Cardiology Commons^™

Reducing The Risk Of Mortality In Chronic Obstructive Pulmonary Disease With Pharmacotherapy: A Narrative Review, Matthew Mintz, Igor Barjaktarevic, Donald A. Mahler, Barry Make, Neil Skolnik, Barbara Yawn, Bree Zeyzus-Johns, Nicola A. Hanania

Abington Jefferson Health Papers

In 2020, chronic obstructive pulmonary disease (COPD) was the fifth leading cause of death in the United States excluding COVID-19, and its mortality burden has been rising since the 1980s. Smoking cessation, long-term oxygen therapy, noninvasive ventilation, and lung volume reduction surgery have had a beneficial effect on mortality; however, until recently, the effects of pharmacologic therapies on all-cause mortality have been unclear. Inhaled pharmacologic treatments for patients with COPD include combinations of long-acting muscarinic receptor antagonists (LAMAs), long-acting-β2-agonists (LABAs), and inhaled corticosteroids (ICS). The recent IMPACT and ETHOS clinical trials reported mortality benefits with ICS/LAMA/LABA triple therapy compared with …

Trend Of Left Ventricular Assist Device Related Complications: Insight From The National Inpatient Sample Database, Waqas Ullah, Muhammad Khawar Sana, Alexander G. Hajduczok, Yevgeniy Brailovsky, Donald C. Haas, Indranee N. Rajapreyar

Division of Cardiology Faculty Papers

No abstract provided.

Persistent Fdg Uptake At Apical Aneurysm In A Patient With Cardiac Sarcoidosis, Chaitanya Rojulpote, Shivaraj Patil, Mahesh K. Vidula, Robert Kotloff, Stuart Prenner, Paco E. Bravo

Einstein Health Papers

We present a case of cardiac sarcoidosis with persistent, focal fluorodeoxyglucose uptake at the left ventricular apical aneurysm concerning for ongoing active inflammatory injury, prompting aggressive immunosuppressive therapy. This case highlights the importance of understanding the various clinical entities that may resemble disease activity on fluorodeoxyglucose positron emission tomography/computed tomography imaging. (Level of Difficulty: Intermediate.)

Robotically Assisted Mitral Valve Repair—Port-Only Totally Endoscopic Approach, Kellen J. Round, Colin C. Yost, Jake L. Rosen, Jenna L. Mandel, Meagan Wu, Luke C. Olson, Jordan E. Goldhammer, T. Sloane Guy

Department of Surgery Faculty Papers

Robotic mitral valve repair (MVR) is an emerging option to treat degenerative valve disease. Compared to open thoracotomy, robotic mitral valve surgery has been shown to afford decreased postoperative length of stay with comparable rates of mortality and morbidity. Among the variety of techniques for robotic MVR, the totally endoscopic approach remains the least invasive method to date. In this report, we describe our technique for totally endoscopic robotically-assisted MVR. In particular, we seek to highlight the use of several unique techniques in MVR. Percutaneous cannulation with use of the endoballoon is employed for cardiopulmonary bypass (CPB), thus avoiding traditional …

Feasibility Of Mediastinal Radiation Use In Heartmate 3 Lvad Recipients With Cancer., Nausharwan Butt, Farooq H Sheikh

Division of Cardiology Faculty Papers

The HeartMate 3 left ventricular assist device possesses the unique feature of having its electronics and software located within the housing of the pump, which may predispose it to malfunction from radiation exposure during cancer treatment. We investigated this association in a case series of two patients at our institution.

Outcomes Among St-Elevation Myocardial Infarction (Stemi) Patients With Cardiogenic Shock And Covid-19: A Nationwide Analysis, Bruce Adrian Casipit, Zurab Azmaiparashvili, Kevin Bryan Lo, Aman Amanullah

Division of Cardiology Faculty Papers

Background: There is paucity of data regarding the characteristics and outcomes of patients admitted for ST Elevation Myocardial Infarction (STEMI) complicated by cardiogenic shock (CS) with concomitant Coronavirus Disease 2019 (COVID-19) infection.

Methods: Using the National Inpatient Sample (NIS) Database for the year 2020, we conducted a retrospective cohort study to investigate the outcomes of patients who sustained STEMI-associated cardiogenic shock (STEMI-CS) with concomitant COVID-19 infection looking at its impact on in-hospital mortality and secondarily at the in-hospital procedure and intervention utilization rates as well as hospital length of stay.

