant imaging predictors of early or late stroke. CONCLUSIONS Predictors of early stroke after TAVR included clinical and procedural factors; predictors of later stroke were limited to patient but not anatomic characteristics. These findings indicate that further refinement of imaging to identify anatomic factors predisposing to embolization may help improve stroke prediction in patients undergoing TAVR. CLINICAL TRIAL REGISTRATIONS URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01240902, NCT01531374.
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Affiliation(s)
- Neal S Kleiman
- From the Houston Methodist DeBakey Heart and Vascular Institute, TX (N.S.K., M.J.R.); Tenet Healthcare Corporation, Delray Beach, FL (B.J.M.); Johns Hopkins University, Baltimore, MD (J.C.); Hofstra North Shore University Hospital, New Hyde Park, NY (S.K., A.H.); Hartford Hospital, CT (R.M., R. H.); Piedmont Heart Institute, Atlanta, GA (V.R., J.K.); Medtronic, Minneapolis, MN (J.H.); and Beth Israel Deaconess Medical Center, Boston, MA (J.J.P.).
| | - Brijeshwar J Maini
- From the Houston Methodist DeBakey Heart and Vascular Institute, TX (N.S.K., M.J.R.); Tenet Healthcare Corporation, Delray Beach, FL (B.J.M.); Johns Hopkins University, Baltimore, MD (J.C.); Hofstra North Shore University Hospital, New Hyde Park, NY (S.K., A.H.); Hartford Hospital, CT (R.M., R. H.); Piedmont Heart Institute, Atlanta, GA (V.R., J.K.); Medtronic, Minneapolis, MN (J.H.); and Beth Israel Deaconess Medical Center, Boston, MA (J.J.P.)
| | - Michael J Reardon
- From the Houston Methodist DeBakey Heart and Vascular Institute, TX (N.S.K., M.J.R.); Tenet Healthcare Corporation, Delray Beach, FL (B.J.M.); Johns Hopkins University, Baltimore, MD (J.C.); Hofstra North Shore University Hospital, New Hyde Park, NY (S.K., A.H.); Hartford Hospital, CT (R.M., R. H.); Piedmont Heart Institute, Atlanta, GA (V.R., J.K.); Medtronic, Minneapolis, MN (J.H.); and Beth Israel Deaconess Medical Center, Boston, MA (J.J.P.)
| | - John Conte
- From the Houston Methodist DeBakey Heart and Vascular Institute, TX (N.S.K., M.J.R.); Tenet Healthcare Corporation, Delray Beach, FL (B.J.M.); Johns Hopkins University, Baltimore, MD (J.C.); Hofstra North Shore University Hospital, New Hyde Park, NY (S.K., A.H.); Hartford Hospital, CT (R.M., R. H.); Piedmont Heart Institute, Atlanta, GA (V.R., J.K.); Medtronic, Minneapolis, MN (J.H.); and Beth Israel Deaconess Medical Center, Boston, MA (J.J.P.)
| | - Stanley Katz
- From the Houston Methodist DeBakey Heart and Vascular Institute, TX (N.S.K., M.J.R.); Tenet Healthcare Corporation, Delray Beach, FL (B.J.M.); Johns Hopkins University, Baltimore, MD (J.C.); Hofstra North Shore University Hospital, New Hyde Park, NY (S.K., A.H.); Hartford Hospital, CT (R.M., R. H.); Piedmont Heart Institute, Atlanta, GA (V.R., J.K.); Medtronic, Minneapolis, MN (J.H.); and Beth Israel Deaconess Medical Center, Boston, MA (J.J.P.)
| | - Vivek Rajagopal
- From the Houston Methodist DeBakey Heart and Vascular Institute, TX (N.S.K., M.J.R.); Tenet Healthcare Corporation, Delray Beach, FL (B.J.M.); Johns Hopkins University, Baltimore, MD (J.C.); Hofstra North Shore University Hospital, New Hyde Park, NY (S.K., A.H.); Hartford Hospital, CT (R.M., R. H.); Piedmont Heart Institute, Atlanta, GA (V.R., J.K.); Medtronic, Minneapolis, MN (J.H.); and Beth Israel Deaconess Medical Center, Boston, MA (J.J.P.)
| | - James Kauten
- From the Houston Methodist DeBakey Heart and Vascular Institute, TX (N.S.K., M.J.R.); Tenet Healthcare Corporation, Delray Beach, FL (B.J.M.); Johns Hopkins University, Baltimore, MD (J.C.); Hofstra North Shore University Hospital, New Hyde Park, NY (S.K., A.H.); Hartford Hospital, CT (R.M., R. H.); Piedmont Heart Institute, Atlanta, GA (V.R., J.K.); Medtronic, Minneapolis, MN (J.H.); and Beth Israel Deaconess Medical Center, Boston, MA (J.J.P.)
