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Mathias IS, Rahi W, Ramos A, Na J, Angulo C, Rothstein P, Lador A, Schurmann P, Dave A, Valderrabano M, Nagueh SF. Validation of Noninvasive Left Atrial Stiffness Against Left Atrial Operating Chamber Stiffness by Cardiac Catheterization. JACC Cardiovasc Imaging 2024:S1936-878X(24)00117-7. [PMID: 38661609 DOI: 10.1016/j.jcmg.2024.03.004] [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] [Received: 11/12/2023] [Revised: 02/01/2024] [Accepted: 03/04/2024] [Indexed: 04/26/2024]
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Ezzeddine FM, Pistiolis SM, Pujol-Lopez M, Lavelle M, Wan EY, Patton KK, Robinson M, Lador A, Tamirisa K, Karim S, Linde C, Parkash R, Birgersdotter-Green U, Russo AM, Chung M, Cha YM. Outcomes of conduction system pacing for cardiac resynchronization therapy in patients with heart failure: A multicenter experience. Heart Rhythm 2023; 20:863-871. [PMID: 36842610 PMCID: PMC10225322 DOI: 10.1016/j.hrthm.2023.02.018] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/17/2023] [Accepted: 02/19/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Whether conduction system pacing (CSP) is an alternative option for cardiac resynchronization therapy (CRT) in patients with heart failure remains an area of active investigation. OBJECTIVE The purpose of this study was to assess the echocardiographic and clinical outcomes of CSP compared to biventricular pacing (BiVP). METHODS This multicenter retrospective study included patients who fulfilled CRT indications and received CSP. Patients with CSP were matched using propensity score matching and compared in a 1:1 ratio to patients who received BiVP. Echocardiographic and clinical outcomes were assessed. Response to CRT was defined as an absolute increase of ≥5% in left ventricular ejection fraction (LVEF) at 6 months post-CRT. RESULTS A total of 238 patients were included. Mean age was 69.8 ± 12.5 years, and 66 (27.7%) were female. Sixty-nine patients (29%) had His-bundle pacing, 50 (21%) had left bundle branch area pacing, and 119 (50%) had BiVP. Mean follow-up duration in the CSP and BiVP groups was 269 ± 202 days and 304 ± 262 days, respectively (P = .293). The proportion of CRT responders was greater in the CSP group than in the BiVP group (74% vs 60%, respectively; P = .042). On Kaplan-Meier analysis, there was no statistically significant difference in the time to first heart failure hospitalization (log-rank P = .78) and overall survival (log-rank P = .68) between the CSP and BiVP groups. CONCLUSION In patients with heart failure and reduced ejection fraction, CSP resulted in greater improvement in LVEF compared to BiVP. Large-scale randomized trials are needed to validate these outcomes and further investigate the different options available for CSP.
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Affiliation(s)
- Fatima M Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Margarida Pujol-Lopez
- Arrhythmia Section, Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Universitat de Barcelona, and Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Michael Lavelle
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center-New York Presbyterian, New York, New York
| | - Elaine Y Wan
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center-New York Presbyterian, New York, New York
| | - Kristen K Patton
- Division of Cardiology, University of Washington Medical Center, Seattle, Washington
| | - Melissa Robinson
- Division of Cardiology, University of Washington Medical Center, Seattle, Washington
| | - Adi Lador
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
| | | | - Saima Karim
- Heart and Vascular Center, Metrohealth Campus of Case Western Reserve University, Cleveland, Ohio
| | - Cecilia Linde
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Ratika Parkash
- Division of Cardiology QEII Health Sciences Center/Dalhousie University, Halifax, Nova Scotia, Canada
| | | | | | - Mina Chung
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Yong-Mei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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Lador A, Wang S, Schurmann PA, Chihara R, Dave AS, Valderrábano M. Stellate ganglion instrumentation for pharmacological blockade, nerve recording, and stimulation in patients with ventricular arrhythmias: Preliminary experience. Heart Rhythm 2023; 20:797-805. [PMID: 36863635 DOI: 10.1016/j.hrthm.2023.02.024] [Citation(s) in RCA: 1] [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] [Received: 01/23/2023] [Revised: 02/14/2023] [Accepted: 02/22/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Stellate ganglion blockade (SGB) can control ventricular arrhythmias (VAs), but outcomes are unclear. Percutaneous stellate ganglion (SG) recording and stimulation in humans has not been reported. OBJECTIVE The purpose of this study was to assess the outcomes of SGB and the feasibility of SG stimulation and recording in humans with VAs. METHODS Two patient cohorts were included-group 1: patients undergoing SGB for drug-refractory VAs. SGB was performed by injection of liposomal bupivacaine. Incidence of VAs at 24 and 72 hours and clinical outcomes were collected; group 2: patients undergoing SG stimulation and recording during VA ablation; a 2-F octapolar catheter was placed at the SG at the C7 level. Recording (30 kHz sampling, 0.5-2 kHz filter) and stimulation (up to 80 mA output, 50 Hz, 2 ms pulse width for 20-30 seconds) was performed. RESULTS Group 1 included 25 patients [age 59.2 ± 12.8 years; 19 (76%) men] who underwent SGB for VAs. Nineteen patients (76.0%) were free of VA up to 72 hours postprocedure. However, 15 (60.0%) had VAs recurrence for a mean of 5.47 ± 4.52 days. Group 2 included 11 patients (mean age 63 ± 12.7 years; 82.7% men). SG stimulation caused consistent increases in systolic blood pressure. We recorded unequivocal signals with temporal association with arrhythmias in 4 of 11 patients. CONCLUSION SGB provides short-term VA control, but has no benefit in the absence of definitive VA therapies. SG recording and stimulation is feasible and may have value to elicit VA and understand neural mechanisms of VA in the electrophysiology laboratory.
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Affiliation(s)
- Adi Lador
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Sufen Wang
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Paul A Schurmann
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Ray Chihara
- Division of Thoracic Surgery, Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Amish S Dave
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Miguel Valderrábano
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas.