Results: We identified a total of 22,775 patients with STEMI-CS, …

Resistant Drug-Eluting Stent Restenosis And Resurrection Of Intracoronary Brachytherapy: The Lazarus Of Contemporary Coronary Intervention, Michael P. Savage, David L. Fischman

Division of Cardiology Faculty Papers

No abstract provided.

A Meta-Analysis Of Standard Versus Ultrasound-Assisted Catheter-Directed Thrombolysis In The Management Of Acute Pulmonary Embolism, Elizabeth S. Bruno, Mark Terence P. Mujer, Parth V. Desai, Yevgeniy Brailovsky, Amir Darki

Division of Cardiology Faculty Papers

Background: Standard catheter-directed thrombolysis (SCDT) harnesses the therapeutic benefit of systemic thrombolytics while minimizing bleeding complications in patients presenting with pulmonary embolism (PE). Ultrasound-assisted catheter-directed thrombolysis (USAT) theoretically improves upon SCDT by disrupting fibrin and increasing the surface area exposed to thrombolytic agent. However, it is unclear if this translates into improved outcomes.

Methods: A systematic search of prior publications comparing SCDT and USAT in patients with intermediate or high-risk PE was conducted. Primary outcomes of interest were bleeding events, ICU and hospital length of stay. Secondary outcomes included changes in pulmonary artery systolic pressure (PASP), mean pulmonary artery pressure …

Reflecting On The Advancements Of Hfref Therapies Over The Last Two Decades And Predicting What Is Yet To Come, Iliana L. Piña, Gregory T. Gibson, Shelley Zieroth, Rachna Kataria

Division of Cardiology Faculty Papers

What was once considered a topic best avoided, managing heart failure with reduced ejection fraction (HFrEF) has become the focus of many drug and device therapies. While the four pillars of guideline-directed medical therapies have successfully reduced heart failure hospitalizations, and some have even impacted cardiovascular mortality in randomized controlled trials (RCTs), patient-reported outcomes have emerged as important endpoints that merit greater emphasis in future studies. The prospect of an oral inotrope seems more probable now as targets for drug therapies have moved from neurohormonal modulation to intracellular mechanisms and direct cardiac myosin stimulation. While we have come a long …

Advancing Global Equity In Cardiac Care As Cardiac Implantable Electronic Device Reuse Comes Of Age, Daniel Alyesh, Behzad B. Pavri, William Choe, Mam Chandara, Mahmoud U. Sani, Phong Dinh Phan, Aime Bonny, Paul Khairy, Sunil K. Sinha, Uma Srivatsa, Joseph E. Marine, Kim Eagle, Thomas C. Crawford, Dhanunjaya Lakkireddy, Sri Sundaram

Division of Cardiology Faculty Papers

A nation’s health and economic development are inextricably and synergistically connected. Stark differences exist between wealthy and developing nations in the use of cardiac implantable electronic devices (CIEDs). Cardiovascular disease is now the leading cause of death in low- and middle-income countries (LMIC), with a significant burden from rhythm-related diseases. As science, technology, education, and regulatory frameworks have improved, CIED recycling for exportation and reuse in LMIC has become possible and primed for widespread adoption. In our manuscript, we outline the science and regulatory pathways regarding CIED reuse. We propose a pathway to advance this technology that includes creating a …

Clinical Characteristics And Electrophysiologic Properties Of Scn5a Variants In Fever-Induced Brugada Syndrome, Gan-Xiao Chen, Hector Barajas-Martinez, Giuseppe Ciconte, Cheng-I Wu, Michelle M Monasky, Hao Xia, Bian Li, John A Capra, Kai Guo, Zhong-He Zhang, Xiu Chen, Bo Yang, Hong Jiang, Gary Tse, Chloe Miu Mak, Yoshiyasu Aizawa, Michael H Gollob, Charles Antzelevitch, Arthur A M Wilde, Carlo Pappone, Dan Hu

Division of Cardiology Faculty Papers

Background: Brugada syndrome (BrS) is a severe inherited arrhythmia syndrome that can be unmasked by fever.

