Publications by authors named "Ankit Rathod"

49 Publications

Is positron emission tomography enough to rule out cardiac sarcoidosis? A case report.

Eur Heart J Case Rep 2021 Sep 13;5(9):ytab300. Epub 2021 Sep 13.

Cardiology, University of California, San Francisco, Fresno, 2335 E Kashian Ln, Fresno, CA 93701, USA.

Background: Cardiac sarcoidosis (CS) is associated with poor prognosis, yet the clinical diagnosis is often challenging. Advanced cardiac imaging including cardiac magnetic resonance (CMR) and positron emission tomographic (PET) have emerged as useful modalities to diagnose CS.

Case Summary: A 66-year-old woman presented with palpitations. A 24-h Holter monitor detected a high premature ventricular contraction burden of 25.6%. She underwent two transthoracic echocardiograms; both showed normal results. Stress perfusion CMR did not show any evidence of ischaemic aetiology; however, myocardial lesions detected by late gadolinium enhancement (LGE) imaging raised suspicion for CS. While there was no myocardial uptake of fluorodeoxyglucose (FDG) in subsequent cardiac PET, high FDG uptake was seen in hilar lymph nodes. Lymph node biopsy confirmed the diagnosis of sarcoidosis.

Discussion: Cardiac magnetic resonance and PET imaging are designed to evaluate different aspects CS pathophysiology. The characteristic LGE in the absence of increased FDG uptake suggested inactive CS with residual myocardial scarring.
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http://dx.doi.org/10.1093/ehjcr/ytab300DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8453392PMC
September 2021

Supracristal Ventricular Septal Defect Complicated by Formation of an Aorto-Right Ventricular Outflow Tract Fistula: A Rare Cause of Biventricular Enlargement.

Methodist Debakey Cardiovasc J 2021 1;17(2):157-160. Epub 2021 Jul 1.

University of California, San Francisco-Fresno, Fresno, California.

Aorto-right ventricular outflow tract fistulas typically occur secondary to trauma, infective endocarditis, and sinus of Valsalva aneurysm rupture. We describe an unusual case of a spontaneous aorto-right ventricular outflow tract fistula in the absence of such findings, instead forming secondary to a complicating supracristal ventricular septal defect and leading to dilated cardiomyopathy.
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http://dx.doi.org/10.14797/PEFD1523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8298126PMC
October 2021

Recurrent ventricular tachycardia associated with lipomatous metaplasia of a myocardial scar.

BMJ Case Rep 2021 Mar 19;14(3). Epub 2021 Mar 19.

Cardiology, UCSF Fresno Center for Medical Education and Research Edward and Ann Hildebrand Medical Library, Fresno, California, USA.

Lipomatous metaplasia in chronic postmyocardial infarction scars is a common and underappreciated finding seen in histopathology and cardiac MRI. Evidence suggests that lipomatous metaplasia is capable of altering the electroconductivity of the myocardium leading to re-entry pathways that are implicated in the pathogenesis of postmyocardial infarction arrhythmogenesis. We report a case of a patient who presented with non-sustained ventricular tachycardia and was found to have lipomatous metaplasia of a prior myocardial infarct-related scar.
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http://dx.doi.org/10.1136/bcr-2020-240626DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7986890PMC
March 2021

Where Is the Bubble? A Case of Systemic-to-Pulmonary Venous Shunt in Superior Vena Cava Occlusion.

CASE (Phila) 2020 Dec 8;4(6):482-484. Epub 2020 Sep 8.

Division of Cardiology, Department of Medicine, University of California San Francisco Fresno, Fresno, California.

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http://dx.doi.org/10.1016/j.case.2020.08.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7756161PMC
December 2020

Unusual presentation of left ventricular rupture.

BMJ Case Rep 2020 Feb 2;13(1). Epub 2020 Feb 2.

Cardiology, University of California San Francisco, Fresno, California, USA.

We describe a case of 49-year-old man who presented with chest pain and was diagnosed with non-ST elevation myocardial infarction. Transthoracic echocardiogram (TTE) showed severe global hypokinesis of left ventricle with ejection fraction of 25%-30%. Left heart catheterisation showed severe right coronary stenosis and focal 60%-70% distal left anterior descending artery stenosis. Cardiac MRI (CMR) was done for evaluation of viability which showed a large pseudoaneurysm which was missed on TTE and left ventriculogram. Our case demonstrates the increasing importance of cardiac MRI in the diagnosis of left ventricular pseudoaneurysm. In our case left ventricular pseudoaneurysm was missed on TTE and left ventriculogram. It was diagnosed on CMR which was ordered for evaluation of myocardium viability.
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http://dx.doi.org/10.1136/bcr-2019-231680DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7021133PMC
February 2020

Influence of hospital volume on outcomes of percutaneous atrial septal defect and patent foramen ovale closure: a 10-years US perspective.

Catheter Cardiovasc Interv 2015 May 3;85(6):1073-81. Epub 2015 Feb 3.

Cardiology, University of Miami Miller School of Medicine, Miami, Florida.