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Valderrábano M, Rojas SCF, Lador A, Patel A, Schurmann PA, Tapias C, Rodríguez D, Sáenz LC, Malahjfi M, Shah DJ, Mathuria N, Dave AS. Substrate Ablation by Multivein, Multiballoon Coronary Venous Ethanol for Refractory Ventricular Tachycardia in Structural Heart Disease. Circulation 2022; 146:1644-1656. [PMID: 36321460 PMCID: PMC9712228 DOI: 10.1161/circulationaha.122.060882] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/15/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Ablation of ventricular tachycardia (VT) in the setting of structural heart disease often requires extensive substrate elimination that is not always achievable by endocardial radiofrequency ablation. Epicardial ablation is not always feasible. Case reports suggest that venous ethanol ablation (VEA) through a multiballoon, multivein approach can lead to effective substrate ablation, but large data sets are lacking. METHODS VEA was performed in 44 consecutive patients with ablation-refractory VT (ischemic, n=21; sarcoid, n=3; Chagas, n=2; idiopathic, n=18). Targeted veins were selected by mapping coronary veins on the epicardial aspect of endocardial scar (identified by bipolar voltage <1.5 mV), using venography and signal recording with a 2F octapolar catheter or by guidewire unipolar signals. Epicardial mapping was performed in 15 patients. Vein segments in the epicardial aspect of VT substrates were treated with double-balloon VEA by blocking flow with 1 balloon while injecting ethanol through the lumen of the second balloon, forcing (and restricting) ethanol between balloons. Multiple balloon deployments and multiple veins were used as needed. In 22 patients, late gadolinium enhancement cardiac magnetic resonance imaged the VEA scar and its evolution. RESULTS Median ethanol delivered was 8.75 (interquartile range, 4.5-13) mL. Injected veins included interventricular vein (6), diagonal (5), septal (12), lateral (16), posterolateral (7), and middle cardiac vein (8), covering the entire range of left ventricular locations. Multiple veins were targeted in 14 patients. Ablated areas were visualized intraprocedurally as increased echogenicity on intracardiac echocardiography and incorporated into 3-dimensional maps. After VEA, vein and epicardial ablation maps showed elimination of abnormal electrograms of the VT substrate. Intracardiac echocardiography demonstrated increased intramural echogenicity at the targeted region of the 3-dimensional maps. At 1 year of follow-up, median of 314 (interquartile range, 198-453) days of follow-up, VT recurrence occurred in 7 patients, for a success of 84.1%. CONCLUSIONS Multiballoon, multivein intramural ablation by VEA can provide effective substrate ablation in patients with ablation-refractory VT in the setting of structural heart disease over a broad range of left ventricular locations.
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Affiliation(s)
- Miguel Valderrábano
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | | | - Adi Lador
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Apoor Patel
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Paul A. Schurmann
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | | | | | | | - Maan Malahjfi
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Dipan J. Shah
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Nilesh Mathuria
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Amish S. Dave
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
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Patel A, Nsahlai M, Flautt T, Da-Warikobo A, Lador A, Tapias C, Rodríguez D, Carlos Sáenz L, Schurmann PA, Dave A, Valderrábano M. Advanced Techniques for Ethanol Ablation of Left Ventricular Summit Region Arrhythmias. Circ Arrhythm Electrophysiol 2022; 15:e011017. [PMID: 35917467 PMCID: PMC9388546 DOI: 10.1161/circep.122.011017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coronary venous ethanol ablation (VEA) can be used as a strategy to treat ventricular arrhythmias arising from the left ventricular summit, but collateral flow and technical challenges cannulating intramural veins in complex venous anatomies can limit its use. Advanced techniques for VEA can capitalize on collateral vessels between target and nontarget sites to improve success. METHODS Of 55 patients with left ventricular summit ventricular arrhythmia, advanced techniques were used in 15 after initial left ventricular summit intramural vein mapping failed to show suitable targets for single vein, single-balloon VEA. All patients had previous radiofrequency ablation attempts. Techniques included: double-balloon for distal protection to block distal flow and target the proximal portion of a large intramural vein where best signal was proximal (n=6); balloons in 2 different left ventricular summit veins for a cross-fire multivein VEA (n=4); intramural collateral vein-to-vein cannulation to reach of targeted vein via collateral with antegrade ethanol and proximal balloon block (n=2); prolonged ethanol dwell time for vein sclerosis of large intramural vein and subsequent VEA (n=3); and intramural collateral VEA (n=1). RESULTS Fifteen (8 females) patients (age 60.6±17.6 years) required advanced techniques. Procedure time was 210±49.9 minutes, fluoroscopy time was 25.3±14.1 minutes, and 113±17.9 cc of contrast was utilized. A median of 7 cc of ethanol was delivered (range, 4-15 cc). Intraprocedural radiofrequency ablation was delivered before ethanol in 9 out of 15 patients but failed. Ethanol achieved acute success in all 15 patients. Ethanol was used as the sole treatment in two patients. At a median follow-up of 194 days, one patient experienced recurrence. CONCLUSIONS Advanced techniques capitalizing on venous anatomy can enable successful VEA and selective targeting of arrhythmogenic sites, by blocking distal flow, utilization of collaterals between nontarget and target veins and multivein VEA. Understanding individual anatomy is critical for VEA success.
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Affiliation(s)
- Apoor Patel
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX (A.P., M.N., T.F., A.D.-W., A.L., C.T., P.A.S., A.D., M.V.)
| | - Michelle Nsahlai
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX (A.P., M.N., T.F., A.D.-W., A.L., C.T., P.A.S., A.D., M.V.)
| | - Thomas Flautt
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX (A.P., M.N., T.F., A.D.-W., A.L., C.T., P.A.S., A.D., M.V.)
| | - Akanibo Da-Warikobo
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX (A.P., M.N., T.F., A.D.-W., A.L., C.T., P.A.S., A.D., M.V.)
| | - Adi Lador
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX (A.P., M.N., T.F., A.D.-W., A.L., C.T., P.A.S., A.D., M.V.)
| | - Carlos Tapias
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX (A.P., M.N., T.F., A.D.-W., A.L., C.T., P.A.S., A.D., M.V.)
| | - Diego Rodríguez
- International Arrhythmia Center, Fundación Cardioinfantil, Bogotá, Colombia (D.R., L.C.S.)
| | - Luis Carlos Sáenz
- International Arrhythmia Center, Fundación Cardioinfantil, Bogotá, Colombia (D.R., L.C.S.)
| | - Paul A Schurmann
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX (A.P., M.N., T.F., A.D.-W., A.L., C.T., P.A.S., A.D., M.V.)
| | - Amish Dave
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX (A.P., M.N., T.F., A.D.-W., A.L., C.T., P.A.S., A.D., M.V.)
| | - Miguel Valderrábano
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX (A.P., M.N., T.F., A.D.-W., A.L., C.T., P.A.S., A.D., M.V.)
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Da-Wariboko A, Flautt T, Lador A, Patel A, Valderrabano M. CE-538-04 INTRACARDIAC ECHOCARDIOGRAPHY-GUIDED LEFT ATRIAL APPENDAGE OCCLUSION WITHOUT CINEANGIOGRAPHY. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.613] [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: 11/04/2022]
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Lador A, Wang S, Dave AS, Valderrabano M. CE-521-01 STELLATE GANGLION INSTRUMENTATION FOR RECORDING AND STIMULATION IN PATIENTS WITH VENTRICULAR ARRHYTHMIAS. PRELIMINARY EXPERIENCE. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.111] [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: 11/04/2022]
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Lador A, Giudicessi JR, Barake WM, Noseworthy PA, Kapa S, McLeod CJ, Cannon BC, Asirvatham SJ, Ackerman MJ. Premature Ventricular Contraction-Triggered Ventricular Fibrillation and Sudden Cardiac Arrest in the Young. JACC Clin Electrophysiol 2022; 8:380-382. [PMID: 35331434 DOI: 10.1016/j.jacep.2021.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/13/2021] [Accepted: 09/29/2021] [Indexed: 11/29/2022]
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Flautt T, Lador A, Da-Wariboko A, Schwartz M, Valderrábano M. PET-Driven, Voltage-Guided Atrial Endomyocardial Biopsy Clinches the Diagnosis of Cardiac Sarcoidosis. JACC Case Rep 2021; 3:1764-1768. [PMID: 34825206 PMCID: PMC8603053 DOI: 10.1016/j.jaccas.2021.08.021] [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: 04/02/2021] [Revised: 08/19/2021] [Accepted: 08/26/2021] [Indexed: 11/18/2022]
Abstract
Endomyocardial biopsy (EMB) is used in diagnosing infiltrative and other suspected cardiomyopathies. We present a case in which positron emission tomography– and electroanatomic mapping-guided EMB of the atrial septum confirmed the diagnosis of cardiac sarcoidosis in a patient with negative findings on ventricular and lymph node biopsy. (Level of Difficulty: Advanced.)