Methods: A multicentre clinical analysis was performed in 261 patients diagnosed with fever-induced BrS, including 198 (75.9%) and 27 (10.3%) patients who received next-generation genetic sequencing and epicardial arrhythmogenic substrate (AS) mapping, respectively.

Findings: In fever-induced BrS patients, pathogenic or likely pathogenic (P/LP) SCN5A variant carriers developed fever-induced BrS at a younger age, and more often in females and those of Caucasian descent. They exhibited significant electrophysical abnormalities, including a larger epicardial AS area, and more prolonged abnormal epicardial electrograms. During a median follow-up …

There's A Hole In My Heart: A Case Of An Unrepaired Vsd, Brittany Hartman, Alex Dwyer, Robert Dejoy

Einstein Health Papers

No abstract provided.

Ten Year Real World Experience With Ultrafiltration For The Management Of Acute Decompensated Heart Failure, Donald C. Haas, Maureen Hummel, Patricia Barrella, Waqas Ullah, Misung Yi, Robert Watson

Abington Jefferson Health Papers

Background: Randomized controlled trials (RCT) of ultrafiltration (UF) have demonstrated conflicting results regarding its efficacy and safety.

Objective: We reviewed 10 years of data for adjustable UF during heart failure hospitalizations in a real world cohort.

Methods: We performed a retrospective, single center analysis of 335 consecutive patients treated with adjustable rate UF using the CHF Solutions Aquadex Flex Flo System from 2009 to 2019.

Results: Compared to previous RCTs investigating UF, our cohort was older, with worse renal impairment and more antecedent HF hospitalizations in the year preceding therapy. Mean fluid removal with UF was 14.6 l. Mean weight …

Transradial-Transfistula Access For Cardiac Catheterization In Patients With Abandoned Hemodialysis Fistulas, Noah Q. Haroian, Michael P. Savage, David L. Fischman

Department of Medicine Faculty Papers

Guidelines consider radial access a relative contraindication in patients with end-stage renal disease as part of a vessel preservation strategy. Radial access distal to a hemodialysis fistula, what we term transradial-transfistula access, offers a solution to radially access this population without affecting their vessel preservation plan. (Level of Difficulty: Advanced.)

Association Between Sacubitril/Valsartan Initiation And Mitral Regurgitation Severity In Heart Failure With Reduced Ejection Fraction: The Prove-Hf Study, James L Januzzi, Alaa Mabrouk Salem Omar, Yuxi Liu, Sean Murphy, Javed Butler, G Michael Felker, Iliana L Piña, Jonathan Ward, Scott Solomon, Johanna Contreras

Division of Cardiology Faculty Papers

No abstract provided.

The Development Of A Mobile App-Focused Deduplication Strategy For The Apple Heart Study That Informs Recommendations For Future Digital Trials, Ariadna Garcia, Justin Lee, Vidhya Balasubramanian, Rebecca Gardner, Santosh E. Gummidipundi, Grace Hung, Todd Ferris, Lauren Cheung, Sumbul Desai, Christopher B. Granger, Mellanie True Hills, Peter Kowey, Divya Nag, John S. Rumsfeld, Andrea M. Russo, Jeffrey W. Stein, Nisha Talati, David Tsay, Kenneth W. Mahaffey, Marco V. Perez, Mintu P. Turakhia, Haley Hedlin, Manisha Desai

Department of Medicine Faculty Papers

An app-based clinical trial enrolment process can contribute to duplicated records, carrying data management implications. Our objective was to identify duplicated records in real time in the Apple Heart Study (AHS). We leveraged personal identifiable information (PII) to develop a dissimilarity score (DS) using the Damerau-Levenshtein distance. For computational efficiency, we focused on four types of records at the highest risk of duplication. We used the receiver operating curve (ROC) and resampling methods to derive and validate a decision rule to classify duplicated records. We identified 16,398 (4%) duplicated participants, resulting in 419,297 unique participants out of a total of …

Cardiogenic Shock Due To Atrial Arrhythmia As The Initial Presentation Of Transthyretin Cardiac Amyloidosis, Svenja M. Schneider, Kirpal Kochar, Max Ruge, Stefanie Marek-Iannucci, Tanuka Datta, Alexander Hajduczok, Waqas Ullah, Indranee Rajapreyar, Yevgeniy Brailovsky

Jefferson Hospital Staff Papers and Presentations

Atrial arrhythmias are common in transthyretin cardiac amyloidosis (ATTR-CA), with a prevalence of ≤80%. They are often not well tolerated. We describe 3 patients with decompensated heart failure and cardiogenic shock precipitated by atrial arrhythmias who ultimately received diagnoses of ATTR-CA. (Level of Difficulty: Intermediate.)