| | - Alan Hartman
- From the Houston Methodist DeBakey Heart and Vascular Institute, TX (N.S.K., M.J.R.); Tenet Healthcare Corporation, Delray Beach, FL (B.J.M.); Johns Hopkins University, Baltimore, MD (J.C.); Hofstra North Shore University Hospital, New Hyde Park, NY (S.K., A.H.); Hartford Hospital, CT (R.M., R. H.); Piedmont Heart Institute, Atlanta, GA (V.R., J.K.); Medtronic, Minneapolis, MN (J.H.); and Beth Israel Deaconess Medical Center, Boston, MA (J.J.P.)
| | - Raymond McKay
- From the Houston Methodist DeBakey Heart and Vascular Institute, TX (N.S.K., M.J.R.); Tenet Healthcare Corporation, Delray Beach, FL (B.J.M.); Johns Hopkins University, Baltimore, MD (J.C.); Hofstra North Shore University Hospital, New Hyde Park, NY (S.K., A.H.); Hartford Hospital, CT (R.M., R. H.); Piedmont Heart Institute, Atlanta, GA (V.R., J.K.); Medtronic, Minneapolis, MN (J.H.); and Beth Israel Deaconess Medical Center, Boston, MA (J.J.P.)
| | - Robert Hagberg
- From the Houston Methodist DeBakey Heart and Vascular Institute, TX (N.S.K., M.J.R.); Tenet Healthcare Corporation, Delray Beach, FL (B.J.M.); Johns Hopkins University, Baltimore, MD (J.C.); Hofstra North Shore University Hospital, New Hyde Park, NY (S.K., A.H.); Hartford Hospital, CT (R.M., R. H.); Piedmont Heart Institute, Atlanta, GA (V.R., J.K.); Medtronic, Minneapolis, MN (J.H.); and Beth Israel Deaconess Medical Center, Boston, MA (J.J.P.)
| | - Jian Huang
- From the Houston Methodist DeBakey Heart and Vascular Institute, TX (N.S.K., M.J.R.); Tenet Healthcare Corporation, Delray Beach, FL (B.J.M.); Johns Hopkins University, Baltimore, MD (J.C.); Hofstra North Shore University Hospital, New Hyde Park, NY (S.K., A.H.); Hartford Hospital, CT (R.M., R. H.); Piedmont Heart Institute, Atlanta, GA (V.R., J.K.); Medtronic, Minneapolis, MN (J.H.); and Beth Israel Deaconess Medical Center, Boston, MA (J.J.P.)
| | - Jeffrey Popma
- From the Houston Methodist DeBakey Heart and Vascular Institute, TX (N.S.K., M.J.R.); Tenet Healthcare Corporation, Delray Beach, FL (B.J.M.); Johns Hopkins University, Baltimore, MD (J.C.); Hofstra North Shore University Hospital, New Hyde Park, NY (S.K., A.H.); Hartford Hospital, CT (R.M., R. H.); Piedmont Heart Institute, Atlanta, GA (V.R., J.K.); Medtronic, Minneapolis, MN (J.H.); and Beth Israel Deaconess Medical Center, Boston, MA (J.J.P.)
