Publications by authors named "Brett J Carroll"

26 Publications

  • Page 1 of 1

Epidemiology of Endovascular and Open Repair for Abdominal Aortic Aneurysms in the United States from 2004-2015 and Implications for Screening.

J Vasc Surg 2021 Feb 13. Epub 2021 Feb 13.

Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston MA. Electronic address:

Introduction: Contemporary national trends in repair of ruptured abdominal aortic aneurysms and intact abdominal aortic aneurysms are relatively unknown. Furthermore, screening is only covered for patient's 65 to 75 years old with a family history or men with a smoking history. It is unclear what proportion of patients who present with a ruptured aneurysm would have been candidates for screening.

Methods: Using the National Inpatient Sample from 2004 to 2015, we identified rupture and intact AAA admissions and repairs based on International Classification of Diseases codes. We generated the screening eligible cohort using previously identified proportions of male smokers (87%) and all patients with a family history of aneurysm (10%) and applied these proportions to patients aged 65-75. We accounted for those who may have had a prior AAA diagnosis (17%) either from screening or incidental detection in patients over age 75 presenting with rupture. The primary outcomes were treatment and in-hospital mortality stratified by patients meeting criteria for screening versus those who did not.

Results: We evaluated 65,125 admissions for ruptured AAA and 461,191 repairs for intact AAA. Overall, an estimated 45,037 (68%) of patients admitted and 25,777 (59%) of patients undergoing repair for ruptured AAA did not meet criteria for screening. Of the patients who did not qualify; 27,653 (63%) were older than 75 years old; 10,603 (24%) were younger than 65 years old; and 16,103 (36%) were females. EVAR use increased for ruptured AAA from 10% in 2004 to 55% in 2015 (P<0.001) with an operative mortality of 35%, and for intact AAA from 45% in 2004 to 83% in 2015 (P<0.001) with an operative mortality of 2.0%.

Conclusions: The majority of patients who underwent repair for ruptured AAA did not qualify for screening. EVAR is the primary treatment for both ruptured AAA and intact AAA with a relatively low in-hospital mortality. Therefore, expansion of screening criteria to include selected women and a wider age range should be considered.
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http://dx.doi.org/10.1016/j.jvs.2021.01.044DOI Listing
February 2021

Health Care Utilization Following Inpatient Femoropopliteal Revascularization With Drug-Coated Balloon Angioplasty: A Nationwide Cohort Analysis.

J Endovasc Ther 2021 Apr 11;28(2):246-254. Epub 2021 Jan 11.

Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.

Purpose: To examine nationwide variations in inpatient use of drug-coated balloons (DCBs) for treating femoropopliteal segment occlusive disease and whether DCBs are associated with reduced early out-of-hospital health care utilization.

Materials And Methods: The study included 24,022 patients who survived hospitalization for femoropopliteal revascularization using DCB angioplasty (n=7850) or uncoated balloon angioplasty (n=16,172) in the 2016-2017 Nationwide Readmissions Database. Differences in patient, hospitalization, and institutional characteristics were compared between treatment strategies. Adjusted logistic regression models were used to examine differences in 6-month rates of readmission, amputation, and repeat intervention. Results are presented as the odds ratio (OR) and 95% confidence interval (CI).

Results: Patients treated with DCBs had a higher prevalence of chronic limb-threatening ischemia, diabetes, hypertension, and tobacco use. Revascularization with a DCB was associated with shorter hospitalizations, lower median hospitalization costs, and fewer inpatient lower extremity amputations. Readmissions at 6 months were decreased in patients treated with DCBs compared with uncoated balloon angioplasty (OR 0.90, 95% CI 0.83 to 0.98, p=0.014). The most common reasons for readmission were complications related to procedures (15.4%) and diabetes (15.4%). Compared to patients treated with DCBs, patients treated with uncoated balloon angioplasty were more often readmitted with early procedure-related complications (13.3% vs 17.5%). There were no between-group differences in readmission for sepsis, myocardial infarction, or congestive heart failure.

Conclusion: DCBs are less often used compared to uncoated balloons during inpatient femoropopliteal procedures. While DCB utilization is associated with more severe comorbidities and advanced peripheral artery disease, readmission rates are decreased through the first 6 months.
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http://dx.doi.org/10.1177/1526602820984111DOI Listing
April 2021

Sex differences in presentation, management, and outcomes among patients hospitalized with acute pulmonary embolism.

Vasc Med 2020 12 17;25(6):541-548. Epub 2020 Nov 17.

Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA, USA.