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Affiliation(s)
- Thomas Flautt
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Adi Lador
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Akanibo Da-Wariboko
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Mary Schwartz
- Department of Pathology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Miguel Valderrábano
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
- Address for correspondence: Dr Miguel Valderrábano, Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist Hospital, 6550 Fannin Street, Suite 1901, Houston, Texas 77030, USA.
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Lador A, Cheng C, Valderrábano M, Patel A. High-risk left atrial appendage occlusion via isoproterenol infusion and carotid filter placement. HeartRhythm Case Rep 2021; 7:620-623. [PMID: 34552855 PMCID: PMC8441192 DOI: 10.1016/j.hrcr.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Adi Lador
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Charlie Cheng
- Division of Vascular Surgery, Department of Cardiovascular Surgery, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Miguel Valderrábano
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Apoor Patel
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
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Bains S, Lador A, Neves R, Bos JM, Giudicessi JR, Cannon BC, Ackerman MJ. Role of chronic continuous intravenous lidocaine in the clinical management of patients with malignant type 3 long QT syndrome. Heart Rhythm 2021; 19:81-87. [PMID: 34537410 DOI: 10.1016/j.hrthm.2021.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 08/17/2021] [Accepted: 09/10/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Type 3 long QT syndrome (LQT3) is caused by pathogenic, gain-of-function variants in SCN5A leading to a prolonged action potential, ventricular ectopy, and torsades de pointes. Treatment options include pharmacotherapy, cardiac denervation, and/or device therapy. Rarely, patients with malignant LQT3 require cardiac transplantation. OBJECTIVE The purpose of this study was to evaluate the role of chronic continuous intravenous (IV) lidocaine as a therapeutic option for select patients with LQT3 refractory to standard therapy. METHODS We performed a retrospective review of patients evaluated and treated at Mayo Clinic and identified 4 of 161 patients with LQT3 (2.5%) who were refractory to standard therapies and therefore treated with IV lidocaine. RESULTS There were 4 patients (2 female [50%]). The median age at first IV lidocaine infusion was 2 months (interquartile range 1.5-4.8 months), and the median cumulative duration on IV lidocaine was 11.5 months (interquartile range 8.7-17.8 months). The main indication for IV lidocaine in all patients was persistent ventricular arrhythmias. Before IV lidocaine, all patients received an implantable cardioverter-defibrillator, and while on intermittent IV lidocaine, all patients underwent bilateral cardiac sympathetic denervation. Additionally, 2 (50%) patients had cardiac ablation for premature ventricular complexes. In all patients, lidocaine infusion resulted in a significant reduction of LQT3-triggered cardiac events. The main side effects of IV lidocaine observed were dizziness (n = 2, 50%) and seizures (n = 2, 50%). During follow-up, 3 of 4 (75%) patients underwent orthotopic cardiac transplantation. The remaining patient continues to receive IV lidocaine bolus for rescue as needed. CONCLUSION For patients with LQT3 who are refractory to standard treatment, chronic IV lidocaine infusion can be used as a potential "bridge to transplant."
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Affiliation(s)
- Sahej Bains
- Medical Scientist Training Program, Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota; Department of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Adi Lador
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Raquel Neves
- Department of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | - J Martijn Bos
- Department of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | - John R Giudicessi
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota
| | - Bryan C Cannon
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Michael J Ackerman
- Department of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, Minnesota; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota.
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Bains S, Lador A, Bos JM, Ackerman MJ. B-PO04-169 ROLE OF CHRONIC, LONG TERM INTRAVENOUS LIDOCAINE IN THE CLINICAL MANAGEMENT OF PATIENTS WITH MALIGNANT TYPE 3 LONG QT SYNDROME. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.861] [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: 10/20/2022]
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Lador A, Valderrábano M, Patel A. Cardioneural ablation in a patient with spinal cord injury and significant sinus bradycardia. HeartRhythm Case Rep 2021; 7:398-402. [PMID: 34194989 PMCID: PMC8226309 DOI: 10.1016/j.hrcr.2021.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Adi Lador
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Miguel Valderrábano
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Apoor Patel
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
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Tavares L, Fuentes S, Lador A, Da-Wariboko A, Wang S, Schurmann PA, Dave AS, Valderrábano M. Venous anatomy of the left ventricular summit: Therapeutic implications for ethanol infusion. Heart Rhythm 2021; 18:1557-1565. [PMID: 33989783 DOI: 10.1016/j.hrthm.2021.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/04/2021] [Accepted: 05/06/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Venous ethanol ablation (VEA) is effective for treatment of left ventricular (LV) summit (LVS) arrhythmias. The LVS venous anatomy is poorly understood and has inconsistent nomenclature. OBJECTIVE The purpose of this study was to delineate the LVS venous anatomy by selective venography and 3-dimensional (3D) mapping during VEA and by venous-phase coronary computed tomographic angiography (vCTA). METHODS We analyzed (1) LVS venograms and 3D maps of 53 patients undergoing VEA; and (2) 3D reconstructions of 52 vCTAs, tracing LVS veins. RESULTS Angiography identified the following LVS veins: (1) LV annular branch of the great cardiac vein (GCV) (19/53); (2) septal (rightward) branches of the anterior ventricular vein (AIV) (53/53); and (3) diagonal branches of the AIV (51/53). Collateral connections between LVS veins and outflow, conus, and retroaortic veins were common. VEA was delivered to target arrhythmias in 38 of 53 septal, 6 of 53 annular, and 2 of 53 diagonal veins. vCTA identified LVS veins (range 1-5) in a similar distribution. GCV-AIV transition could either form an angle close to the left main artery bifurcation (n = 16; 88° ± 13°) or cut diagonally (n = 36; 133°±12°) (P ≤.001). Twenty-one patients had LV annular vein. In 28 patients only septal LVS veins were visualized in vCTA, in 2 patients only diagonal veins and in 22 patients both septal and diagonal veins were seen. In 39 patients the LVS veins reached the outflow tracts and their vicinity. CONCLUSION We provide a systematic atlas and nomenclature of LVS veins related to arrhythmogenic substrates. vCTA can be useful for noninvasive evaluation of LVS veins before ethanol ablation.