| | | | | | | | | | | | - Amar Bafi
- Washington Hospital Center/Georgetown Hospital
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- Texas Heart Institute at St Lukes Episcopal Hospital/Baylor College of Medicine
| | | | | | | | | | | | | | - Jose Diez
- Texas Heart Institute at St Lukes Episcopal Hospital/Baylor College of Medicine
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Scott Henry
- Detroit Medical Center Cardiovascular Institute
| | | | | | | | | | - Ali Kafi
- Detroit Medical Center Cardiovascular Institute
| | - Biswajit Kar
- Texas Heart Institute at St Lukes Episcopal Hospital/Baylor College of Medicine
| | | | | | | | - Neal Kon
- Wake Forest University Baptist Medical Center
| | | | | | | | | | | | | | | | | | - Ray Matthews
- University of Southern California University Hospital
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Lee Siwek
- Providence Sacred Heart Medical Center
| | | | | | | | | | | | | | | | - Ron Waksman
- Washington Hospital Center/Georgetown Hospital
| | - Daniel Watson
- Riverside Methodist Hospital/Ohio Health Research Institute
| | - Steven Yakubov
- Riverside Methodist Hospital/Ohio Health Research Institute
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Forrest JK, Mangi A, Popma J, Khabbaz K, Reardon M, Kleiman N, Yakubov S, Watson D, Kodali S, George I, Tadros P, Zorn G, Brown J, Kipperman R, Staniloae C, Williams M. INITIAL USE OF THE EVOLUT PRO SELF-EXPANDING TRANSCATHETER AORTIC VALVE. J Am Coll Cardiol 2017. [DOI: 10.1016/s0735-1097(17)34677-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Tooley JE, Bohl DD, Kulkarni S, Rodriguez-Davalos MI, Mangi A, Mulligan DC, Yoo PS. Perioperative outcomes of coronary artery bypass graft in renal transplant recipients in the United States: results from the Nationwide Inpatient Sample. Clin Transplant 2016; 30:1258-1263. [PMID: 27440000 DOI: 10.1111/ctr.12816] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cardiovascular disease is the leading cause of morbidity and mortality in patients with chronic kidney disease (CKD). In fact, death from cardiovascular disease is the number one cause of graft loss in kidney transplant (KTx) patients. Compared to patients on dialysis, CKD patients with KTx have increased quality and length of life. It is not known, however, whether outcomes of coronary artery bypass graft (CABG) surgery differ between CKD patients with KTx or on dialysis. METHODS This was a retrospective cohort study comparing CKD patients with KTx or on dialysis undergoing CABG surgery included in the Nationwide Inpatient Sample from 2002 to 2011. Logistic and linear regression models were used to estimate the adjusted associations of KTx on all-cause in-hospital mortality, length of stay, cost of hospitalization, and rate of complications in CABG surgery. RESULTS CKD patients with KTx had decreased all-cause in-hospital mortality (2.68% vs 5.86%, odds ratio (OR)=0.56, 95% confidence interval (CI)=0.32 to 0.99, P=.046), length of stay (β=-2.96, 95% CI=-3.67 to -2.46, P<.001), and total hospital charges (difference=-$38 884, 95% CI=-$48 173 to -29 596, P<.001). They also had decreased rate of a number of perioperative complications. CONCLUSIONS CKD patient with KTx have better perioperative outcomes in CABG surgery compared to patients on dialysis.
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Affiliation(s)
- James E Tooley
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Daniel D Bohl
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Sanjay Kulkarni
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | | | - Abeel Mangi
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - David C Mulligan
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Peter S Yoo
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.
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14
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Panaich SS, Patel N, Arora S, Patel NJ, Patel SV, Savani C, Singh V, Sonani R, Deshmukh A, Cleman M, Mangi A, Forrest JK, Badheka AO. Influence of hospital volume and outcomes of adult structural heart procedures. World J Cardiol 2016; 8:302-309. [PMID: 27152142 PMCID: PMC4840163 DOI: 10.4330/wjc.v8.i4.302] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 09/23/2015] [Accepted: 01/22/2016] [Indexed: 02/06/2023] Open
Abstract
Hospital volume is regarded amongst many in the medical community as an important quality metric. This is especially true in more complicated and less commonly performed procedures such as structural heart disease interventions. Seminal work on hospital volume relationships was done by Luft et al more than 4 decades ago, when they demonstrated that hospitals performing > 200 surgical procedures a year had 25%-41% lower mortality than those performing fewer procedures. Numerous volume-outcome studies have since been done for varied surgical procedures. An old adage “practice makes perfect” indicating superior operator and institutional experience at higher volume hospitals is believed to primarily contribute to the volume outcome relationship. Compelling evidence from a slew of recent publications has also highlighted the role of hospital volume in predicting superior post-procedural outcomes following structural heart disease interventions. These included transcatheter aortic valve repair, transcatheter mitral valve repair, septal ablation and septal myectomy for hypertrophic obstructive cardiomyopathy, left atrial appendage closure and atrial septal defect/patent foramen ovale closure. This is especially important since these structural heart interventions are relatively complex with evolving technology and a steep learning curve. The benefit was demonstrated both in lower mortality and complications as well as better economics in terms of lower length of stay and hospitalization costs seen at high volume centers. We present an overview of the available literature that underscores the importance of hospital volume in complex structural heart disease interventions.