While the presence of gender disparities in cardiovascular disease have been described, there is a paucity of data regarding the impact of sex in acute pulmonary embolism (PE). We identified all patients admitted to a tertiary care hospital with acute PE between August 1, 2012 through July 1, 2018. We stratified the presenting characteristics, management, and outcomes between women and men. Of the 2031 patients admitted with acute PE, 1081 (53.2%) were women. Women were more likely to present with dyspnea (59.8% vs 52.0%, < 0.001) and less likely to present with hemoptysis (1.9% vs 4.0%, = 0.01). Women were older (63.8 ± 17.4 years vs 62.3 ± 15.0 years, = 0.04), but had lower rates of myocardial infarction, liver disease, smoking history, and prior DVT. PE severity was similar between women and men (massive: 4.9% vs 3.6%; submassive: 43.9% vs 41.8%; = 0.19), yet women were more likely to present with normal right ventricular size on a surface echocardiogram (63.2% vs 54.8%, = 0.01). In unadjusted analyses, women were less likely to survive to discharge (92.4% vs 94.7%, = 0.04), but after adjustment, there was no sex-based survival difference. There were no sex differences in the PE-related diagnostic studies performed, use of advanced therapies, or short-term outcomes, before and after adjustment ( > 0.05 for all). In this large PE cohort from a tertiary care institution, women had different comorbidity profiles and PE presentations compared with men. Despite these differences, there were no sex disparities in PE management or outcomes.
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http://dx.doi.org/10.1177/1358863X20964577DOI Listing
December 2020

Correction to: Risk assessment of acute pulmonary embolism utilizing coronary artery calcifications in patients that have undergone CT pulmonary angiography and transthoracic echocardiography.

Eur Radiol 2020 Nov 17. Epub 2020 Nov 17.

Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.

The original version of this article, published on 13 October 2020, unfortunately contained a mistake.
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http://dx.doi.org/10.1007/s00330-020-07442-zDOI Listing
November 2020

Acute pulmonary embolism following recent hospitalization or surgery.

J Thromb Thrombolysis 2020 Nov 6. Epub 2020 Nov 6.

Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, 185 Pilgrim Rd, Boston, MA, 02215, USA.

Pulmonary embolism (PE) is a major cause of cardiovascular morbidity and mortality. Recent hospitalization or surgery is a leading risk factor for PE, yet there are minimal data examining its effect on treatment and outcomes. We conducted a retrospective review of institutional billing codes for hospitalized patients with acute PE from August 2012 to August 2018. Patients were stratified based on whether they had a recent major medical encounter (MME), defined as surgery or hospitalization within 90 days. Primary outcomes included in-hospital mortality and 30- and 90-day readmission rates. Secondary outcomes included length of stay (LOS), use of advanced therapies, major bleeding, discharge anticoagulation and recurrent venous thromboembolism (VTE) at 90 days. Outcomes were adjusted for confounders using multivariable regression modeling. 2063 patients were hospitalized for an acute PE; 633 (30.7%) had a recent MME. Patients with a recent MME had a higher average Charlson Comorbidity Index (4.6 vs. 4.0, p < 0.01). Both 30- and 90-day readmission rates were higher in patients with a recent MME (21.7% vs. 14.4%; adjusted OR 1.06 [1.00, 1.12], p = 0.037; 30.8% vs 18.7%; adjusted OR 1.11 [1.11, 1.62], p = 0.003, respectively). After adjustment, there were no between-group differences in in-hospital mortality, LOS, use of advanced therapies, major bleeding, or recurrent VTE at 90 days. In-hospital mortality was higher for patients with a recent medical hospitalization compared to those with a recent surgery (10.2% vs. 5.6%, adjusted OR 1.08 [1.01, 1.15] p = 0.032). Despite recent hospitalization and/or surgery and greater number of comorbidities, patients admitted with a PE and recent MME had similar in-hospital outcomes, but experienced higher readmission rates. In-hospital mortality was higher in those with a recent medical compared to surgical encounter. Clinicians should optimize post-discharge transitional care in this subset of patients.
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http://dx.doi.org/10.1007/s11239-020-02322-1DOI Listing
November 2020

Risk assessment of acute pulmonary embolism utilizing coronary artery calcifications in patients that have undergone CT pulmonary angiography and transthoracic echocardiography.

Eur Radiol 2021 May 13;31(5):2809-2818. Epub 2020 Oct 13.

Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.

Objective: To evaluate the relation of coronary artery calcifications (CAC) on non-ECG-gated CT pulmonary angiography (CTPA) with short-term mortality in patients with acute pulmonary embolism (PE).

Methods: We retrospectively included all in-patients between May 2007 and December 2014 with an ICD-9 code for acute PE and CTPA and transthoracic echocardiography available. CAC was qualitatively graded as absent, mild, moderate, or severe. Relations of CAC with overall and PE-related 30-day mortality were assessed using logistic regression analyses. The independence of those relations was assessed using a nested approach, first adjusting for age and gender, then for RV strain, peak troponin T, and cardiovascular risk factors for an overall model.