The Enigma Of Primary Hypertension In Childhood, Bonita Falkner

Department of Medicine Faculty Papers

Beginning in the 1970s, hypertension in children and adolescents has been defined as systolic and/or diastolic blood pressure (BP) that is equal to or greater than the 95th percentile of the normal BP distribution in healthy children. The definition of hypertension in adults is based on longitudinal data that links a BP level with an increased risk for subsequent adverse outcomes related to hypertension including heart failure, kidney failure, stroke, or death. The statistical definition of hypertension continues to be used in childhood because there have been no data that link a BP level in childhood with a heightened risk …

Systematic Review And Meta-Analysis Of Mid-Term Survival, Reoperation, And Recurrent Mitral Regurgitation For Robotic-Assisted Mitral Valve Repair, Michael L. Williams, Aditya Eranki, Andrew Mamo, Ashley Wilson-Smith, Bridget Hwang, Ramanen Sugunesegran, Tristan Yan, Emiliano Navarra, T. Sloane Guy, Johannes Bonatti

Department of Surgery Faculty Papers

Background: Over the past two decades surgical approaches for mitral valve (MV) disease have evolved with the advent of minimally invasive techniques. Robotic mitral valve repair (RMVr) safety and efficacy has been well documented, however, mid- to long-term data are limited. The aim of this review was to provide a comprehensive analysis of the available mid- to long-term data for RMVr.

Methods: Electronic searches of five databases were performed to identify all relevant studies reporting minimum five-year data on RMVr. Pre-defined primary outcomes of interest were overall survival, freedom from MV reoperation and from moderate or worse mitral regurgitation (MR) …

Prevalence Of High Blood Pressure Among Youth In India And Association With Future Cardiovascular Disease, Abbas H. Zaidi, Sarah D. De Ferranti

Department of Pediatrics Faculty Papers

No abstract provided.

Serum High Mobility Group Box-1 Levels Associated With Cardiovascular Events After Lower Extremity Revascularization: A Prospective Study Of A Diabetic Population, Maria Margherita Rando, Federico Biscetti, Andrea Leonardo Cecchini, Elisabetta Nardella, Maria Anna Nicolazzi, Flavia Angelini, Roberto Iezzi, Luis H. Eraso, Paul J Dimuzio, Dario Pitocco, Antonio Gasbarrini, Massimo Massetti, Andrea Flex

Department of Surgery Faculty Papers

Background: Peripheral arterial disease (PAD) is one of the most disabling cardiovascular complications of type 2 diabetes mellitus and is indeed associated with a high risk of cardiovascular and limb adverse events. High mobility group box-1 (HMGB-1) is a nuclear protein involved in the inflammatory response that acts as a pro-inflammatory cytokine when released into the extracellular space. HMBG-1 is associated with PAD in diabetic patients. The aim of this study was to evaluate the association between serum HMGB-1 levels and major adverse cardiovascular events (MACE) and major adverse limb events (MALE) after lower-extremity endovascular revascularization (LER) in a group …

Retrospective Comparison Of Patients ≥ 80 Years With Atrial Fibrillation Prescribed Either An Fda-Approved Reduced Or Full Dose Direct-Acting Oral Anticoagulant, Roy Taoutel, Michael D. Ezekowitz, Usman A. Chaudhry, Carly Weber, Dana Hassan, Ed J. Gracely, Mohammed H. Kamareddine, Benjamin I. Horn, Glenn R. Harper