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15
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Thakkar B, Patel A, Mohamad B, Patel NJ, Bhatt P, Bhimani R, Patel A, Arora S, Savani C, Solanki S, Sonani R, Patel S, Patel N, Deshmukh A, Mohamad T, Grines C, Cleman M, Mangi A, Forrest J, Badheka AO. Transcatheter aortic valve replacement versus surgical aortic valve replacement in patients with cirrhosis. Catheter Cardiovasc Interv 2015; 87:955-62. [DOI: 10.1002/ccd.26345] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [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: 08/10/2015] [Accepted: 11/08/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Badal Thakkar
- Tulane University School of Public Health and Tropical Medicine; New Orleans Louisiana
| | - Aashay Patel
- Lankenau Institute for Medical Research; Wynnewood Pennsylvania
| | | | | | - Parth Bhatt
- Tulane University School of Public Health and Tropical Medicine; New Orleans Louisiana
| | | | - Achint Patel
- Icahn School of Public Health at Mount Sinai; New York New York
| | | | - Chirag Savani
- New York Medical College School of Public Health; Valhalla New York
| | - Shantanu Solanki
- New York Medical College at Westchester Medical Center; Valhalla New York
| | - Rajesh Sonani
- Emory University School of Medicine; Atlanta Georgia
| | - Samir Patel
- Western Reserve Health System; Youngstown Ohio
| | - Nilay Patel
- Saint Peter's University Hospital; New Brunswick New Jersey
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16
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Singh V, Patel SV, Savani C, Patel NJ, Patel N, Arora S, Panaich SS, Deshmukh A, Cleman M, Mangi A, Forrest JK, Badheka AO. Mechanical circulatory support devices and transcatheter aortic valve implantation (from the National Inpatient Sample). Am J Cardiol 2015; 116:1574-80. [PMID: 26434512 DOI: 10.1016/j.amjcard.2015.08.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 08/20/2015] [Accepted: 08/20/2015] [Indexed: 11/16/2022]
Abstract
High-risk surgical patients undergoing transcatheter aortic valve implantation (TAVI) represent an emerging population, which may benefit from short-term use of mechanical circulatory support (MCS) devices. The aim of this study was to determine the practice and inhospital outcomes of MCS utilization in patients undergoing TAVI. We analyzed data from Nationwide Inpatient Sample (2011 and 2012) using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. A total of 1,794 TAVI procedures (375 hospitals in the United States) were identified of which 190 (10.6%) used an MCS device (MCS group) and 1,604 (89.4%) did not (non-MCS group). The use of MCS devices with TAVI was associated with significant increase in the inhospital mortality (14.9% vs 3.5%, p <0.01). The mean length (11.8 ± 0.8 vs 8.1 ± 0.2 days, p <0.01) and cost ($68,997 ± 3,656 vs $55,878 ± 653, p = 0.03) of hospitalization were also significantly greater in the MCS group. Ventricular fibrillation arrest, transapical access for TAVI, and cardiogenic shock were the most significant predictors of MCS use during TAVI. In the multivariate model, use of any MCS device was found to be an independent predictor of increased mortality (odds ratio 3.5, 95% confidence interval 2.6 to 4.6, p <0.0001) and complications (odds ratio 3.3, 95% confidence interval 2.8 to 3.9, p <0.0001). The propensity score-matched analysis also showed a similar result. In conclusion, the unacceptably high rates of mortality and complications coupled with a significant increase in the length and cost of hospitalization should raise concerns about utility of MCS devices during TAVI in this prohibitive surgical risk population.
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Affiliation(s)
- Vikas Singh
- Cardiology Department, University of Miami Miller School of Medicine, Miami, Florida
| | - Samir V Patel
- Internal Medicine Department, Western Reserve Health Education, Youngstown, Ohio
| | - Chirag Savani
- Public Health Department, New York Medical College, Valhalla, New York
| | - Nileshkumar J Patel
- Cardiology Department, University of Miami Miller School of Medicine, Miami, Florida
| | - Nilay Patel
- Internal Medicine Department, Saint Peter's University Hospital, New Brunswick, New Jersey
| | - Shilpkumar Arora
- Internal Medicine Department, Mount Sinai St. Luke's Roosevelt Hospital, New York, New York
| | | | | | - Michael Cleman
- Cardiology Department, Yale School of Medicine, New Haven, Connecticut
| | - Abeel Mangi
- Interventional Cardiology Department, The Everett Clinic, Everett, Washington
| | - John K Forrest
- Interventional Cardiology Department, The Everett Clinic, Everett, Washington
| | - Apurva O Badheka
- Interventional Cardiology Department, The Everett Clinic, Everett, Washington.