Results: Four hundred seventy-nine patients were included (63 ± 16 years, 52.8% women, 47.2% men). In total, 253 (52.8%) had CAC-mild: 143 (29.9%); moderate: 89 (18.6%); severe: 21 (4.4%). Overall mortality was 8.8% (n = 42) with higher mortality with any CAC (12.6% vs. 4.4% without; odds ratio [OR] 3.1 [95%CI 2.1-14.5]; p = 0.002). Mortality with severe (19.0%; OR 5.1 [95%CI 1.4-17.9]; p = 0.011), moderate (11.2%; OR 2.7 [95%CI 1.1-6.8]; p = 0.031), and mild CAC (12.6%; OR 3.1 [95%CI 1.4-6.9]; p = 0.006) was higher than without. OR adjusted for age and gender was 2.7 (95%CI 1.0-7.1; p = 0.050) and 2.6 (95%CI 0.9-7.1; p = 0.069) for the overall model. PE-related mortality was 4.0% (n = 19) with higher mortality with any CAC (5.9% vs. 1.8% without; OR 3.5 [95%CI 1.1-10.7]; p = 0.028). PE-related mortality with severe CAC was 9.5% (OR 5.8 [95%CI 1.0-34.0]; p = 0.049), with moderate CAC 6.7% (OR 4.0 [95%CI 1.1-14.6]; p = 0.033), and with mild 4.9% (OR 2.9 [95%CI 0.8-9.9]; p = 0.099). OR adjusted for age and gender was 4.2 (95%CI 0.9-20.7; p = 0.074) and 3.4 (95%CI 0.7-17.4; p = 0.141) for the overall model. Patients with sub-massive PE showed similar results.

Conclusion: CAC is frequent in acute PE patients and associated with short-term mortality. Visual assessment of CAC may serve as an easy, readily available tool for early risk stratification in those patients.

Key Points: • Coronary artery calcification assessed on computed tomography pulmonary angiography is frequent in patients with acute pulmonary embolism. • Coronary artery calcification assessed on computed tomography pulmonary angiography is associated with 30-day overall and PE-related mortality in patients with acute pulmonary embolism. • Coronary artery calcification assessed on computed tomography pulmonary angiography may serve as an additional, easy readily available tool for early risk stratification in those patients.
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http://dx.doi.org/10.1007/s00330-020-07385-5DOI Listing
May 2021

Pregnancy-associated arterial dissections: a nationwide cohort study.

Eur Heart J 2020 11;41(44):4234-4242

Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA.

Aims: Pregnancy is a known risk factor for arterial dissection, which can result in significant morbidity and mortality in the peripartum period. However, little is known about the risk factors, timing, distribution, and outcomes of arterial dissections associated with pregnancy.

Methods And Results: We included all women ≥12 years of age with hospitalizations associated with pregnancy and/or delivery in the Nationwide Readmissions Database between 2010 and 2015. The primary outcome was any dissection during pregnancy, delivery, or the postpartum period (42-days post-delivery). Secondary outcomes included timing of dissection, location of dissection, and in-hospital mortality. Among 18 151  897 pregnant patients, 993 (0.005%) patients were diagnosed with a pregnancy-related dissection. Risk factors included older age (32.8 vs. 28.0 years), multiple gestation (3.6% vs. 1.9%), gestational diabetes (14.3% vs. 0.2%), gestational hypertension (6.0% vs. 0.6%), and pre-eclampsia/eclampsia (2.7% vs. 0.4%), in addition to traditional cardiovascular risk factors. Of the 993 patients with dissection, 150 (15.1%) dissections occurred in the antepartum period, 232 (23.4%) were diagnosed during the admission for delivery, and 611 (61.5%) were diagnosed in the postpartum period. The most common locations for dissections were coronary (38.2%), vertebral (22.9%), aortic (19.8%), and carotid (19.5%). In-hospital mortality was 3.7% among pregnant patients with a dissection vs. <0.001% in patients without a dissection. Deaths were isolated to patients with an aortic (8.6%), coronary (4.2%), or supra-aortic (<2.5%) dissection.

Conclusion: Arterial dissections occurred in 5.5/100 000 hospitalized pregnant or postpartum women, most frequently in the postpartum period, and were associated with high mortality risk. The coronary arteries were most commonly involved. Pregnancy-related dissections were associated with traditional risk factors, as well as pregnancy-specific conditions.
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http://dx.doi.org/10.1093/eurheartj/ehaa497DOI Listing
November 2020

Mitral annular plane systolic excursion and tricuspid annular plane systolic excursion for risk stratification of acute pulmonary embolism.

Echocardiography 2020 07 14;37(7):1008-1013. Epub 2020 Jun 14.

Departments of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.

Introduction: Risk stratification for acute pulmonary embolism (PE) incorporates metrics of right ventricle (RV) function. Significant RV dysfunction influences left ventricular (LV) function, though LV function metrics are not utilized for stratifying outcomes in patients with PE. Mitral annular plane systolic excursion (MAPSE) is a linear echocardiographic (TTE) measure that evaluates longitudinal LV function and may aid in risk stratification for acute PE.