Background: Contemporary data regarding percutaneous closure of atrial septal defect/patent foramen ovale (ASD/PFO) are lacking. We evaluated the current trends in utilization of ASD/PFO closure in adults and investigated the effect of annual hospital volume on in-hospital outcomes.

Methods: We queried the Nationwide Inpatient Sample between the years 2001 and 2010 using the International Classification of Diseases (ICD-9-CM) procedure code for percutaneous closure of ASD/PFO with device. Hierarchical mixed effects models were generated to identify the independent multivariate predictors of outcomes.

Results: A total of 7,107 percutaneous ASD/PFO closure procedures (weighted n = 34,992) were available for analysis. A 4.7-fold increase in the utilization of this procedure from 3/million in 2001 to 14/million adults in 2010 in US (P < 0.001) was noted. Overall, percutaneous ASD/PFO closure was associated with 0.5% mortality and 12% in-hospital complications. The utilization of intracardiac echocardiography (ICE) increased 15 fold (P < 0.001) during the study period. The procedures performed at the high volume hospitals [2nd (14-37 procedures/year) and 3rd (>38 procedures/year) tertile] were associated with significant reduction in complications, length of stay and cost of hospitalization when compared to those performed at lowest volume centers (<13 procedures/year). Majority (70.5%) of the studied hospitals were found to be performing <10 procedures/year hence deviating from the ACC/AHA/SCAI clinical competency guidelines.

Conclusions: Low hospital volume is associated with an increased composite (mortality and procedural complications) adverse outcome following ASD/PFO closure. In the interest of patient safety, implementation of the current guidelines for minimum required annual hospital volume to improve clinical outcomes is warranted.
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http://dx.doi.org/10.1002/ccd.25794DOI Listing
May 2015

Utilization and adverse outcomes of percutaneous left atrial appendage closure for stroke prevention in atrial fibrillation in the United States: influence of hospital volume.

Circ Arrhythm Electrophysiol 2015 Feb 5;8(1):42-8. Epub 2014 Dec 5.

From the Detroid Medical Center, Detroit, MI (A.O.B., S.S.P., N.P., S.A., V.B., C.L.G., T.S.); MedStar Washington Hospital Center, Washington, DC (A.C.); UPMC Shadyside Hospital, Pittsburgh, PA (K.M.); Staten Island University Hospital, NY (N.J.P., N.S.); University of Arkansas, Little Rock (A.D.); University of Miami Miller School of Medicine, FL (M.H., V.S., P.G., G.T.S., J.O.C., J.F.V.-G.); Cedar-Sinai Medical Center, Los Angeles, CA (A.R., R.M.); Henry Ford Hospital, Detroit, MI (W.O'N.); and Texas Cardiac Arrhythmia Institute, Austin (L.D.B., A.N.).

Background: Safety data on percutaneous left atrial appendage closure arises from centers with considerable expertise in the procedure or from clinical trial, which might not be reproducible in clinical practice. We sought to estimate the frequency and predictors of adverse outcomes and costs of percutaneous left atrial appendage closure procedure in the US.

Methods And Results: The data were obtained from the Nationwide Inpatient Sample from the years 2006 to 2010. The Nationwide Inpatient Sample is the largest all-payer inpatient data set in the US. Complications were calculated using patient safety indicators and International Classification of Diseases-Ninth Revision, Clinical Modification codes. Annual hospital volume was calculated using unique hospital identifiers. Weights provided by the Nationwide Inpatient Sample were used to generate national estimates. A total of 268 (weighted=1288) procedures were analyzed. The overall composite rate of mortality or any adverse event was 24.3% (65), with 3.4% patients required open cardiac surgery after procedure. Average length of stay was 4.61±1.05 days and cost of care was 26,024±34,651. Annual hospital procedural volume was significantly associated with reduced complications and mortality (every unit increase: odds ratio, 0.89; 95% confidence interval, 0.85-0.94; P<0.001), decrease in length of stay (every unit increase: hazard ratio, 0.95; 95% confidence interval, 0.92-0.98; P<0.001) and cost of care (every unit increase: hazard ratio, 0.96; 95% confidence interval, 0.93-0.98; P<0.001).

Conclusions: Our study demonstrates that the frequency of inhospital adverse outcomes associated with percutaneous left atrial appendage closure is higher in the real-world population than in clinical trials. We also demonstrate that higher annual hospital volume is associated with safer procedures, with lower length of stay and cost.
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http://dx.doi.org/10.1161/CIRCEP.114.001413DOI Listing
February 2015

Major electrocardiographic abnormalities and 25-hydroxy vitamin D deficiency: insights from National Health and Nutrition Examination Survey-III.

Clin Cardiol 2014 Nov 15;37(11):660-6. Epub 2014 Sep 15.

Department of Internal Medicine, Division of Cardiology, Wayne State University/Detroit Medical Center, Detroit, Michigan.

Background: We explored the relationship between major electrocardiogram (ECG) abnormalities (mECG) and 25-hydroxy (25-OH) vitamin D deficiency (VDD) and the effect of mECG abnormalities on all-cause and cardiovascular mortality in a healthy cohort with 25-OH vitamin D insufficiency and deficiency.