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Affiliation(s)
- Liliana Tavares
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Stephanie Fuentes
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Adi Lador
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Akanibo Da-Wariboko
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Sufen Wang
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Paul A Schurmann
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Amish S Dave
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Miguel Valderrábano
- Division of Cardiac Electrophysiology, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas.
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Lador A, Peterson L, Valderrabano M. DETERMINANTS OF OUTCOME IMPACT OF VEIN OF MARSHALL ETHANOL INFUSION WHEN ADDED TO CATHETER ABLATION OF PERSISTENT ATRIAL FIBRILLATION: A SECONDARY ANALYSIS OF THE VENUS RANDOMIZED CLINICAL TRIAL. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)01588-6] [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: 10/21/2022]
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16
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Tavares L, Lador A, Valderrábano M. Sleep Apnea and Atrial Fibrillation: Role of the Cardiac Autonomic Nervous System. Methodist Debakey Cardiovasc J 2021; 17:49-52. [PMID: 34104320 DOI: 10.14797/zyut2951] [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] [Indexed: 11/08/2022] Open
Abstract
Sleep apnea is highly associated with atrial fibrillation (AF), and both diseases are highly prevalent in the United States. The mechanistic underpinnings that contribute to their association remain uncertain, but numerous possible mechanisms have been proposed, including dysfunction of the cardiac autonomic nervous system (ANS). Studies have reported that apnea induces hyperactivity of the ANS, leading to increases in AF susceptibility. This review compiles the latest evidence on the role of the ANS in sleep-apnea-induced AF.
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Affiliation(s)
- Liliana Tavares
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Adi Lador
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Miguel Valderrábano
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
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Abstract
Catheter-based radiofrequency (RF) ablation is an effective, well-established therapy for ventricular tachycardia (VT). However, a large number of patients still have recurrences, particularly those with substrates arising from intramural locations that are inaccessible through endo- or epicardial catheter approaches. Several unconventional ablation techniques have been proposed to treat RF-refractory VT, including transarterial coronary ethanol ablation and retrograde coronary venous ethanol ablation. We review the evidence regarding the mechanisms, procedural aspects, and alcohol ablation outcomes for ventricular arrhythmias.
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Affiliation(s)
- Adi Lador
- Houston Methodist Debakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Akanibo Da-Wariboko
- Houston Methodist Debakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Liliana Tavares
- Houston Methodist Debakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Miguel Valderrábano
- Houston Methodist Debakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
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Abstract
Catheter ablation has become a cornerstone treatment for atrial fibrillation (AF). Pulmonary vein isolation is the accepted approach for paroxysmal AF ablation, but it is less effective for persistent AF. The vein of Marshall (VOM) is located in the epicardial left atrium and can be a source of AF triggers as well as a tract for autonomic nerves. It directly communicates with the underlying myocardium, including the left atrial ridge and the posterior mitral isthmus. This review discusses the latest evidence regarding the mechanisms, procedural aspects, and outcomes of VOM ethanol infusion when used as an adjunct to pulmonary vein isolation in patients with persistent AF.
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Affiliation(s)
- Adi Lador
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Miguel Valderrábano
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
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Lador A, Peterson LE, Swarup V, Schurmann PA, Makkar A, Doshi RN, DeLurgio D, Athill CA, Ellenbogen KA, Natale A, Koneru J, Dave AS, Giorgberidze I, Afshar H, Guthrie ML, Bunge R, Morillo CA, Kleiman NS, Valderrábano M. Determinants of outcome impact of vein of Marshall ethanol infusion when added to catheter ablation of persistent atrial fibrillation: A secondary analysis of the VENUS randomized clinical trial. Heart Rhythm 2021; 18:1045-1054. [PMID: 33482387 DOI: 10.1016/j.hrthm.2021.01.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/01/2021] [Accepted: 01/05/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Vein of Marshall Ethanol for Untreated Persistent AF (VENUS) trial demonstrated that adding vein of Marshall (VOM) ethanol infusion to catheter ablation (CA) improves ablation outcomes in persistent atrial fibrillation (AF). There was significant heterogeneity in the impact of VOM ethanol infusion on rhythm control. OBJECTIVE The purpose of this study was to assess the association between outcomes and (1) achievement of bidirectional perimitral conduction block and (2) procedural volume. METHODS The VENUS trial randomized patients with persistent AF (N = 343) to CA combined with VOM ethanol or CA alone. The primary outcome (freedom from AF or atrial tachycardia [AT] lasting longer than 30 seconds after a single procedure) was analyzed by 2 categories: (1) successful vs no perimitral block and (2) high- (>20 patients enrolled) vs low-volume centers. RESULTS In patients with perimitral block, the primary outcome was reached 54.3% after VOM-CA and 37% after CA alone (P = .01). Among patients without perimitral block, freedom from AF/AT was 34.0% after VOM-CA and 37.0% after CA (P = .583). In high-volume centers, the primary outcome was reached in 56.4% after VOM-CA and 40.2% after CA (P = .01). In low-volume centers, freedom from AF/AT was 30.77% after VOM-CA and 32.61% after CA (P = .84). In patients with successful perimitral block from high-volume centers, the primary outcome was reached in 59% after VOM-CA and 39.1% after CA (P = .01). Tests for interaction were significant (P = .002 for perimitral block and P = .04 for center volume). CONCLUSION Adding VOM ethanol infusion to CA has a greater impact on outcomes when associated with perimitral block and performed in high-volume centers. Perimitral block should be part of the VOM procedure.
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Affiliation(s)
- Adi Lador
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Leif E Peterson
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | | | - Paul A Schurmann
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas; Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | | | - Rahul N Doshi
- Division of Cardiology, Keck-USC University Hospital, University of Southern California, Los Angeles, California
| | - David DeLurgio
- Division of Cardiology, Emory St. Joseph's Hospital, Emory University, Atlanta, Georgia
| | - Charles A Athill
- San Diego Cardiac Center, Sharp Memorial Hospital, San Diego, California
| | - Kenneth A Ellenbogen
- Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas
| | - Jayanthi Koneru
- Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Amish S Dave
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | | | - Hamid Afshar
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Michelle L Guthrie
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Raquel Bunge
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Carlos A Morillo
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Neal S Kleiman
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas
| | - Miguel Valderrábano
- Houston Methodist DeBakey Heart and Vascular Center and Research Institute, Houston, Texas.