Methods: Using a single-center database of patients with PE from 2007 to 2014, MAPSE was calculated for all TTE's available with sufficient quality (n = 362). A MAPSE of ≥11 mm was used as a normal reference. Thirty-day adverse outcomes were defined as administration of vasopressor, fibrinolytic therapy, open embolectomy, or 30-day PE-related mortality. Odds ratios (OR) and adjusted OR (AOR) were calculated using logistic regression analysis. Tricuspid annular plane systolic excursion (TAPSE) measurements were incorporated to determine the additive benefit of MAPSE.

Results: Compared with the reference MAPSE ≥ 11 mm and LVEF > 50%, patients with MAPSE < 11 mm and an LVEF > 50% had worse outcomes (AOR 2.94 [95% CI: 1.08-7.98], P = 0.035). Among patients with LVEF > 50%, the presence of both a MAPSE < 11 mm and TAPSE < 16 mm was associated with greater odds of adverse outcomes compared with isolated depressed TAPSE (AOR 10.75 [95% CI: 3.06-37.8], P < 0.01 vs AOR 1.68 [95% CI: 0.18-15.6], P = 0.65).

Conclusion: A depressed MAPSE, in patients with preserved LVEF, is associated with worse outcomes in patients with acute PE. The addition of MAPSE to TAPSE appears to have a greater prognostic value than either alone and may further aid in risk stratification, but for confirmation further prospective data are needed.
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http://dx.doi.org/10.1111/echo.14761DOI Listing
July 2020

Changes in Care for Acute Pulmonary Embolism Through A Multidisciplinary Pulmonary Embolism Response Team.

Am J Med 2020 11 19;133(11):1313-1321.e6. Epub 2020 May 19.

Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.

Background: Optimal management of acute pulmonary embolism requires expertise offered by multiple subspecialties. As such, pulmonary embolism response teams (PERTs) have increased in prevalence, but the institutional consequences of a PERT are unclear.

Methods: We compared all patients that presented to our institution with an acute pulmonary embolism in the 3 years prior to and 3 years after the formation of our PERT. The primary outcome was in-hospital pulmonary embolism-related mortality before and after the formation of the PERT. Sub-analyses were performed among patients with elevated-risk pulmonary embolism.

Results: Between August 2012 and August 2018, 2042 patients were hospitalized at our institution with acute pulmonary embolism, 884 (41.3%) pre-PERT implementation and 1158 (56.7%) post-PERT implementation, of which 165 (14.2%) were evaluated by the PERT. There was no difference in pulmonary embolism-related mortality between the two time periods (2.6% pre-PERT implementation vs 2.9% post-PERT implementation, P = .89). There was increased risk stratification assessment by measurement of cardiac biomarkers and echocardiograms post-PERT implementation. Overall utilization of advanced therapy was similar between groups (5.4% pre-PERT implementation vs 5.4% post-PERT implementation, P = 1.0), with decreased use of systemic thrombolysis (3.8% pre-PERT implementation vs 2.1% post-PERT implementation, P = 0.02) and increased catheter-directed therapy (1.3% pre-PERT implementation vs 3.3% post-PERT implementation, P = 0.05) post-PERT implementation. Inferior vena cava filter use decreased after PERT implementation (10.7% pre-PERT implementation vs 6.9% post-PERT implementation, P = 0.002). Findings were similar when analyzing elevated-risk patients.

Conclusion: Pulmonary embolism response teams may increase risk stratification assessment and alter application of advanced therapies, but a mortality benefit was not identified.
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http://dx.doi.org/10.1016/j.amjmed.2020.03.058DOI Listing
November 2020

Readmissions after acute type B aortic dissection.

J Vasc Surg 2020 07 12;72(1):73-83.e2. Epub 2019 Dec 12.

Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.

Objective: Acute type B aortic dissection can be treated with medical management alone, open surgical repair, or thoracic endovascular aortic repair (TEVAR). The nationwide burden of readmissions after acute type B aortic dissection has not been comprehensively assessed.

Methods: We analyzed adults with a hospitalization due to acute type B aortic dissection between January 1, 2010, and December 31, 2014, in the Nationwide Readmissions Database. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify hospitalizations with a primary diagnosis code for thoracic or thoracoabdominal aortic dissection. The primary outcome was nonelective 90-day readmission. Predictors of readmission were determined using hierarchical logistic regression.

Results: The study population consisted of 6937 patients with unplanned admissions for type B aortic dissections from 2010 through 2014. Medical management alone was the treatment for 62.6% of patients, 21.0% had open surgical repair, and 16.4% underwent TEVAR. Nonelective 90-day readmission rate was 25.1% (23.6% with medical management alone, 26.9% with open repair, and 28.7% with TEVAR; P < .001). An additional 4.7% of patients were electively readmitted. The most common cause for nonelective readmission was new or recurrent arterial aneurysm or dissection (24.8%). Of those with unplanned readmissions, 5.2% underwent an aortic procedure. The mortality rate during nonelective readmission was 5.0%, and the mean cost of the rehospitalization was $22,572 ± $41,598.