Hypothesis: Lower levels of serum 25-OH vitamin D are associated with increased prevalence of mECG on resting ECG.

Methods: We identified 5108 individuals from the National Health and Nutrition Examination Survey-III. mECG abnormalities included: major Q-QS wave abnormalities, ST depression/elevation, negative T waves, Wolff-Parkinson-White pattern, and ventricular conduction defect. Our cohort was divided into 3 groups based on 25-OH vitamin D levels: Group 1 (referent): > 40 ng/mL; group 2 (insufficient): ≥ 20.01 to ≤ 40 ng/mL; and group 3 (deficient): ≤ 20 ng/mL. Logistic regression and Cox proportional hazards regression models were built.

Results: The prevalence of major ECG abnormalities across 25-OH vitamin D sufficiency, insufficiency, and deficiency was .9%, 11%, and 13 %, respectively (P = 0.01). VDD was an independent predictor of mECG abnormalities after adjusting for traditional risk factors (continuous variable odds ratio [OR]: 0.98, 95% confidence interval [CI]: 0.97-0.99, P = 0.007; categorical variable group 3 vs group 1 OR: 2.36, 95% CI: 1.1-5.12, P = 0.03). Baseline major ECG abnormalities were predictive of long-term all-cause (hazard ratio [HR]:1.52, 95% CI: 1.23-1.89), composite cardiovascular (HR: 1.7, 95% CI: 1.34-2.15), cardiovascular (HR: 1.64, 95% CI: 1.27-2.12), and ischemic heart disease mortality (HR: 1.98, 95% CI: 1.46-2.69) in individuals with 25-OH vitamin D levels ≤ 40 ng/mL.

Conclusions: VDD is associated with increased prevalence of major ECG abnormalities. Well-structured trials are needed to assess progression/resolution of mECG abnormalities with vitamin D supplementation in deficient individuals.
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http://dx.doi.org/10.1002/clc.22329DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6649437PMC
November 2014

Impact of annual operator and institutional volume on percutaneous coronary intervention outcomes: a 5-year United States experience (2005-2009).

Circulation 2014 Oct 4;130(16):1392-406. Epub 2014 Sep 4.

From Yale New Haven Medical Center, New Haven, CT (A.O.B.); Staten Island University Hospital, Staten Island, NY (N.J.P., N.S., F.V.T.); UMass Memorial Medical Center, Worcester, MA (P.G.); University of Miami Miller School of Medicine, Miami, FL (V.S., G.T.S., E.D.M., M.G.C.); Saint Peter's University Hospital, New Brunswick, NJ (N.P.); Mount Sinai's St Luke Roosevelt Hospital Center, New York, NY (S.A.); MedStar Washington Hospital Center, Washington, DC (A.C.); UPMC Shadyside Hospital, Pittsburgh, PA (K.M.); University of Arkansas, Little Rock, AR (A.D.); Icahn School of Medicine at Mount Sinai, New York, NY (A.P.); Detroit Medical Center, Detroit, MI (S.S.P., M.B., T.M., T.S., C.L.G.); Cedar-Sinai Medical Center, Los Angeles, CA (A.R., S.K., R.M.); Henry Ford Hospital, Detroit, MI (W.W.O.); Mayo Clinic, Rochester, MN (C.S.R.).

Background: The relationship between operator or institutional volume and outcomes among patients undergoing percutaneous coronary interventions (PCI) is unclear.

Methods And Results: Cross-sectional study based on the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample between 2005 to 2009. Subjects were identified by International Classification of Diseases, 9(th) Revision, Clinical Modification procedure code, 36.06 and 36.07. Annual operator and institutional volumes were calculated using unique identification numbers and then divided into quartiles. Three-level hierarchical multivariate mixed models were created. The primary outcome was in-hospital mortality; secondary outcome was a composite of in-hospital mortality and peri-procedural complications. A total of 457,498 PCIs were identified representing a total of 2,243,209 PCIs performed in the United States during the study period. In-hospital, all-cause mortality was 1.08%, and the overall complication rate was 7.10%. The primary and secondary outcomes of procedures performed by operators in 4(th) [annual procedural volume; primary and secondary outcomes] [>100; 0.59% and 5.51%], 3(rd) [45-100; 0.87% and 6.40%], and 2(nd) quartile [16-44; 1.15% and 7.75%] were significantly less (P<0.001) when compared with those by operators in the 1(st) quartile [≤15; 1.68% and 10.91%]. Spline analysis also showed significant operator and institutional volume outcome relationship. Similarly operators in the higher quartiles witnessed a significant reduction in length of hospital stay and cost of hospitalization (P<0.001).

Conclusions: Overall in-hospital mortality after PCI was low. An increase in operator and institutional volume of PCI was found to be associated with a decrease in adverse outcomes, length of hospital stay, and cost of hospitalization.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.114.009281DOI Listing
October 2014

Optimal blood pressure in patients with atrial fibrillation (from the AFFIRM Trial).

Am J Cardiol 2014 Sep 18;114(5):727-36. Epub 2014 Jun 18.

Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida. Electronic address:

Many medications used to treat atrial fibrillation (AF) also reduce blood pressure (BP). The relation between BP and mortality is unclear in patients with AF. We performed a post hoc analysis of 3,947 participants from the Atrial Fibrillation Follow-Up Investigation of Rhythm Management trial. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) at baseline and follow-up were categorized by 10-mm Hg increments. The end points were all-cause mortality (ACM) and secondary outcome (combination of ACM, ventricular tachycardia and/or fibrillation, pulseless electrical activity, significant bradycardia, stroke, major bleeding, myocardial infarction, and pulmonary embolism). SBP and DBP followed a "U-shaped" curve with respect to primary and secondary outcomes after multivariate analysis. A nonlinear Cox proportional hazards model showed that the incidence of ACM was lowest at 140/78 mm Hg. Subgroup analyses revealed similar U-shaped curves. There was an increased ACM observed with BP <110/60 mm Hg (hazard ratio 2.4, p <0.01, respectively, for SBP and DBP). In conclusion, in patients with AF, U-shaped relation existed between BP and ACM. These data suggest that the optimal BP target in patients with AF may be greater than the general population and that pharmacologic therapy to treat AF may be associated with ACM or adverse events if BP is reduced to <110/60 mm Hg.
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http://dx.doi.org/10.1016/j.amjcard.2014.06.002DOI Listing
September 2014

Balloon mitral valvuloplasty in the United States: a 13-year perspective.

Am J Med 2014 Nov 20;127(11):1126.e1-1126.e12. Epub 2014 May 20.

University of Miami Miller School of Medicine, Fla. Electronic address:

Background: Incidence and prevalence of mitral stenosis is declining in the US. We performed this study to determine recent trends in utilization, complications, mortality, length of stay, and cost associated with balloon mitral valvuloplasty.

Methods: Utilizing the nationwide inpatient sample database from 1998 to 2010, we identified patients using the International Classification of Diseases, 9th Revision, Clinical Modification procedure code for "percutaneous valvuloplasty." Patients ≥18 years of age with mitral stenosis were included. Patients with concomitant aortic, tricuspid, or pulmonic stenosis were excluded. Primary outcome included death and procedural complications.

Results: A total of 1308 balloon mitral valvuloplasties (weighted n = 6540) were analyzed. There was a 7.5% decrease in utilization of the procedure from 24.6 procedures/10 million population in 1998-2001 to 22.7 procedures/10 million population in 2008-2010 (P for trend = .098). We observed a 15.9% overall procedural complication rate and 1.7% mortality rate. The procedural complication rates have increased in recent years (P = .001), corresponding to increasing age and burden of comorbidities in patients. The mean cost per admission for balloon mitral valvuloplasty has gone up significantly over the 10 years, from $11,668 ± 1046 in 2001 to $23,651 ± 301 in 2010 (P <.001).

Conclusions: In a large cross-sectional study of balloon mitral valvuloplasty in the US, we have reported trends of decreasing overall utilization and increasing procedural complication rates and cost over a period of 13 years.
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http://dx.doi.org/10.1016/j.amjmed.2014.05.015DOI Listing
November 2014

Contemporary trends of hospitalization for atrial fibrillation in the United States, 2000 through 2010: implications for healthcare planning.

Circulation 2014 Jun 19;129(23):2371-9. Epub 2014 May 19.

From the Staten Island University Hospital, Staten Island, NY (N.J.P., N.S., V.P., J.L., M.K.); University of Arkansas, Little Rock (A.D., S.P., J.L.M., H.P.); University of Miami Miller School of Medicine, Miami, FL (V.S., G.T.S., R.D.M., J.F.V.-G.); Detroit Medical Centre, Detroit, MI (N.P., S.A., A.O.B.); MedStar Washington Hospital Center, Washington, DC (A.C.); UPMC Shadyside, Pittsburgh, PA (K.M.); and Cedar-Sinai Medical Center, Los Angeles, CA (A.R.).

Background: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. The associated morbidity and mortality make AF a major public health burden. Hospitalizations account for the majority of the economic cost burden associated with AF. The main objective of this study is to examine the trends of AF-related hospitalizations in the United States and to compare patient characteristics, outcomes, and comorbid diagnoses.

Methods And Results: With the use of the Nationwide Inpatient Sample from 2000 through 2010, we identified AF-related hospitalizations using International Classification of Diseases, 9th Revision, Clinical Modification code 427.31 as the principal discharge diagnosis. Overall AF hospitalizations increased by 23% from 2000 to 2010, particularly in patients ≥65 years of age. The most frequent coexisting conditions were hypertension (60.0%), diabetes mellitus (21.5%), and chronic pulmonary disease (20.0%). Overall in-hospital mortality was 1%. The mortality rate was highest in the group of patients ≥80 years of age (1.9%) and in the group of patients with concomitant heart failure (8.2%). In-hospital mortality rate decreased significantly from 1.2% in 2000 to 0.9% in 2010 (29.2% decrease; P<0.001). Although there was no significant change in mean length of stay, mean cost of AF hospitalization increased significantly from $6410 in 2001 to $8439 in 2010 (24.0% increase; P<0.001).