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17
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Bhatt P, Patel NJ, Patel A, Sonani R, Patel A, Panaich SS, Thakkar B, Savani C, Jhamnani S, Patel N, Patel N, Pant S, Patel S, Arora S, Dave A, Singh V, Chothani A, Patel J, Ansari M, Deshmukh A, Bhimani R, Grines C, Cleman M, Mangi A, Forrest JK, Badheka AO. Impact of Hospital Volume on Outcomes of Endovascular Stenting for Adult Aortic Coarctation. Am J Cardiol 2015; 116:1418-24. [PMID: 26471501 DOI: 10.1016/j.amjcard.2015.07.066] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 07/29/2015] [Accepted: 07/29/2015] [Indexed: 10/23/2022]
Abstract
Use of transcatheter endovascular stenting has been increasing in the treatment of coarctation of aorta (CoA). The present study was undertaken on adults with CoA who underwent stent placement from 2000 to 2011 to analyze the relation of hospital volumes to the outcomes of stenting in adults with CoA. It was a retrospective study based on Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) database from 2000 to 2011 and identified subjects using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure code of 747.10 (CoA). Annual hospital volume was calculated using unique hospital identifiers. Weights provided by the Nationwide Inpatient Sample were used to generate national estimates. A total of 105 (weighted 521) subjects were identified with International Classification of Diseases, Ninth Revision, code of 39.90 (Endovascular stent). Hospital volumes were divided into tertiles. We compared the highest tertile (≥3 procedures annually) with other tertiles (<3 procedure annually). The composite outcomes of the analysis were procedure-related complications, length of stay (LOS), and cost in relation to the hospital volume. No inhospital death was reported in either group. Hospitals with ≥3 procedures annually had significantly lower incidence of complications (9.5% vs 23.0%) compared to the hospitals with <3 procedures annually (p-value 0.002). Similar results were obtained after multivariate regression analysis in relation to hospital volume. Shorter LOS and lower cost were observed with annual hospital volume of ≥3 procedures. In conclusion, stenting adults for CoA is remarkably safe, and the outcomes of the procedure have improved in centers with annual hospital volume of ≥3 procedures. There is also decreasing trend of procedure-related complications, shorter LOS, and lower costs compared to centers with annual volume <3 procedures.
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18
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Singh V, Badheka AO, Patel SV, Patel NJ, Thakkar B, Patel N, Arora S, Patel N, Patel A, Savani C, Ghatak A, Panaich SS, Jhamnani S, Deshmukh A, Chothani A, Sonani R, Patel A, Bhatt P, Dave A, Bhimani R, Mohamad T, Grines C, Cleman M, Forrest JK, Mangi A. Comparison of Inhospital Outcomes of Surgical Aortic Valve Replacement in Hospitals With and Without Availability of a Transcatheter Aortic Valve Implantation Program (from a Nationally Representative Database). Am J Cardiol 2015; 116:1229-36. [PMID: 26297512 DOI: 10.1016/j.amjcard.2015.07.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [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: 06/01/2015] [Revised: 07/12/2015] [Accepted: 07/12/2015] [Indexed: 11/28/2022]
Abstract
We hypothesized that the availability of a transcatheter aortic valve implantation (TAVI) program in hospitals impacts the overall management of patients with aortic valve disease and hence may also improve postprocedural outcomes of conventional surgical aortic valve replacement (SAVR). The aim of the present study was to compare the inhospital outcomes of SAVR in centers with versus without availability of a TAVI program in an unrestricted large nationwide patient population >50 years of age. SAVRs performed on patients aged >50 years were identified from the Nationwide Inpatient Sample (NIS) for the years 2011 and 2012 using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. SAVR cases were divided into 2 categories: those performed at hospitals with a TAVI program (SAVR-TAVI) and those without (SAVR-non-TAVI). A total of 9,674 SAVR procedures were identified: 4,526 (46.79%) in the SAVR-TAVI group and 5,148 (53.21%) in SAVR-non-TAVI group. The mean age of the study population was 70.2 ± 0.1 years with majority (53%) of the patients aged >70 years. The mean Charlson's co-morbidity score for patients in SAVR-TAVI group was greater (greater percentage of patients were aged >80 years, had hypertension, congestive heart failure, renal failure, and peripheral arterial disease) than that of patients in SAVR-non-TAVI group (1.6 vs 1.4, p <0.001). The propensity score matching analysis showed a statistically significant lower inhospital mortality (1.25% vs 1.72%, p = 0.001) and complications rate (35.6% vs 37.3%, p = 0.004) in SAVR-TAVI group compared to SAVR-non-TAVI group. The mean length of hospital stay was similar in the 2 groups the cost of hospitalization was higher in the SAVR-TAVI group ($43,894 ± 483 vs $41,032 ± 473, p <0.0001). Having a TAVI program was a significant predictor of reduced mortality and complications rate after SAVR in multivariate analysis. In conclusion, this largest direct comparative analysis demonstrates that SAVRs performed in centers with a TAVI program are associated with significantly lower mortality and complications rates compared to those performed in centers without a TAVI program.