Conclusions: More than one in four patients have a nonelective readmission 90 days after hospitalization for acute type B aortic dissection. Absolute rates of readmission varied by initial treatment received but were high irrespective of the initial treatment. The most common cause of readmission was aortic disease, particularly among those treated with medication alone. Further research is required to determine potential interventions to decrease these costly and morbid readmissions, including the role of multidisciplinary aortic teams.
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http://dx.doi.org/10.1016/j.jvs.2019.08.280DOI Listing
July 2020

Imaging for acute aortic syndromes.

Heart 2020 02 10;106(3):182-189. Epub 2019 Dec 10.

Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.

Acute aortic syndromes (AAS) represent a spectrum of disorders with a common theme of disruption in aortic integrity. AAS are associated with high morbidity and mortality and warrant emergent medical or surgical intervention as delayed treatment is associated with worse outcomes. There are multiple advanced imaging modalities for the diagnosis and complimentary assessment of AAS, each with advantages and limitations. CT angiography remains the imaging modality of choice for diagnosis in the overwhelming majority of patients as it is rapidly acquired and widely available; however, transoesophageal echocardiogram also offers excellent diagnostic accuracy in addition to complimentary data for surgical repair in those with type A dissection. Transthoracic echocardiography and magnetic resonance angiography can also be valuable in select patients. Imaging is increasingly important for risk stratification in the subacute and chronic phases of AAS. Additionally, imaging is vital for planning of interventions in both acute and delayed intervention. Endovascular treatment options are used with increasing frequency-multimodality imaging during the procedure allows for optimisation of these increasingly complex procedures.
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http://dx.doi.org/10.1136/heartjnl-2019-314897DOI Listing
February 2020

Utilization and Outcomes of Thrombolytic Therapy for Acute Pulmonary Embolism: A Nationwide Cohort Study.

Chest 2020 03 26;157(3):645-653. Epub 2019 Nov 26.

Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. Electronic address:

Background: There are increased options to deliver thrombolytic treatment for acute, high-risk pulmonary embolism (PE). The goals of this study were to examine practice patterns of systemic thrombolysis and catheter-directed thrombolysis (CDT) and to compare outcomes following CDT with ultrasound facilitation (CDT-ultrasound) and CDT alone.

Methods: The study analyzed adults aged > 18 years with hospitalizations associated with acute PE and thrombolysis in the 2016 Nationwide Readmissions Database. The study identified characteristics associated with the use of systemic thrombolysis and CDT. Comparisons of CDT-ultrasound vs CDT alone were then made by evaluating in-hospital events and readmissions. The primary outcomes were in-hospital mortality and 30-day readmission rates.

Results: Among 5,436 hospitalizations, systemic thrombolysis was used more often (n = 3,376; 62.1%) than CDT (n = 2,060; 37.9%). Compared with CDT, systemic thrombolysis was used more frequently in patients with higher rates of vasopressor use (4.3% vs 1.0%), shock (15.8% vs. 6.9%), cardiac arrest (12.7% vs 3.4%), and mechanical ventilation (19.0% vs 5.9%). Among patients who underwent CDT, 417 (20.2%) received CDT-ultrasound, and 1,643 (79.8%) received CDT alone. Rates of bleeding events, vasopressor use, and mechanical ventilation were similar between therapeutic strategies. Following adjustment, in-hospital mortality (OR, 1.19; 95% CI, 0.63-2.26; P = .59) and 30-day readmission rates (OR, 0.75; 95% CI, 0.47-1.22; P = .25) were not significantly different between CDT-ultrasound and CDT alone.

Conclusions: Systemic thrombolysis is used more often than CDT in patients with acute PE, in particular among those with a greater prevalence of high-risk features. Among patients treated with CDT, there were no differences in events between CDT-ultrasound and CDT alone.
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http://dx.doi.org/10.1016/j.chest.2019.10.049DOI Listing
March 2020

Right ventricular strain in patients with pulmonary embolism and syncope.

J Thromb Thrombolysis 2020 Jul;50(1):157-164

Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.