Conclusions: Hospitalization rates for AF have increased exponentially among US adults from 2000 to 2010. The proportion of comorbid chronic diseases has also increased significantly. The last decade has witnessed an overall decline in hospital mortality; however, the hospitalization cost has significantly increased.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.114.008201DOI Listing
June 2014

Influence of left ventricular remodeling on atrial fibrillation recurrence and cardiovascular hospitalizations in patients undergoing rhythm-control therapy.

Int J Cardiol 2014 Jun 13;174(2):288-92. Epub 2014 Apr 13.

University of Miami Miller School of Medicine, Miami, FL, United States. Electronic address:

Background: Atrial fibrillation (AF) patients with left ventricular hypertrophy (LVH) and diastolic dysfunction may derive benefit from being in sinus rhythm but no data are available to support this strategy in them. We sought to investigate effect of left ventricular remodeling on cardiovascular outcomes in AF patients undergoing rhythm control strategy.

Methods: We identified 1088 patients with echocardiographic data on left ventricular mass (LVM) enrolled in the AFFIRM trial. Using the American Society of Echocardiography (ASE) criteria, patients were divided into 4 categories: 1) normal geometry, 2) concentric remodeling, 3) eccentric hypertrophy, and 4) concentric hypertrophy. The primary endpoint was AF recurrence and the secondary endpoint was cardiovascular hospitalization (CVH).

Results: In rhythm control arm, median time to recurrence in patients with concentric LVH was 13.3 months (95% CI 8.2-24.5) vs. 28.3 months (95% CI 20.2-48.6) in patients without LVH. Concentric left ventricular hypertrophy (LVH) was independently predictive of AF recurrence (HR 1.49, 95% CI 1.10-2.01, p=0.01) in rhythm control arm, but not in overall population or rate control arm. Both concentric and eccentric LVH were independently predictive of cardiovascular hospitalization (CVH) in the overall population, with respective HRs of 1.36 (1.04-1.78, p=0.03) and 1.38 (1.02-1.85, p=0.04).

Conclusion: Concentric LVH is predictive of AF recurrences when a predominantly pharmacologic rhythm-control strategy is employed. Different patterns of LVH seem to be important determinants of outcomes (AF recurrence and CVH). These findings may have important clinical implications for the management of patients with AF and LVH. Further studies are warranted to confirm our findings.
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http://dx.doi.org/10.1016/j.ijcard.2014.04.011DOI Listing
June 2014

Percutaneous aortic balloon valvotomy in the United States: a 13-year perspective.

Am J Med 2014 Aug 6;127(8):744-753.e3. Epub 2014 Mar 6.

Henry Ford Hospital, Detroit, Mich. Electronic address:

Background: We determined the contemporary trends of percutaneous aortic balloon valvotomy and its outcomes using the nation's largest hospitalization database. There has been a resurgence in the use of percutaneous aortic balloon valvotomy in patients at high surgical risk because of the development of less-invasive endovascular therapies.

Methods: This is a cross-sectional study with time trends using the Nationwide Inpatient Sample database between the years 1998 and 2010. We identified patients using the International Classification of Diseases, 9th Revision, Clinical Modification procedure code for valvotomy. Only patients aged more than 60 years with aortic stenosis were included. Primary outcome included in-hospital mortality, and secondary outcomes included procedural complications and length of hospital stay.

Results: A total of 2127 percutaneous aortic balloon valvotomies (weighted n = 10,640) were analyzed. The use rate of percutaneous aortic balloon valvotomy increased by 158% from 12 percutaneous aortic balloon valvotomies per million elderly patients in 1998-1999 to 31 percutaneous aortic balloon valvotomies per million elderly patients in 2009-2010 in the United States (P < .001). The hospital mortality decreased by 23% from 11.5% in 1998-1999 to 8.8% in 2009-2010 (P < .001). Significant predictors of in-hospital mortality were the presence of increasing comorbidities (P = .03), unstable patient (P < .001), any complication (P < .001), and weekend admission (P = .008), whereas increasing operator volume was associated with significantly reduced mortality (P = .03). Patients who were admitted to hospitals with the highest procedure volume and the highest volume operators had a 51% reduced likelihood (P = .05) of in-hospital mortality when compared with those in hospitals with the lowest procedure volume and lowest volume operators.

Conclusion: This study comprehensively evaluates trends for percutaneous aortic balloon valvotomy in the United States and demonstrates the significance of operator and hospital volume on outcomes.
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http://dx.doi.org/10.1016/j.amjmed.2014.02.025DOI Listing
August 2014

Outcomes in atrial fibrillation patients with and without left ventricular hypertrophy when treated with a lenient rate-control or rhythm-control strategy.

Am J Cardiol 2014 Apr 14;113(7):1159-65. Epub 2014 Jan 14.