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Lador A, Patel A, Valderrábano M. Trans-coronary sinus puncture for catheter ablation and left atrial appendage closure device implantation in a patient with dextrocardia and persistent right superior vena cava. HeartRhythm Case Rep 2020; 6:903-906. [PMID: 33365235 PMCID: PMC7749198 DOI: 10.1016/j.hrcr.2020.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Adi Lador
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas
| | - Apoor Patel
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas
| | - Miguel Valderrábano
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas
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21
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Tavares L, Lador A, Fuentes S, Da-wariboko A, Blaszyk K, Malaczynska-Rajpold K, Papiashvili G, Korolev S, Peichl P, Kautzner J, Webber M, Hooks D, Rodríguez-Mañero M, Di Toro D, Labadet C, Sasaki T, Okishige K, Patel A, Schurmann PA, Dave AS, Rami TG, Valderrábano M. Intramural Venous Ethanol Infusion for Refractory Ventricular Arrhythmias. JACC Clin Electrophysiol 2020; 6:1420-1431. [DOI: 10.1016/j.jacep.2020.07.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/22/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023]
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Affiliation(s)
- Adi Lador
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas
| | - Miguel Valderrábano
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas
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23
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Witberg G, Landes U, Lador A, Yahav D, Kornowski R. Meta-analysis of transcatheter aortic valve implantation versus surgical aortic valve replacement in patients at low surgical risk. EUROINTERVENTION 2019; 15:e1047-e1056. [DOI: 10.4244/eij-d-19-00663] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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24
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Lador A, Hasdai D, Mager A, Porter A, Goldenberg I, Shlomo N, Vorobeichik D, Beigel R, Kornowski R, Iakobishvili Z. Incidence and Prognosis of Pericarditis After ST-Elevation Myocardial Infarction (from the Acute Coronary Syndrome Israeli Survey 2000 to 2013 Registry Database). Am J Cardiol 2018; 121:690-694. [PMID: 29370922 DOI: 10.1016/j.amjcard.2017.12.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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: 10/07/2017] [Revised: 12/02/2017] [Accepted: 12/07/2017] [Indexed: 11/17/2022]
Abstract
There are scarce contemporary data regarding the incidence and prognosis of early postmyocardial infarction pericarditis (PMIP). Thus, we retrospectively analyzed 6,282 patients with ST-segment elevation myocardial infarction (STEMI) enrolled with known PMIP status in the Acute Coronary Syndrome Israeli Survey 2000 to 2013 registry. The primary outcome was the composite of all-cause mortality, nonfatal myocardial infarction, cerebrovascular event, stent thrombosis, or revascularization. The secondary outcomes were mortality and length of stay during the acute hospitalization. Overall, 76 patients with STEMI had PMIP (1.2%). PMIP incidence gradually decreased from 170 per 10,000 in 2000 to 110 per 10,000 in 2013, respectively (35% reduction, p for trend = 0.035). Patients with PMIP were younger (median 58.0 vs 61.0; p = 0.045), had less hypertension, higher cardiac biomarkers, and more frequently reduced left ventricular ejection fraction (87.0% vs 67.0%; p = 0.001). Patients with PMIP had longer time to reperfusion (225 minutes vs 183 minutes; p = 0.016) and length of stay (7.0 vs 5.0 days; p < 0.001). The composite end point occurred similarly in patients with and without PMIP (10.5% vs 13.2%, respectively). There was no significant difference in 30-day, 1-year, and 5-year survival. In conclusion, PMIP is a relatively rare complication of STEMI in the coronary reperfusion era, portends worse short-term but not long-term outcomes, and is associated with bigger infarct size.
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Affiliation(s)
- Adi Lador
- Department of Cardiology, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Hasdai
- Department of Cardiology, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviv Mager
- Department of Cardiology, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avital Porter
- Department of Cardiology, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Goldenberg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Nir Shlomo
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel; The Israeli Association for Cardiovascular Trials, Tel Hashomer, Israel
| | - Dina Vorobeichik
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel; The Israeli Association for Cardiovascular Trials, Tel Hashomer, Israel
| | - Roy Beigel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zaza Iakobishvili
- Department of Cardiology, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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25
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Witberg G, Lador A, Yahav D, Kornowski R. Transcatheter versus surgical aortic valve replacement in patients at low surgical risk: A meta-analysis of randomized trials and propensity score matched observational studies. Catheter Cardiovasc Interv 2018; 92:408-416. [PMID: 29388308 DOI: 10.1002/ccd.27518] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [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: 11/12/2017] [Revised: 01/02/2018] [Accepted: 01/06/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Although transcatheter aortic valve replacement (TAVR) is officially indicated for high risk aortic stenosis (AS) patients, the procedure is increasingly being performed in patients who are not at high surgical risk, including a substantial number of low risk patients. However, data on the benefit of TAVR in this patient population is limited. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies with propensity score matching (PSM) of TAVR versus surgical aortic valve replacement (SAVR) in patients who are at low surgical risk. The primary outcome was all-cause mortality. The secondary outcomes included stroke, myocardial infarction, bleeding, and various procedural complications. RESULTS Six studies (2 RCTs and 4 PSM studies) totaling 3,484 patients were included. Follow-up ranged from 3 months to 3 years (median 2 years). The short-term mortality was similar with either TAVR or SAVR (2.2% for TAVR and 2.6% for SAVR, RR 0.89, 95% CI 0.56-1.41, P = 0.62), however, TAVR was associated with increased risk for intermediate-term mortality (17.2% for TAVR and 12.7% for SAVR, RR 1.45, 95% CI 1.11-1.89, P = 0.006). In terms of periprocedural complications, TAVR was associated with reduced risk for bleeding and renal failure and an increase in vascular complications and Pacemaker implantation. CONCLUSIONS In patients who are at low surgical risk, TAVR seems to be associated with increased mortality risk. Until more data in this population is available, SAVR should remain the treatment of choice for these patients.
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Affiliation(s)
- Guy Witberg
- Department of Cardiology, Rabin medical center, Petach, Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv university, Tel, Aviv, Israel
| | - Adi Lador
- Department of Cardiology, Rabin medical center, Petach, Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv university, Tel, Aviv, Israel
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel-Aviv university, Tel, Aviv, Israel.,Infectious diseases unit, , Rabin medical center, Petach, Tikva, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin medical center, Petach, Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv university, Tel, Aviv, Israel
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Zusman O, Kornowski R, Witberg G, Lador A, Orvin K, Levi A, Assali A, Vaknin-Assa H, Sharony R, Shapira Y, Sagie A, Landes U. Transcatheter Aortic Valve Implantation Futility Risk Model Development and Validation Among Treated Patients With Aortic Stenosis. Am J Cardiol 2017; 120:2241-2246. [PMID: 29037446 DOI: 10.1016/j.amjcard.2017.09.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/02/2017] [Accepted: 09/06/2017] [Indexed: 10/18/2022]
Abstract
Risk-benefit assessment for transcatheter aortic valve implantation (TAVI) is still evolving. A sizeable group of patients do not fully benefit from intervention despite a technically successful procedure. All patients who underwent TAVI with device success and with no Valve Academic Research Consortium (VARC)-2 defined complications were included. Various demographic data, clinical details, and echocardiographic findings were examined. The outcome was defined as 1-year composite of mortality, stroke, lack of functional-class improvement (by New York Heart Association class), and readmissions (≥1 month after the procedure). Logistic regression was used to fit the prediction model. We used a 10-fold cross-validation to validate our results. Of 543 patients, 435 met the inclusion criteria. The mean age was 82 (±6.5) years, 43% were men, and the mean Society of Thoracic Surgeons score was 6.6 (±4.7). At 1 year, 66 of 435 patients (15%) experienced the study end point. The final logistic regression model included diabetes, baseline New York Heart Association functional class, diastolic dysfunction, need for diuretics, mean gradient, hemoglobin level, and creatinine level. The area under the curve was 0.73 and was reduced to 0.71 after validation, with a 97% specificity using a single cutoff. Dividing to low-, medium-, and high-risk groups for futility produced a corresponding prevalence of 6%, 19%, and 59% futility. A web application for the prediction model was developed and provided. In conclusion, this prediction score may provide an important insight and may facilitate identification of patients who, despite a technically successful and uncomplicated procedure, have risk that may outweigh the benefit of a contemplated TAVI.