Department of Medicine Faculty Papers

Direct-acting oral anticoagulants (DOACs) represent the standard for preventing stroke and systemic embolization (SSE) in patients with atrial fibrillation (AF). There is limited information for patients ≥ 80 years. We report a retrospective analysis of AF patients ≥ 80 years prescribed either a US Food and Drug Administration (FDA)-approved reduced (n = 514) or full dose (n = 199) DOAC (Dabigatran, Rivaroxaban, or Apixaban) between January 1st, 2011 (first DOAC commercially available) and May 31st, 2017. The following multivariable differences in baseline characteristics were identified: patients prescribed a reduced dose DOAC were older (p < 0.001), had worse renal function (p = 0.001), were more often prescribed aspirin (p = 0.004) or aspirin and clopidogrel (p < 0.001), and more often had new-onset AF (p = 0.001). SSE and central nervous system (CNS) bleed rates were low and not different (1.02 vs 0 %/yr and 1.45 vs 0.44 %/yr) for the reduced and full dose groups, respectively. For non-CNS bleeds, rates were 10.89 vs 4.15 %/yr (p < 0.001, univariable) for the reduced and full doses, respectively. The mortality rate was 6.24 vs 1.75 %/yr (p = 0.001, univariable) for the reduced and full doses. Unlike the non-CNS bleed rate, mortality rate differences remained significant when adjusted for baseline characteristics. Thus, DOACs in patients ≥ 80 with AF effectively reduce SSE with a low risk of CNS bleeding, independent of DOAC dose. The higher non-CNS bleed rate and not the mortality rate is explained by the higher risk baseline characteristics in the reduced DOAC dose group. Further investigation of the etiology of non-CNS bleeds and mortality is warranted.

A Critical Review Of Medication Adherence In Hypertension: Barriers And Facilitators Clinicians Should Consider, Seyed Mehrdad Hamrahian, Omar H. Maarouf, Tibor Fülöp

Department of Medicine Faculty Papers

Hypertension is a global public health problem, and its prevalence is increasing worldwide. Impacting all human societies and socioeconomic strata, it remains the major modifiable risk factor for global burden of cardiovascular disease all-cause mortality and the leading cause of loss of disability-adjusted life years. Despite increased awareness, the rate of blood pressure control remains unsatisfactory, particularly in low-to middle-income countries. Apparent treatment-resistant hypertension is associated with worse adverse health outcomes. It includes both true resistant and pseudo-resistant hypertension, which requires out-of-office blood pressure monitoring to exclude white-coat effect and confirmation of adherence to the agreed recommended antihypertensive therapy. The …

Differential Patterns And Outcomes Of 20.6 Million Cardiovascular Emergency Department Encounters For Men And Women In The United States., Zahra Raisi-Estabragh, Ofer Kobo, Ayman Elbadawi, Poonam Velagapudi, Garima Sharma, Renee P Bullock-Palmer, Steffen E Petersen, Laxmi S Mehta, Waqas Ullah, Ariel Roguin, Louise Y Sun, Mamas A Mamas

Division of Cardiology Faculty Papers

Background We describe sex-differential disease patterns and outcomes of >20.6 million cardiovascular emergency department encounters in the United States. Methods and Results We analyzed primary cardiovascular encounters from the Nationwide Emergency Department Sample between 2016 and 2018. We grouped cardiovascular diagnoses into 15 disease categories. The sample included 48.7% women; median age was 67 (interquartile range, 54-78) years. Men had greater overall baseline comorbidity burden; however, women had higher rates of obesity, hypertension, and cerebrovascular disease. For women, the most common emergency department encounters were essential hypertension (16.0%), hypertensive heart or kidney disease (14.1%), and atrial fibrillation/flutter (10.2%). For men, …

Sex-Specific Considerations In Degenerative Aortic Stenosis For Female-Tailored Transfemoral Aortic Valve Implantation Management, Giulia Masiero, Valeria Paradies, Anna Franzone, Barbara Bellini, Chiara De Biase, Nicole Karam, Francesca Sanguineti, Mamas A Mamas, Hélène Eltchaninoff, Chiara Fraccaro, Battistina Castiglioni, Tiziana Attisano, Giovanni Esposito, Alaide Chieffo

Department of Medicine Faculty Papers

The impact of sex on pathophysiological processes, clinical presentation, treatment options, as well as outcomes of degenerative aortic stenosis remain poorly understood. Female patients are well represented in transfemoral aortic valve implantation (TAVI) trials and appear to derive favorable outcomes with TAVI. However, higher incidences of major bleeding, vascular complications, and stroke have been reported in women following TAVI. The anatomical characteristics and pathophysiological features of aortic stenosis in women might guide a tailored planning of the percutaneous approach. We highlight whether a sex-based TAVI management strategy might impact on clinical outcomes. This review aimed to evaluate the impact of …