University of Miami Miller School of Medicine, Miami, Florida. Electronic address:

Although left ventricular (LV) hypertrophy has been proposed as a factor predisposing to atrial fibrillation (AF), its relevance to prognosis and selection of therapeutic strategies is unclear. We identified 2,105 patients with echocardiographic data on LV mass enrolled in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial. LV hypertrophy was defined as increased LV mass, stratified by American Society of Echocardiography criteria. The primary end point was all-cause mortality, secondary end point was as per AFFIRM trial definition, and tertiary end point was cardiovascular hospitalizations. We compared "strict" versus "lenient" rate control in patients with increased LV mass, and studied association of heart failure (HF) with preserved and decreased systolic function in patients with increased LV mass. Over 6 years, 332 deaths (15.7%) were reported. Adjusted hazard ratio (HR) of severely increased LV mass for all-cause mortality was 1.34 (95% confidence interval [CI] 1.01 to 1.79, p=0.045) for the overall population and 1.61 (95% CI 1.09 to 2.37, p=0.016) for the rhythm-control arm. Increased LV mass was a predictor of cardiovascular hospitalizations in the lenient rate-control group (HR 1.72, 95% CI 1.05 to 2.82, p=0.03) but not in the strict rate-control group. Severely increased LV mass was predictive of cardiovascular hospitalizations in patients with HF with preserved (HR 1.8, 95% CI 1.0 to 3.2, p=0.03) and decreased LV systolic function (HR 2.4, 95% CI 1.1 to 5.2, p=0.02). Thus, LV hypertrophy is a significant independent predictor of mortality in patients with AF, especially those managed with rhythm control. In patients with LV hypertrophy, strict rate control may be associated with better outcomes than lenient rate control. LV hypertrophy portends higher cardiovascular morbidity in patients with AF and HF.
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http://dx.doi.org/10.1016/j.amjcard.2013.12.021DOI Listing
April 2014

Neutrophil lymphocyte ratio significantly improves the Framingham risk score in prediction of coronary heart disease mortality: insights from the National Health and Nutrition Examination Survey-III.

Int J Cardiol 2014 Feb 23;171(3):390-7. Epub 2013 Dec 23.

Department of Cardiology, Staten Island University Hospital, Staten Island, NY, United States.

Background: Neutrophil lymphocyte ratio (NLR) has been shown to predict cardiovascular events in several studies. We sought to study if NLR predicts coronary heart disease (CHD) in a healthy US cohort and if it reclassifies the traditional Framingham risk score (FRS) model.

Methods: We performed post hoc analysis of National Health and Nutrition Examination Survey-III (1998-94) including subjects aged 30-79 years free from CHD or CHD equivalent at baseline. Primary endpoint was death from ischemic heart disease. NLR was divided into four categories: <1.5, ≥1.5 to <3.0, 3.0-4.5 and >4.5. Statistical analyses involved multivariate Cox proportional hazards models as well as discrimination, calibration and reclassification.

Results: We included 7363 subjects with a mean follow up of 14.1 years. There were 231 (3.1%) CHD deaths, more in those with NLR>4.5 (11%) compared to NLR<1.5 (2.4%), p<0.001. Adjusted hazard ratio of NLR>4.5 was 2.68 (95% CI 1.07-6.72, p=0.035). There was no significant improvement in C-index (0.8709 to 0.8713) or area under curve (0.8520 to 0.8531) with addition of NLR to FRS model. Model with NLR was well calibrated with Hosmer-Lemeshow chi-square of 8.57 (p=0.38). Overall net reclassification index (NRI) was 6.6% (p=0.003) with intermediate NRI of 10.1% (p<0.001) and net upward reclassification of 5.6%. Absolute integrated discrimination index (IDI) was 0.003 (p=0.039) with relative IDI of 4.3%.

Conclusions: NLR can independently predict CHD mortality in an asymptomatic general population cohort. It reclassifies intermediate risk category of FRS, with significant upward reclassification. NLR should be considered as an inflammatory biomarker of CHD.
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http://dx.doi.org/10.1016/j.ijcard.2013.12.019DOI Listing
February 2014

Impact of implantable cardioverter-defibrillator therapy on a secondary prevention population.

JAMA Intern Med 2013 Dec 9-23;173(22):2093-4

Department of Cardiology, Cedars Sinai Medical Center, Los Angeles, California.

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http://dx.doi.org/10.1001/jamainternmed.2013.10402DOI Listing
February 2014

Three-dimensional echocardiographic assessment of patent foramen ovale in platypnea-orthodeoxia.

Echocardiography 2013 Sep 25;30(8):E239-42. Epub 2013 Jun 25.

Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.

Platypnea-orthodeoxia is an uncommon syndrome characterized by positional dyspnea and hypoxia when upright that improves with lying down. We present a 75-year-old man with platypnea-orthodeoxia in the setting of a patent foramen ovale (PFO) and a 2.1 cm highly mobile atrial septal aneurysm with 2 cm bowing. Prior reports have established the use of three-dimensional echocardiography to facilitate percutaneous closure of PFO and atrial septal defect, but its use in patients with platypnea-orthodeoxia is unclear. We document three-dimensional echocardiographic images that accurately estimated PFO defect size and confirmed placement of the occluder device.
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http://dx.doi.org/10.1111/echo.12265DOI Listing
September 2013

ST-T wave abnormality in lead aVR and reclassification of cardiovascular risk (from the National Health and Nutrition Examination Survey-III).