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27
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Lador A, Hasdai D, Porter A, Mager A, Goldenberg I, Shlomo N, Beigel R, Kornowski R, Iakobishvili Z. P3646Trends in frequency and prognosis of post myocardial infarction pericarditis: ACSIS 2000–2013. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx504.p3646] [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: 11/13/2022] Open
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28
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Weissler-Snir A, Gurevitz C, Assali A, Vaknin-Assa H, Bental T, Lador A, Yavin H, Perl L, Kornowski R, Lev E. Prognosis of STEMI Patients with Multi-Vessel Disease Undergoing Culprit-Only PCI without Significant Residual Ischemia on Non-Invasive Stress Testing. PLoS One 2015; 10:e0138474. [PMID: 26406235 PMCID: PMC4583296 DOI: 10.1371/journal.pone.0138474] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 08/31/2015] [Indexed: 12/28/2022] Open
Abstract
Aims In about 50–80% of ST-segment elevation myocardial infarction (STEMI) patients there is significant atherosclerotic disease in other coronary arteries in addition to the culprit vessel. There is substantial controversy as to the optimal revascularization approach in these patients. We sought to compare the outcomes of STEMI patients with multi-vessel disease (MVD) treated with culprit-only primary percutaneous coronary intervention (PPCI) without significant ischemia on subsequent non-invasive testing, to those of STEMI patients with single-vessel disease (SVD). Methods and Results Between 2001–2010, 1,540 consecutive patients treated with primary PCI for STEMI were prospectively observed and entered into a comprehensive clinical database. The primary end point was a composite of major adverse cardiac events (MACE), consisting of mortality, re-infarction and revascularization within 1 and 3 years following PPCI (excluding events occurring during the first 30 days). Patients with cardiogenic shock were excluded. The study included 720 patients with SVD and 185 patients with MVD who underwent culprit-only PPCI and had no residual ischemia on subsequent non-invasive stress testing. Patients with MVD were older, more likely to have hypertension or previous MI and less likely to be smokers and present with anterior MI than patients with SVD. One and 3-year MACE rates were similar between the groups. On cox proportional-hazards regression MVD without residual ischemia was not independently associated with MACE and its components. Conclusions STEMI patients with MVD treated with culprit only-PCI without significant residual ischemia on non-invasive stress testing appear to have similar prognosis to STEMI patients with SVD.
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Affiliation(s)
| | - Chen Gurevitz
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Abid Assali
- Cardiology Department, Rabin Medical Center, Petah-Tikva, Israel
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Hana Vaknin-Assa
- Cardiology Department, Rabin Medical Center, Petah-Tikva, Israel
| | - Tamir Bental
- Cardiology Department, Rabin Medical Center, Petah-Tikva, Israel
| | - Adi Lador
- Cardiology Department, Rabin Medical Center, Petah-Tikva, Israel
| | - Hagai Yavin
- Cardiology Department, Rabin Medical Center, Petah-Tikva, Israel
| | - Leor Perl
- Cardiology Department, Rabin Medical Center, Petah-Tikva, Israel
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Cardiology Department, Rabin Medical Center, Petah-Tikva, Israel
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Eli Lev
- Cardiology Department, Rabin Medical Center, Petah-Tikva, Israel
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
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Abstract
BACKGROUND Asymptomatic bacteriuria is commonly detected in women aged up to 60 years, patients with diabetes, and the elderly. The benefit of antibiotic treatment for this condition is controversial. OBJECTIVES To assess the effectiveness and safety of antibiotics treatment for asymptomatic bacteriuria in adults. Specific objectives were to assess 1) the effectiveness of antibiotics for preventing development of symptomatic UTI, UTI-related complications, overall mortality, UTI-related mortality, and resolution of bacteriuria; 2) the development of resistance to antibiotic treatment by comparing resistance of grown bacteria in urine before and after therapy; and 3) the frequency of adverse events. SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register up to 24 February 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing antibiotics to placebo or no treatment for asymptomatic bacteriuria in adults were included. The outcomes of interest were the development of symptomatic urinary tract infection (UTI), complications, death, any adverse event, development of antibiotic resistance, bacteriological cure, and decline in kidney function. DATA COLLECTION AND ANALYSIS Two authors independently extracted the data and assessed study quality. Statistical analyses were performed using the random effects model and the results expressed as risk ratios (RR) with 95% confidence intervals (CI). MAIN RESULTS We included nine studies (1614 participants) in this review. Symptomatic UTI (RR 1.11, 95% CI 0.51 to 2.43), complications (RR 0.78, 95% CI 0. 35 to 1.74), and death (RR 0.99, 95% CI 0.70 to 1.41) were similar between the antibiotic and placebo or no treatment arms. Antibiotics were more effective for bacteriological cure (RR 2.32, 95% CI 1.11 to 4.83) but also more adverse events developed in this group (RR 3.77, 95% CI 1.40 to 10.15). No decline in the kidney function was observed across the studies; minimal data were available on the emergence of resistant strains after antimicrobial treatment.The included studies were of medium and high quality, used different treatments for different durations of treatment and follow-up, different populations, but this did not appear to influence the results of review. AUTHORS' CONCLUSIONS No differences were observed between antibiotics versus no treatment of asymptomatic bacteriuria for the development of symptomatic UTI, complications or death. Antibiotics were superior to no treatment for the bacteriological cure but with significantly more adverse events. There was no clinical benefit from treating asymptomatic bacteriuria in the studies included in this review.