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Affiliation(s)
- Vikas Singh
- Cardiology Department, University of Miami Miller School of Medicine, Miami, Florida
| | - Apurva O Badheka
- Interventional Cardiology Department, The Everett Clinic, Everett, Washington.
| | - Samir V Patel
- Internal Medicine Department, Western Reserve Health System, Youngstown, Ohio
| | - Nileshkumar J Patel
- Cardiology Department, University of Miami Miller School of Medicine, Miami, Florida
| | - Badal Thakkar
- Epidemiology Department, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Nilay Patel
- Internal Medicine Department, Saint Peter's University Hospital, New Brunswick, New Jersey
| | - Shilpkumar Arora
- Internal Medicine Department, Mount Sinai St. Luke's Roosevelt Hospital, New York, New York
| | - Nish Patel
- Cardiology Department, University of Miami Miller School of Medicine, Miami, Florida
| | - Achint Patel
- Public Health Department, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Chirag Savani
- Epidemiology Department, New York Medical College, Valhalla, New York
| | - Abhijit Ghatak
- Cardiology Department, University of Miami Miller School of Medicine, Miami, Florida
| | | | - Sunny Jhamnani
- Interventional Cardiology Department, The Everett Clinic, Everett, Washington
| | | | - Ankit Chothani
- Internal Medicine Department, MedStar Washington Hospital Center, Washington, DC
| | - Rajesh Sonani
- Internal Medicine Department, Emory University School of Medicine, Atlanta, Georgia
| | - Aashay Patel
- Internal Medicine Department, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
| | - Parth Bhatt
- Internal Medicine Department, Saint Peter's University Hospital, New Brunswick, New Jersey
| | - Abhishek Dave
- Public Health Department, Texas A&M Medical Centre, College Station, Texas
| | - Ronak Bhimani
- Internal Medicine Department, St. Vincent Charity Medical Centre, Cleveland, Ohio
| | - Tamam Mohamad
- Cardiology Department, Detroit Medical Center, Detroit, Michigan
| | - Cindy Grines
- Cardiology Department, Detroit Medical Center, Detroit, Michigan
| | - Michael Cleman
- Cardiology Department, Yale School of Medicine, New Haven, Connecticut
| | - John K Forrest
- Cardiology Department, Yale School of Medicine, New Haven, Connecticut
| | - Abeel Mangi
- Cardiology Department, Yale School of Medicine, New Haven, Connecticut
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Badheka A, Singh V, Patel N, Arora S, Patel N, Thakkar B, Jhamnani S, Chothani A, Panaich S, Patel J, Deshmukh A, Manvar S, Mangi A, Pfau S, Cleman M, Forrest J. AORTIC VALVE DISEASE IN ELDERLY: TRENDS OF HOSPITALIZATIONS IN US, 2000-2012. J Am Coll Cardiol 2015. [DOI: 10.1016/s0735-1097(15)61951-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Singh V, Patel NJ, Badheka AO, Arora S, Patel N, Macon C, Savani GT, Manvar S, Patel J, Thakkar B, Panchal V, Solanki S, Patel N, Chothani A, Panaich SS, Ram V, Kliger CA, Schreiber T, O' Neill W, Cohen MG, Alfonso CE, Grines CL, Mangi A, Pfau S, Forrest JK, Cleman M, Makkar R. Comparison of outcomes of balloon aortic valvuloplasty plus percutaneous coronary intervention versus percutaneous aortic balloon valvuloplasty alone during the same hospitalization in the United States. Am J Cardiol 2015; 115:480-6. [PMID: 25543235 DOI: 10.1016/j.amjcard.2014.11.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 11/20/2014] [Accepted: 11/20/2014] [Indexed: 11/29/2022]
Abstract
The use of percutaneous aortic balloon balvotomy (PABV) in high surgical risk patients has resurged because of development of less invasive endovascular therapies. We compared outcomes of concomitant PABV and percutaneous coronary intervention (PCI) with PABV alone during same hospitalization using nation's largest hospitalization database. We identified patients and determined time trends using the International Classification of Diseases, Ninth Revision, Clinical Modification, procedure code for valvulotomy from Nationwide Inpatient Sample database 1998 to 2010. Only patients >60 years with aortic stenosis were included. Primary outcome included in-hospital mortality, and secondary outcomes included procedural complications, length of stay (LOS), and cost of hospitalization. Total 2,127 PABV procedures were identified, with 247 in PABV + PCI group and 1,880 in the PABV group. Utilization rate of concomitant PABV + PCI during same hospitalization increased by 225% from 5.1% in 1998 to 1999 to 16.6% in 2009 to 2010 (p <0.001). Overall in-hospital mortality rate and complication rates in PABV + PCI group were similar to that of PABV group (10.3% vs 10.5% and 23.4% vs 24.7%, respectively). PABV + PCI group had similar LOS but higher hospitalization cost (median [interquartile range] $30,089 [$21,925 to $48,267] versus $18,421 [$11,482 to $32,215], p <0.001) in comparison with the PABV group. Unstable condition, occurrence of any complication, and weekend admission were the main predictors of increased LOS and cost of hospital admission. Concomitant PCI and PABV during the same hospitalization are not associated with change in in-hospital mortality, complications rate, or LOS compared with PABV alone; however, it increases the cost of hospitalization.