Patients with acute pulmonary embolism (PE) can present with various clinical manifestations including syncope. The mechanism of syncope in PE is not fully elucidated and data of right ventricular (RV) function in patients has been limited. We retrospectively identified 477 consecutive patients hospitalized with acute PE diagnosed with a computed tomogram (CT) who also had a transthoracic echocardiogram (TTE) 24 h prior to or 48 h after diagnosis. Parameters of RV strain on CT, TTE, electrocardiogram (ECG), and clinical characteristics and adverse outcomes were collected. Patients with all three studies available for assessment were included (n = 369) and those with syncope (n = 34) were compared to patients without syncope (n = 335). Patients with syncope were more likely to demonstrate RV strain on all three modes of assessment compared to those without syncope [17 (50%) vs. 67 (20%); p = 0.001], and those patients were more likely to receive advanced therapies [9 (53%) vs. 15 (22%); p = 0.02]. PE-related mortality was highest among those presenting with high-risk PE and syncope (36%, OR 20.1, 95% CI 5.3-81.1; p < 0.001) and was low in patients with syncope without criteria for high-risk PE (3%, OR 1.2, 95% CI 0.2-10.0; p < 0.001). In conclusion, acute PE patients with syncope are more likely to demonstrate multimodality evidence of RV strain and to receive advanced therapies. Syncope was only associated with increased PE-related mortality in patients presenting with a high-risk PE. Syncope alone without evidence of RV strain is associated with low short-term adverse events and is similar to those without syncope.
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http://dx.doi.org/10.1007/s11239-019-01976-wDOI Listing
July 2020

Moving Forward by Pulling Back?

JACC Cardiovasc Interv 2019 05;12(9):870-872

Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1016/j.jcin.2019.01.218DOI Listing
May 2019

Inferior Vena Cava Filters and Mortality: Is It the Underlying Process, the Patient, or the Device?

JAMA Netw Open 2018 07 6;1(3):e180453. Epub 2018 Jul 6.

Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamanetworkopen.2018.0453DOI Listing
July 2018

Invited commentary.

J Vasc Surg 2019 01;69(1):199-200

Boston, Mass.

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http://dx.doi.org/10.1016/j.jvs.2018.07.002DOI Listing
January 2019

Hypercoagulable states in arterial and venous thrombosis: When, how, and who to test?

Vasc Med 2018 08;23(4):388-399

2 Cardiology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Evaluation for underlying hypercoagulable states in patients with thrombosis is a frequent clinical conundrum. Testing for thrombophilias is often reflexively performed without strategic approach nor clear appreciation of the clinical implications of such results. Guidelines vary in the appropriate utilization of thrombophilia testing. In this review, we discuss the more commonly encountered inherited and acquired thrombophilias, their association with initial and recurrent venous thromboembolism, arterial thromboembolism, and role in women's health. We suggest an approach to thrombophilia testing guided by the clinical presentation, suspected pathophysiology, and an understanding of how such results may affect patient care.
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http://dx.doi.org/10.1177/1358863X18755927DOI Listing
August 2018

Multimodality Assessment of Right Ventricular Strain in Patients With Acute Pulmonary Embolism.

Am J Cardiol 2018 07 28;122(1):175-181. Epub 2018 Mar 28.

Beth Israel Deaconess Medical Center, Department of Medicine, Boston, Massachusetts; Beth Israel Deaconess Medical Center, Cardiovascular Division, Boston, Massachusetts; Beth Israel Deaconess Medical Center, Radiology and Harvard Medical School, Boston, Massachusetts.

Optimal risk stratification is essential in managing patients with an acute pulmonary embolism (PE). There are limited data evaluating the potential additive value of various methods of evaluation of right ventricular (RV) strain in PE. We retrospectively evaluated RV strain by computed tomography (CT), transthoracic echocardiography (TTE), electrocardiography (ECG), and troponin levels in consecutive hospitalized patients with acute PE (May 2007 to December 2014). Four-hundred and seventy-seven patients met inclusion criteria. RV strain on ECG (odds ratio [OR] 1.9, confidence interval [CI] 1.1 to 3.3; p = 0.03), CT (OR 2.7, CI 1.5 to 4.8, p <0.001), TTE (OR 2.8, CI 1.5 to 5.4, p <0.001), or a positive troponin (OR 2.7, CI 2.0 to 6.9, p <0.001) were associated with adverse events. In patients with ECG, CT, and TTE data, increased risk was only elevated with RV strain on all 3 parameters (OR 4.6, CI 1.8 to 11.3, p <0.001). In all patients with troponin measurements, risk was only elevated with RV strain on all 3 parameters plus a positive troponin (OR 8.8, CI 2.8 to 28.1, p <0.001) and was similar in intermediate-risk PE (OR 11.1, CI 1.2 to 103.8, p = 0.04). In conclusion, in patients with an acute PE and evaluation of RV strain by ECG, CT, and TTE, risk of adverse events is only elevated when RV strain is present on all 3 modalities. Troponin further aids in discriminating high-risk patients. Multimodality assessment of RV strain is identified as a superior approach to risk assessment.
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http://dx.doi.org/10.1016/j.amjcard.2018.03.013DOI Listing
July 2018

Segmental Arterial Mediolysis: An Important but Often Overlooked Cause of Multi-Vessel Thrombosis.

Am J Med 2018 06 2;131(6):e231-e234. Epub 2018 Mar 2.

Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass; Department of Cardiology, Boston VA Healthcare System, Boston, Mass. Electronic address:

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http://dx.doi.org/10.1016/j.amjmed.2018.01.057DOI Listing
June 2018

Catheter-directed, ultrasound-facilitated fibrinolysis in obese patients with massive and submassive pulmonary embolism.