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Affiliation(s)
| | - Adi Lador
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | | | - Leonard Leibovici
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
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Eliakim-Raz N, Lador A, Leibovici-Weissman Y, Elbaz M, Paul M, Leibovici L. Efficacy and safety of chloramphenicol: joining the revival of old antibiotics? Systematic review and meta-analysis of randomized controlled trials. J Antimicrob Chemother 2015; 70:979-96. [PMID: 25583746 DOI: 10.1093/jac/dku530] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES Chloramphenicol is an old broad-spectrum antibiotic. We assessed its efficacy and safety. METHODS This was a systematic review and meta-analysis. Electronic databases were searched to identify randomized controlled trials (RCTs) that assessed patients, of any age, with systemic bacterial infections that can cause sepsis and compared chloramphenicol alone versus other antibiotics. No restrictions on the date of publication, language or publication status were applied. The primary outcome assessed was overall mortality. RESULTS Sixty-six RCTs fulfilled the inclusion criteria, and these included 9711 patients. We found a higher mortality with chloramphenicol for respiratory tract infections [risk ratio (RR) 1.40, 95% CI 1.00-1.97] and meningitis (RR 1.27, 95% CI 1.00-1.60), both without heterogeneity. The point estimate was similar for enteric fever, without statistical significance. No statistically significant difference was found between chloramphenicol and other antibiotics regarding treatment failure, except for enteric fever (RR 1.46, 95% CI 1.07-2.00, without heterogeneity). This difference derived mainly from studies comparing chloramphenicol with fluoroquinolones (RR 1.85, 95% CI 1.07-3.2). There were no statistically significant differences between chloramphenicol and other antibiotics in terms of adverse events, including haematological events, except for anaemia, which occurred more frequently with chloramphenicol (RR 2.80, 95% CI 1.65-4.75, I(2) =0%), and gastrointestinal side effects, which were less frequent with chloramphenicol (RR 0.67, 95% CI 0.46-0.99, I(2) =0%). Many of the studies included were sponsored by pharmaceutical companies marketing the comparator drug to chloramphenicol, and this might have influenced the results. CONCLUSIONS Chloramphenicol cannot be recommended as a first-line treatment for respiratory tract infections, meningitis or enteric fever as alternatives are probably more effective. Chloramphenicol is as safe as treatment alternatives for short antibiotic courses. RCTs are needed to test this treatment against MDR organisms when better alternatives do not exist.
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Affiliation(s)
- Noa Eliakim-Raz
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tiqva, Israel Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah-Tiqva, Israel
| | - Adi Lador
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tiqva, Israel Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Yaara Leibovici-Weissman
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tiqva, Israel
| | - Michal Elbaz
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tiqva, Israel Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Mical Paul
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel Unit of Infectious Diseases, Rambam Hospital, Haifa, Israel
| | - Leonard Leibovici
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tiqva, Israel Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
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Vinograd I, Baslo R, Eliakim-Raz N, Farbman L, Taha A, Sakhnini A, Lador A, Stemmer S, Gafter-Gvili A, Fraser D, Leibovici L, Paul M. Factors associated with influenza vaccination among adult cancer patients: a case–control study. Clin Microbiol Infect 2014; 20:899-905. [DOI: 10.1111/1469-0691.12625] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 03/12/2014] [Accepted: 03/13/2014] [Indexed: 01/25/2023]
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Paul M, Lador A, Grozinsky‐Glasberg S, Leibovici L. Beta lactam antibiotic monotherapy versus beta lactam-aminoglycoside antibiotic combination therapy for sepsis. Cochrane Database Syst Rev 2014; 2014:CD003344. [PMID: 24395715 PMCID: PMC6517128 DOI: 10.1002/14651858.cd003344.pub3] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Optimal antibiotic treatment for sepsis is imperative. Combining a beta lactam antibiotic with an aminoglycoside antibiotic may provide certain advantages over beta lactam monotherapy. OBJECTIVES Our objectives were to compare beta lactam monotherapy versus beta lactam-aminoglycoside combination therapy in patients with sepsis and to estimate the rate of adverse effects with each treatment regimen, including the development of bacterial resistance to antibiotics. SEARCH METHODS In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 11); MEDLINE (1966 to 4 November 2013); EMBASE (1980 to November 2013); LILACS (1982 to November 2013); and conference proceedings of the Interscience Conference of Antimicrobial Agents and Chemotherapy (1995 to 2013). We scanned citations of all identified studies and contacted all corresponding authors. In our previous review, we searched the databases to July 2004. SELECTION CRITERIA We included randomized and quasi-randomized trials comparing any beta lactam monotherapy versus any combination of a beta lactam with an aminoglycoside for sepsis. DATA COLLECTION AND ANALYSIS The primary outcome was all-cause mortality. Secondary outcomes included treatment failure, superinfections and adverse events. Two review authors independently collected data. We pooled risk ratios (RRs) with 95% confidence intervals (CIs) using the fixed-effect model. We extracted outcomes by intention-to-treat analysis whenever possible. MAIN RESULTS We included 69 trials that randomly assigned 7863 participants. Twenty-two trials compared the same beta lactam in both study arms, while the remaining trials compared different beta lactams using a broader-spectrum beta lactam in the monotherapy arm. In trials comparing the same beta lactam, we observed no difference between study groups with regard to all-cause mortality (RR 0.97, 95% CI 0.73 to 1.30) and clinical failure (RR 1.11, 95% CI 0.95 to 1.29). In studies comparing different beta lactams, we observed a trend for benefit with monotherapy for all-cause mortality (RR 0.85, 95% CI 0.71 to 1.01) and a significant advantage for clinical failure (RR 0.75, 95% CI 0.67 to 0.84). No significant disparities emerged from subgroup and sensitivity analyses, including assessment of participants with Gram-negative infection. The subgroup of Pseudomonas aeruginosa infections was underpowered to examine effects. Results for mortality were classified as low quality of evidence mainly as the result of imprecision. Results for failure were classified as very low quality of evidence because of indirectness of the outcome and possible detection bias in non-blinded trials. We detected no differences in the rate of development of resistance. Nephrotoxicity was significantly less frequent with monotherapy (RR 0.30, 95% CI 0.23 to 0.39). We found no heterogeneity for all these comparisons.We included a small subset of studies addressing participants with Gram-positive infection, mainly endocarditis. We identified no difference between monotherapy and combination therapy in these studies. AUTHORS' CONCLUSIONS The addition of an aminoglycoside to beta lactams for sepsis should be discouraged. All-cause mortality rates are unchanged. Combination treatment carries a significant risk of nephrotoxicity.