Cardiovascular Outcomes And Trends Of Transcatheter Vs. Surgical Aortic Valve Replacement Among Octogenarians With Heart Failure: A Propensity Matched National Cohort Analysis, Yasar Sattar, David Song, Talal Almas, Mohamed Zghouzi, Usama Talib, Abdul-Rahman M Suleiman, Bachar Ahmad, Junaid Arshad, Waqas Ullah, Muhammad Zia Khan, Christopher M Bianco, Rodrigo Bagur, Muhammad Rashid, Mamas A Mamas, M Chadi Alraies

Division of Cardiology Faculty Papers

Background: Heart failure (HF) is a complex clinical syndrome with symptoms and signs that result from any structural or functional impairment of ventricular filling or ejection of blood. Limited data is available regarding the in-hospital outcomes of TAVR compared to SAVR in the octogenarian population with HF.

Methods: The National Inpatient Sample (NIS) database was used to compare TAVR versus SAVR among octogenarians with HF. The primary outcome was in-hospital mortality. The secondary outcome included acute kidney injury (AKI), cerebrovascular accident (CVA), post-procedural stroke, major bleeding, blood transfusions, sudden cardiac arrest (SCA), cardiogenic shock (CS), and mechanical circulatory support (MCS). …

Atrial Fibrillation Induced By Anticancer Drugs And Underling Mechanisms., Alexander Burashnikov

Division of Cardiology Faculty Papers

Cancer therapy has made major progress in the past several decades, but treatments are often accompanied by significant side effects. Arrhythmias are a widespread complication of some antineoplastic drugs, with atrial fibrillation (AF) being the most often encountered drug-associated arrhythmia. Preexisting AF risk factors are commonly present in cancer patients who develop drug-associated AF, and active cancer itself may cause or promote AF. Although anticancer drugs may induce AF in cancer patients without AF risk factors, it appears that most drug-associated AF develop when cancer drugs add or aggravate precancer-existing and/or cancer-related pro-AF factors/alterations, additively or synergistically producing AF. Abnormalities …

The Frog Sign Revisited, Christopher J. Ho, Reginald T. Ho

Division of Cardiology Faculty Papers

The frog sign is a classic physical examination finding of typical atrioventricular nodal re-entrant tachycardia. We present the case of a 78-year-old man with recurrent, symptomatic supraventricular tachycardia referred for ablation in whom the frog sign was observed during physical examination.

Overcoming The Cardiac Toxicities Of Cancer Therapy Immune Checkpoint Inhibitors, Omoruyi Credit Irabor, Nicolas Nelson, Yash Shah, Muneeb Khan Niazi, Spencer Poiset, Eugene Storozynsky, Dinender K Singla, D. Craig Hooper, Bo Lu

Division of Cardiology Faculty Papers

Immune checkpoint inhibitors (ICIs) have led recent advances in the field of cancer immunotherapy improving overall survival in multiple malignancies with abysmal prognoses prior to their introduction. The remarkable efficacy of ICIs is however limited by their potential for systemic and organ specific immune-related adverse events (irAEs), most of which present with mild to moderate symptoms that can resolve spontaneously, with discontinuation of therapy or glucocorticoid therapy. Cardiac irAEs however are potentially fatal. The understanding of autoimmune cardiotoxicity remains limited due to its rareness. In this paper, we provide an updated review of the literature on the pathologic mechanisms, diagnosis, …

Recurrent Giant Cell Myocarditis After Heart Transplant: A Case Report, Eitan S. Frankel, Alexander G. Hajduczok, Indranee N. Rajapreyar, Yevgeniy Brailovsky

Division of Cardiology Faculty Papers

BACKGROUND: Giant cell myocarditis (GCM) is a rare but well-known cause of fulminant myocarditis. Despite optimal medical therapy, many patients progress to orthotopic heart transplant (OHT). We present a case of recurrent GCM following OHT, including complex considerations in patient management and infectious sequelae.

CASE SUMMARY: A 33-year-old previously healthy male presented with 2 months of worsening shortness of breath. Transthoracic echocardiogram (TTE) demonstrated a left ventricular ejection fraction of 30-35%. After ruling out an ischaemic aetiology, he was discharged on guideline-directed medical therapy and later presented with productive cough, worsening dyspnoea on exertion, and diarrhoea. He was found to …