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Affiliation(s)
- Vikas Singh
- Cardiovascular division, University of Miami Miller School of Medicine, Miami, Florida
| | - Nileshkumar J Patel
- Cardiovascular division, Staten Island University Hospital, Staten Island, New York
| | - Apurva O Badheka
- Cardiovascular division, Yale School of Medicine, New Haven, Connecticut.
| | - Shilpkumar Arora
- Cardiovascular division, Mount Sinai St Luke's Roosevelt Hospital, New York, New York
| | - Nilay Patel
- Cardiovascular division, Saint Peter's University Hospital, New Brunswick, New Jersey
| | - Conrad Macon
- Cardiovascular division, University of Miami Miller School of Medicine, Miami, Florida
| | | | | | - Jay Patel
- Cardiovascular division, Detroit Medical Center, Detroit, Michigan
| | - Badal Thakkar
- Cardiovascular division, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Vinaykumar Panchal
- Cardiovascular division, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Shantanu Solanki
- Cardiovascular division, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Neil Patel
- Cardiovascular division, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ankit Chothani
- Cardiovascular division, MedStar Washington Hospital Center, Washington, District of Columbia
| | | | - Vinny Ram
- Cardiovascular division, University of Arizona, Tucson, Arizona
| | - Chad A Kliger
- Cardiovascular division, Lenox Hill Heart and Vascular Institute-North Shore LIJ Health System, New York, New York
| | | | | | - Mauricio G Cohen
- Cardiovascular division, University of Miami Miller School of Medicine, Miami, Florida
| | - Carlos E Alfonso
- Cardiovascular division, University of Miami Miller School of Medicine, Miami, Florida
| | - Cindy L Grines
- Cardiovascular division, Detroit Medical Center, Detroit, Michigan
| | - Abeel Mangi
- Cardiovascular division, Yale School of Medicine, New Haven, Connecticut
| | - Steven Pfau
- Cardiovascular division, Yale School of Medicine, New Haven, Connecticut
| | - John K Forrest
- Cardiovascular division, Yale School of Medicine, New Haven, Connecticut
| | - Michael Cleman
- Cardiovascular division, Yale School of Medicine, New Haven, Connecticut
| | - Raj Makkar
- Cardiovascular division, Cedars Sinai Medical Center, Los Angeles, California
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Laur O, Brisco M, Kula A, Cheng S, Mangi A, Coca S, Tang WH, Testani J. DONOR AND RECIPIENT RENAL DYSFUNCTION AND POST CARDIAC TRANSPLANT GRAFT SURVIVAL: INSIGHTS INTO RENO-CARDIAC INTERACTIONS. J Am Coll Cardiol 2014. [DOI: 10.1016/s0735-1097(14)60886-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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22
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Morbach C, Bellavia D, Bonde P, Mangi A, Yuh D, Vaitkeviciute I, Weinert L, Klas B, Sugeng L. SEGMENTAL ANALYSIS OF MITRAL VALVE LEAFLETS IN ISCHEMIC MITRAL REGURGITATION. J Am Coll Cardiol 2013. [DOI: 10.1016/s0735-1097(13)61100-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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23
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Taghavi S, Clark R, Jayarajan S, Gaughan J, Brann S, Mangi A. Surgical Management of Tricuspid Valve Endocarditis in Systemically Infected Patients. Chest 2012. [DOI: 10.1378/chest.1382725] [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: 11/01/2022] Open
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Taghavi S, Jenkins M, Wilson L, Clark R, Benish L, Mangi A. “Bridging Strategies” Allow Successful Management of INTERMACS Profile 1 and 2 Patients. J Card Fail 2012. [DOI: 10.1016/j.cardfail.2012.06.162] [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: 10/28/2022]
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DePasquale E, Nasir K, Bellumkonda L, Mangi A, Dries D, Jacoby D. 382 Outcomes of Adults with Restrictive Cardiomyopathy (RCM) Post Heart Transplant (HT): UNOS Registry Analysis. J Heart Lung Transplant 2012. [DOI: 10.1016/j.healun.2012.01.391] [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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Taghavi S, Jayarajan S, Benish L, Wilson L, Mangi A. Choice of Left Ventricular Assist Device and Addition of Mitral Valve Repair Do Not Influence Reduction in Pulmonary Vascular Resistance. Chest 2011. [DOI: 10.1378/chest.1112905] [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: 11/01/2022] Open