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Affiliation(s)
- Mical Paul
- Rambam Health Care CampusDivision of Infectious DiseasesHa‐aliya 8 StHaifaIsrael33705
| | - Adi Lador
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Simona Grozinsky‐Glasberg
- Dept of Medicine, Hadassah‐Hebrew University Medical CenterNeuroendocrine Tumors Unit, Endocrinology & Metabolism ServicePOB 12000JerusalemIsrael91120
| | - Leonard Leibovici
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
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Vinograd I, Eliakim-Raz N, Farbman L, Baslo R, Taha A, Sakhnini A, Lador A, Stemmer SM, Gafter-Gvili A, Leibovici L, Paul M. Clinical effectiveness of seasonal influenza vaccine among adult cancer patients. Cancer 2013; 119:4028-35. [DOI: 10.1002/cncr.28351] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 07/28/2013] [Accepted: 08/05/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Inbal Vinograd
- Pharmacy Services; Schneider Children's Medical Center; Petah Tikva Israel
- Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - Noa Eliakim-Raz
- Department of Medicine E, Rabin Medical Center; Beilinson Hospital; Petah Tikva Israel
| | - Laura Farbman
- Department of Medicine E, Rabin Medical Center; Beilinson Hospital; Petah Tikva Israel
| | - Rina Baslo
- Department of Oncology-Hematology; Schneider Children's Medical Center; Petah Tikva Israel
| | - Ahmed Taha
- Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - Ali Sakhnini
- Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - Adi Lador
- Department of Medicine E, Rabin Medical Center; Beilinson Hospital; Petah Tikva Israel
| | - Salomon M. Stemmer
- Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
- Institute of Oncology; Davidoff Center, Rabin Medical Center; Petah Tikva Israel
| | - Anat Gafter-Gvili
- Department of Medicine E, Rabin Medical Center; Beilinson Hospital; Petah Tikva Israel
- Institute of Oncology; Davidoff Center, Rabin Medical Center; Petah Tikva Israel
| | - Leonard Leibovici
- Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
- Department of Medicine E, Rabin Medical Center; Beilinson Hospital; Petah Tikva Israel
| | - Mical Paul
- Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
- Unit of Infectious Diseases, Rabin Medical Center; Beilinson Hospital; Petah Tikva Israel
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Skalsky K, Yahav D, Lador A, Eliakim-Raz N, Leibovici L, Paul M. Macrolides vs. quinolones for community-acquired pneumonia: meta-analysis of randomized controlled trials. Clin Microbiol Infect 2012; 19:370-8. [PMID: 22489673 DOI: 10.1111/j.1469-0691.2012.03838.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The relative efficacy, safety and ecological implications of macrolides vs. quinolones in the treatment of community-acquired pneumonia (CAP) are debatable. We performed a systematic review and meta-analysis of randomized controlled trials comparing any macrolide vs. any quinolone for the treatment of CAP among adult inpatients or outpatients, as monotherapy or both in combination with a beta-lactam. We did not limit inclusion by pneumonia severity, publication status, language or date of publication. The primary outcomes assessed were 30-day all-cause mortality and treatment failure. Two authors independently extracted the data. Fixed effect meta-analysis of risk ratios (RRs) with 95% confidence intervals was performed. Sixteen trials (4989 patients) fulfilling inclusion criteria were identified, mostly assessing outpatients with mild to moderate CAP. All-cause mortality was not significantly different for macrolides vs. quinolones, RR 1.03 (0.63-1.68, seven trials), with a low event rate (2%). Treatment failure was significantly lower with quinolones, RR 0.78 (0.67-0.91, 16 trials). The definition of failure used in the primary studies was not clearly representative of patients' benefit. Microbiological failure was lower with quinolones, RR 0.63 (0.49-0.81, 13 trials). All adverse events, adverse events requiring discontinuation and any premature antibiotic discontinuation were significantly more frequent with macrolides, mainly on account of gastrointestinal adverse events. Resistance development was not assessed in the trials. Randomized controlled trials show an advantage of quinolones in the treatment of CAP with regard to clinical cure without need for antibiotic modification at end of treatment and gastrointestinal adverse events. The clinical significance of this advantage is unclear.
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Affiliation(s)
- K Skalsky
- Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
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Lador A, Nasir H, Mansur N, Sharoni E, Biderman P, Leibovici L, Paul M. Antibiotic prophylaxis in cardiac surgery: systematic review and meta-analysis. J Antimicrob Chemother 2011; 67:541-50. [PMID: 22083832 DOI: 10.1093/jac/dkr470] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Antibiotic prophylaxis is recommended in cardiac surgery. Current debate concerns the type of antibiotic(s), dosing and the duration of prophylaxis. METHODS Systematic review of randomized controlled trials comparing one antibiotic regimen versus another in cardiac surgery. We searched The Cochrane Library, PubMed, LILACS, conference proceedings and bibliographies. Two reviewers independently extracted the data. The primary outcome was deep sternal wound infections (DSWIs). Meta-analysis was performed using the Mantel-Haenszel fixed-effect method. Risk ratios (RRs) with 95% confidence intervals (95% CIs) are reported. RESULTS Fifty-nine trials were included. There were no significant differences in DSWI or all other categories of surgical site infections (SSIs) for antibiotic prophylaxis with β-lactams comprising a Gram-negative spectrum of coverage versus prophylaxis targeting Gram-positive bacteria, but the former led to a significantly lower rate of post-operative pneumonia (RR 0.68, 95% CI 0.51-0.90) and all-cause mortality (RR 0.66, 95% CI 0.47-0.92). In trials comparing different antibiotic regimens for different durations, prophylaxis duration of ≤24 h post-operation led to higher rates of DSWI (RR 1.83, 95% CI 1.25-2.66), any sternal SSI, surgical interventions for SSI and endocarditis compared with longer duration prophylaxis. There was no advantage of regimens lasting >48 h post-operation. In the comparison of glycopeptides versus β-lactams, an advantage of glycopeptides was observed when comparators were given for similar duration and for β-lactams when given for a longer duration than the glycopeptides. There was no significant advantage of high antibiotic dosing. CONCLUSIONS Evidence supports second- or third-generation cephalosporins for cardiac surgery prophylaxis and points at a possible advantage of prophylaxis prolongation up to 48 h post-operatively.
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Affiliation(s)
- Adi Lador
- Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
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Yahav D, Lador A, Paul M, Leibovici L. Efficacy and safety of tigecycline: a systematic review and meta-analysis--authors' responses. J Antimicrob Chemother 2011. [DOI: 10.1093/jac/dkr419] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
BACKGROUND Tigecycline is a novel glycylcycline that exhibits broad-spectrum antibacterial activity. Recently, the US FDA issued a warning concerning increased mortality with tigecycline in randomized controlled trials (RCTs). METHODS We conducted a systematic review and meta-analysis of RCTs that compared tigecycline with any other antibiotic regimen for the treatment of any infection. A comprehensive search, without publication status or other restrictions, was conducted. The primary outcome was overall 30 day mortality. The secondary outcome included clinical and microbiological failure, superinfections and adverse events (AEs). The trials' risks of bias and their effects on results were assessed. Two reviewers independently extracted the data. Individual trials' relative risks (RRs) were pooled using a fixed effect meta-analysis. RESULTS Fifteen trials (7654 patients) were included. Overall mortality was higher with tigecycline compared with other regimens [RR 1.29, 95% confidence interval (CI) 1.02-1.64, without heterogeneity]. The type of infection assessed and the trials' reported risks of bias did not affect this result. Clinical failure was significantly higher with tigecycline (RR 1.16, 95% CI 1.06-1.27) and non-statistically significant higher rates of microbiological failure were demonstrated (RR 1.13, 95% CI 0.99-1.30). Development of septic shock was significantly more frequent with tigecycline (RR 7.01, 95% CI 1.27-38.66). Superinfections were significantly more common with tigecycline and so were AEs, including all AEs and AEs requiring discontinuation. CONCLUSIONS In the light of the increased mortality, probably explained by decreased clinical and microbiological efficacy, clinicians should avoid tigecycline monotherapy in the treatment of severe infections and reserve it as a last-resort drug.
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Affiliation(s)
- Dafna Yahav
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tiqva, Israel.
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Lalazar G, Ben Ya’acov A, Lador A, Livovsky DM, Pappo O, Preston S, Hareati M, Ilan Y. Modulation of intracellular machinery by β-glycolipids is associated with alteration of NKT lipid rafts and amelioration of concanavalin-induced hepatitis. Mol Immunol 2008; 45:3517-25. [DOI: 10.1016/j.molimm.2008.05.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2008] [Revised: 05/11/2008] [Accepted: 05/14/2008] [Indexed: 01/29/2023]
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