Am J Cardiol 2013 Sep 11;112(6):805-10. Epub 2013 Jun 11.

Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.

Electrocardiographic lead aVR is often ignored in clinical practice. The aim of this study was to investigate whether ST-T wave amplitude in lead aVR predicts cardiovascular (CV) mortality and if this variable adds value to a traditional risk prediction model. A total of 7,928 participants enrolled in the National Health and Nutrition Examination Survey (NHANES) III with electrocardiographic data available were included. Each participant had 13.5 ± 3.8 years of follow-up. The study sample was stratified according to ST-segment amplitude and T-wave amplitude in lead aVR. ST-segment elevation (>8 μV) in lead aVR was predictive of CV mortality in the multivariate analysis when not accounting for T-wave amplitude. The finding lost significance after including T-wave amplitude in the model. A positive T wave in lead aVR (>0 mV) was the strongest multivariate predictor of CV mortality (hazard ratio 3.37, p <0.01). The addition of T-wave amplitude in lead aVR to the Framingham risk score led to a net reclassification improvement of 2.7% of subjects with CV events and 2.3% of subjects with no events (p <0.01). Furthermore, in the intermediate-risk category, 20.0% of the subjects in the CV event group and 9.1% of subjects in the no-event group were appropriately reclassified. The absolute integrated discrimination improvement was 0.012 (p <0.01), and the relative integrated discrimination improvement was 11%. In conclusion, T-wave amplitude in lead aVR independently predicts CV mortality in a cross-sectional United States population. Adding T-wave abnormalities in lead aVR to the Framingham risk score improves model discrimination and calibration with better reclassification of intermediate-risk subjects.
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http://dx.doi.org/10.1016/j.amjcard.2013.04.058DOI Listing
September 2013

QRS duration on electrocardiography and cardiovascular mortality (from the National Health and Nutrition Examination Survey-III).

Am J Cardiol 2013 Sep 29;112(5):671-7. Epub 2013 May 29.

Department of Internal Medicine, Cardiovascular Division, University of Miami Miller School of Medicine, Miami, FL, USA.

The relation of bundle branch block (BBB) with adverse outcome is controversial. We hypothesized that increased QRS duration is an independent predictor of cardiovascular (CV) mortality in a cross-sectional US population. This is a retrospective cohort study on prospectively collected data to assess the relationship between QRS duration on routine ECG and CV mortality. Participants included 8,527 patients with ECG data available from the National Health and Nutrition Examination Survey data set, representing 74,062,796 individuals in the United States. Mean age was 60.5 ± 13.6 years. Most subjects were white (87%) and women (53%). During the follow-up period of 106,244.6 person-years, 1,433 CV deaths occurred. Multivariate analysis revealed that the highest quartile of QRS duration was associated with higher CV mortality than lowest quartile (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.01 to 1.7, p = 0.04) after adjustment for established risk factors. Both left BBB (HR 2.4, 95% CI 1.3 to 4.7, p = 0.009) and right BBB (HR 1.90, 95% CI 1.2 to 3.0, p = 0.008) were significantly associated with increased CV mortality. The addition of the QRS duration in 10-millisecond increments to the Framingham Risk Score model resulted in 4.4% overall net reclassification improvement (95% CI 0.02 to 0.04; p = 0.00006). In conclusion, increased QRS duration was found to be an independent predictor of CV mortality in this cross-sectional US population. A model including QRS duration in addition to traditional risk factors was associated with improved CV risk prediction.
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http://dx.doi.org/10.1016/j.amjcard.2013.04.040DOI Listing
September 2013

Comparison of rate versus rhythm control in patients with atrial fibrillation and a pacemaker.

Am J Cardiol 2013 Jun 27;111(12):1759-63. Epub 2013 Mar 27.

Division of Cardiology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.

The effect of rate versus rhythm control in patients with atrial fibrillation who have undergone previous pacemaker (PM) implantation is unknown. We evaluated the mortality in patients with atrial fibrillation and a PM randomized to rate or rhythm control treatment strategies. The Atrial Fibrillation Follow-up Investigation of Rhythm Management data set was stratified by the presence (n = 250) or absence (n = 3,810) of a PM at randomization into the rate or rhythm control arm. Kaplan-Meier curves were used for univariate analysis, and proportional hazards were used for multivariate analysis. The subjects with a PM (n = 250) were older (73 vs 69 years, p <0.01) and had a greater prevalence of coronary artery disease (53% vs 37%, p <0.01) and congestive heart failure (33% vs 23%, p <0.01). All-cause mortality was significantly greater in the PM patients who were randomized to the rhythm control arm (n = 128) than in the patients enrolled in the rate control arm with or without a PM (n = 2,027, p <0.01) and those in the rhythm control arm without a PM (n = 1,905, p <0.01). Multivariate analysis revealed that predictors of all-cause mortality included PM patients randomized to the rhythm control arm (hazard ratio 2.59, 95% confidence interval 1.46 to 4.58, p <0.01) and the presence of congestive heart failure (hazard ratio 2.42, 95% confidence interval 1.40 to 4.16, p <0.01). In conclusion, all-cause mortality was greater among patients with atrial fibrillation with a PM, who were randomized to the rhythm control arm of the Atrial Fibrillation Follow-up Investigation of Rhythm Management study compared with all other patients enrolled in the Atrial Fibrillation Follow-up Investigation of Rhythm Management study. The rhythm control strategy in patients with a PM was an independent predictor of mortality.
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http://dx.doi.org/10.1016/j.amjcard.2013.02.031DOI Listing
June 2013