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28
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Torchiana DF, Mangi A. Reply to the Editor. J Thorac Cardiovasc Surg 2005. [DOI: 10.1016/j.jtcvs.2004.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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29
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Mangi A, Villani MR, Minerva N, Leandro G, Bacca D, Cela M, Carretta V, Attino V, Ventrella F, Giangaspero A, Andriulli A. Efficacy of 5 MU of interferon in combination with ribavirin for naïve patients with chronic hepatitis C virus: a randomized controlled trial. J Hepatol 2001; 34:441-6. [PMID: 11322207 DOI: 10.1016/s0168-8278(00)00024-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND In chronic hepatitis C the schedule of interferon (IFN), 3 MU thrice weekly (tiw) plus ribavirin (1000-1200 mg/daily) needs further evaluation, as IFN dosages >3 MU achieve better responses. AIMS To compare the efficacy of 5 MU tiw of IFN with (96 patients) or without ribavirin (96 patients) for 12 months in naïve patients, to evaluate the effect of baseline features on the response to therapy, and to determine a reliable point in time during treatment to predict non-response. RESULTS Sustained virologic response was 20.8% (95% CI 13-29) with IFN monotherapy and 54.2% (95% CI 44-64) with combination (P = 0.0001), the relapse rate 39.4% (95% CI 23-56) and 9% (95% CI 1-16) (P = 0.0007), and the combined rate of sustained biochemical and virologic response 22.7% (95% CI 14-31) and 60.5% (95% CI 50-71) (P = 0.0001), respectively. Patients given combination therapy were more likely to respond regardless of baseline features. Apart from genotype non-1, predictive factors for IFN monotherapy were ineffective in predicting response to combination therapy. Using logistic regression analysis, IFN-ribavirin was the strongest predictor of response (X2 = 21.3; P = 0.0001). Viral persistence at month 3 of therapy was a more accurate predictor than aminotransferase values for non-response to IFN monotherapy but not to combination therapy (positive predictive values of 98 and 82%, respectively). CONCLUSION In this study, 5 MU of IFN combined with a standard dose of ribavirin has yielded the highest rate of sustained response reported to date. Further dose finding studies are warranted.
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Affiliation(s)
- A Mangi
- Division of Gastroenterology, Ospedale Casa Sollievo della Sofferenza, IRCCS, San Giovanni Rotondo, Italy.
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Lopez FF, Mangi A, Mylonakis E, Chen JL, Schiffman FJ. Atrial fibrillation and tumor emboli as manifestations of metastatic leiomyosarcoma to the heart and lung. Heart Lung 2000; 29:47-9. [PMID: 10636956 DOI: 10.1016/s0147-9563(00)90036-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [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: 01/01/2023]
Abstract
Leiomyosarcoma is a malignant tumor of the smooth muscle that rarely occurs in the gastrointestinal tract. High-grade leiomyosarcomas of the rectosigmoid usually metastasize to the liver and lungs. Although it is unusual, metastases to the heart have been reported. When this occurs, the metastatic tumor usually seeds in the right atrium and pulmonary artery. We report on and discuss a patient who had atrial fibrillation, peripheral emboli, and thrombocytopenia resulting from a low-grade rectosigmoid leiomyosarcoma metastatic to the pulmonary vein and left atrium. Atrial fibrillation is not a common manifestation of malignant neoplasms that have spread to the heart. Surgical removal of the tumor terminated the arrhythmia and thrombocytopenia.
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Affiliation(s)
- F F Lopez
- Brown University School of Medicine, Providence, RI, USA
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