Electrocardiographic abnormalities and reclassification of cardiovascular risk: insights from NHANES-III.

Am J Med 2013 Apr 13;126(4):319-326.e2. Epub 2013 Feb 13.

University of Miami Miller School of Medicine, Miami, FL 33136, USA.

Background: We aimed to assess the additive value of electrocardiogram (ECG) findings to risk prediction models for cardiovascular disease.

Methods: Our dataset consisted of 6025 individuals with ECG data available from the National Health and Nutrition Examination Survey-III. This is a self-weighting sample with a follow-up of 79,046.84 person-years. The primary outcomes were cardiovascular mortality and all-cause mortality. We compared 2 models: Framingham Risk Score (FRS) covariates (Model A) and ECG abnormalities added to Model A (Model B), and calculated the net reclassification improvement index (NRI).

Results: Mean age of our study population was 58.7 years; 45.6% were male and 91.7% were white. At baseline, 54.6% of individuals had ECG abnormalities, of which 545 (9%) died secondary to a cardiovascular event, compared with 194 individuals (3.2%) (P <.01) without ECG abnormalities. ECG abnormalities were significant predictors of cardiovascular mortality after adjusting for traditional cardiovascular risk factors (hazard ratio 1.44; 95% confidence interval, 1.13-1.83). Addition of ECG abnormalities led to an overall NRI of 3.6% subjects (P <.001) and 13.24% in the intermediate risk category. The absolute integrated discrimination index was 0.0001 (P <.001).

Conclusion: Electrocardiographic abnormalities are independent predictors of cardiovascular mortality, and their addition to the FRS improves model discrimination and calibration. Further studies are needed to assess the prospective application of ECG abnormalities in cardiovascular risk prediction in individual subjects.
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http://dx.doi.org/10.1016/j.amjmed.2012.10.020DOI Listing
April 2013

News and views from the literature. Cardiac magnetic resonance imaging. Determinants and functional significance of myocardial perfusion reserve in severe aortic stenosis.

Authors:
Ankit Rathod

Rev Cardiovasc Med 2012 ;13(2-3):e137-8

Division of Cardiology, Cedars-Sinai Hospital and Veterans Affairs Medical Center of West Los Angeles, CA, USA.

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March 2013

Combined use of direct renin inhibitor and carvedilol in heart failure with preserved systolic function.

Med Hypotheses 2012 Oct 15;79(4):448-51. Epub 2012 Jul 15.

Wayne State University, Detroit Medical Center, Internal Medicine, Division of Cardiology, 8 Brush, Harper University Hospital, Detroit, MI 48201, USA.

Hypotheses: Heart failure with preserved systolic function (HFPSF) has attained epidemic proportions; however evidence-based therapeutic interventions have not advanced despite continued research over the past three decades. We propose the combined use of direct renin inhibitor and carvedilol for this condition.

Rationale: The Renin Angiotensin Aldosterone System (RAAS) plays a central role in myocyte hypertrophy, fibrosis and ventricular remodeling which is responsible for the diastolic dysfunction in HFPSF. Rising serum aldosterone levels with age have been implicated as a cause of myocardial fibrosis in the elderly. The sole use of Angiotensin Converting Enzyme Inhibitors or Angiotensin Receptor Blockers is associated with angiotensin-II and aldosterone escape and increased plasma renin activity. Carvedilol is a novel third generation non-selective β-blocker. The use of combination therapy will facilitate in better blood pressure control, reduce afterload, improve ventricular relaxation, cause regression of ventricular remodeling/fibrosis, maintain atrioventricular synchrony and enhance cardio-metabolic profile. The individual benefits of direct renin inhibitor and carvedilol could plausibly have a supra-additive effect when used in combination. Besides this, carvedilol can further reduce generation of free radicals, decrease LDL oxidation, improve Doppler echo diastolic parameters and decrease cardiac norepinephrine and density of cardiac β-receptors.

Conclusion: Evidence suggests that patients with HFPSF are treated less aggressively as compared to patients with heart failure with systolic dysfunction. Aggressive therapy with concurrent use of direct renin inhibitor and carvedilol will help in improving outcomes in this vulnerable patient sub-population. No prior trial has evaluated the combined use of these drugs for the treatment of HFPSF.
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http://dx.doi.org/10.1016/j.mehy.2012.06.019DOI Listing
October 2012
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