J Thromb Thrombolysis 2018 Feb;45(2):257-263

Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.

Obesity is a well-established risk factor for pulmonary embolism (PE). However, treatment of PE in obese patients is challenging because of limited outcomes data, especially with advanced therapies such as catheter-based fibrinolysis. We assessed the efficacy and safety of ultrasound-facilitated, catheter-directed fibrinolysis in obese patients with submassive and massive PE enrolled in the SEATTLE II Trial. Eligible patients had a right ventricular-to-left ventricular (RV/LV) diameter ratio ≥ 0.9 on chest computed tomography (CT). The primary efficacy outcome was the change in chest CT-measured RV/LV diameter ratio at 48 h after procedure initiation. The primary safety outcome was GUSTO major bleeding within 72 h. One-hundred and four patients were obese, as defined by a BMI ≥ 30 kg/m, and 44 were non-obese. Mean RV/LV ratio was greater in obese patients at baseline compared with non-obese patients (1.60 vs. 1.43, p = 0.02). Reduction in RV/LV diameter ratio at 48 h was greater in obese patients compared with non-obese patients (absolute reduction: - 0.47 vs. - 0.30, p = 0.01; relative reduction: - 26 vs. - 18%, p = 0.03). Major bleeding occurred in 12 (12%) of obese patients and in 3 (7%) in non-obese patients (p = 0.55). In conclusion, ultrasound-facilitated, catheter-directed fibrinolysis shows promise in obese patients for whom advanced therapy for acute PE is warranted.
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http://dx.doi.org/10.1007/s11239-018-1608-3DOI Listing
February 2018

Readmissions After Revascularization Procedures for Peripheral Arterial Disease: A Nationwide Cohort Study.

Ann Intern Med 2018 01 5;168(2):93-99. Epub 2017 Dec 5.

From Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts, and Saint Luke's Mid-America Heart Institute, Kansas City, Missouri.

Background: Limited data suggest high rates of unplanned rehospitalization after endovascular and surgical revascularization for peripheral arterial disease. However, the overall burden of readmissions has not been comprehensively explored.

Objective: To evaluate nationwide readmissions after peripheral arterial revascularization for peripheral arterial disease and to assess whether readmission risk varies among hospitals.

Design: Retrospective cohort study.

Setting: 1085 U.S. acute care hospitals participating in the Nationwide Readmissions Database.

Patients: 61 969 unweighted hospitalizations of patients with peripheral arterial disease who had peripheral arterial revascularization and were discharged alive between 1 January and 30 November 2014.

Measurements: 30-day readmission rates, causes, and costs of unplanned rehospitalizations after peripheral arterial revascularization; 30-day risk-standardized readmission rates (RSRRs), calculated using hierarchical logistic regression, to assess for heterogeneity of readmission risk between hospitals.

Results: Among 61 969 hospitalizations of patients with peripheral arterial disease who were discharged alive after peripheral arterial revascularization, the 30-day nonelective readmission rate was 17.6%. The most common cause of readmission was procedural complications (28.0%), followed by sepsis (8.3%) and complications due to diabetes mellitus (7.5%). Among rehospitalized patients, 21.0% underwent a subsequent peripheral arterial revascularization or lower extremity amputation, 4.6% died, and the median cost of a readmission was $11 013. Thirty-day RSRRs varied from 10.0% to 27.3% (interquartile range, 16.6% to 18.8%).

Limitation: Inability to distinguish out-of-hospital deaths after discharge and potential misclassification bias due to use of billing codes to ascertain diagnoses and interventions.

Conclusion: More than 1 in 6 patients with peripheral arterial disease who undergo peripheral arterial revascularization have unplanned readmission within 30 days, with high associated mortality risks and costs. Procedure- and patient-related factors were the primary reasons for readmission. Readmission rates varied moderately between institutions after hospital case mix was accounted for, suggesting that differences in hospital quality may only partially account for readmission.

Primary Funding Source: Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center.
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http://dx.doi.org/10.7326/M17-1058DOI Listing
January 2018

Initiation of a Multidisciplinary, Rapid Response Team to Massive and Submassive Pulmonary Embolism.

Am J Cardiol 2017 Oct 26;120(8):1393-1398. Epub 2017 Jul 26.

Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. Electronic address:

Pulmonary embolism (PE) can result in rapid clinical decompensation in many patients. With increasing patient complexity and advanced treatment options for PE, multidisciplinary, rapid response teams can optimize risk stratification and expedite management strategies. The Massive And Submassive Clot On-call Team (MASCOT) was created at our institution, which comprised specialists from cardiology, pulmonology, hematology, interventional radiology, and cardiac surgery. MASCOT offers rapid consultation 24 hours a day with a web-based conference call to review patient data and discuss management of patients with high-risk PE. We reviewed patient data collected from MASCOT's registry to analyze patient clinical characteristics and outcomes and describe the composition and operation of the team. Between August 2015 and September 2016, MASCOT evaluated 72 patients. Seventy of the 72 patients were admitted to our institution, accounting for 32% of all patients discharged with a primary diagnosis of PE. Average age was 62 ± 17 years with a female predominance (63%). Active malignancy (31%), recent surgery or trauma (21%), and recent hospitalization (24%) were common. PE clinical severity was massive in 16% and submassive in 83%. Patients were managed with anticoagulation alone in 65% (n = 46), systemic fibrinolysis in 11% (n = 8), catheter-directed therapy in 18% (n = 13), extracorporeal membrane oxygenation in 3% (n = 2), and an inferior vena cava filter was placed in 15% (n = 11). Thirteen percent (n = 9) experienced a major bleed with no intracranial hemorrhage. Survival to discharge was 89% (64% with massive PE and 93% with submassive PE). In conclusion, multidisciplinary, rapid response PE teams offer a unique coordinated approach to patient care.
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http://dx.doi.org/10.1016/j.amjcard.2017.07.033DOI Listing
October 2017

Ultrasound-facilitated, catheter-directed, low-dose fibrinolysis in elderly patients with pulmonary embolism: A SEATTLE II sub-analysis.

Vasc Med 2017 08 18;22(4):324-330. Epub 2017 Jun 18.

2 Cardiology Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.

Elderly patients with acute pulmonary embolism (PE) have higher mortality than non-elderly patients, but receive systemic fibrinolysis less frequently. In this sub-analysis of the SEATTLE II trial, we evaluated the efficacy and safety of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis in elderly patients with submassive and massive PE. We compared patients ⩾65 years old with those <65 years old. Eligible patients had proximal PE and a right ventricular-to-left ventricular (RV/LV) diameter ratio ⩾0.9 on chest computed tomography (CT). The primary efficacy outcome was the change in chest CT-measured RV/LV diameter ratio at 48 hours after procedure initiation. The primary safety outcome was major bleeding within 72 hours. Sixty-two patients were ⩾65 years of age and 88 were <65 years of age. The RV/LV diameter ratio decreased in both groups 48 hours post-procedure, with a mean change of -0.47 in those ⩾65 and -0.39 in those <65 years old, with no difference between groups ( p = 0.31). Major bleeding occurred in nine (15%) of those ⩾65 and in six (7%) of those <65 years old ( p = 0.17). Ultrasound-facilitated, catheter-directed, low-dose fibrinolysis resulted in a similar reduction in RV/LV diameter ratio in elderly patients with massive and submassive PE compared with non-elderly patients.
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http://dx.doi.org/10.1177/1358863X17693102DOI Listing
August 2017

Clinical Features and outcomes in adults with cardiogenic shock supported by extracorporeal membrane oxygenation.

Am J Cardiol 2015 Nov 3;116(10):1624-30. Epub 2015 Sep 3.

Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA. Electronic address:

Extracorporeal membrane oxygenation (ECMO) is an increasingly used supportive measure for patients with refractory cardiogenic shock (CS). Despite its increasing use, there remain minimal data regarding which patients with refractory CS are most likely to benefit from ECMO. We retrospectively studied all patients (n = 123) who underwent initiation of ECMO for CS from February 2009 to September 2014 at a single center. Baseline patient characteristics, including demographics, co-morbid illness, cause of CS, available laboratory values, and patient outcomes were analyzed. Overall, 69 patients (56%) were weaned from ECMO, with 48 patients (39%) surviving to discharge. Survivors were younger (50 vs 60 years; p ≤0.0001), had a lower rate of previous smoking (27 vs 56%; p = 0.01) and chronic kidney disease (2% vs 13%; p = 0.03), and had lower lactate measured soon after ECMO initiation (3.1 vs 10.2 mmol/l; p = 0.01). Patients with pulmonary embolism (odds ratio 8.0, 95% confidence interval 2.00 to 31.99; p = 0.01) and acute cardiomyopathy (odds ratio 7.5, 95% confidence interval 1.69 to 33.27; p = 0.01) had a higher rate of survival than acute myocardial infarction, chronic cardiomyopathy, and miscellaneous etiologies compared to postcardiotomy CS as a referent. In conclusion, survival after ECMO initiation differs based on underlying cause of CS. Survival may be lower in older patients and those with early evidence of persistent hypoperfusion after initiation of ECMO for CS.
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http://dx.doi.org/10.1016/j.amjcard.2015.08.030DOI Listing
November 2015

Multi-sensor esophageal temperature probe used during radiofrequency ablation for atrial fibrillation is associated with increased intraluminal temperature detection and increased risk of esophageal injury compared to single-sensor probe.

J Cardiovasc Electrophysiol 2013 Sep 7;24(9):958-64. Epub 2013 Jun 7.

Department of Medicine.

Background: Radiofrequency (RF) ablation in the posterior left atrium has risk of thermal injury to the adjacent esophagus. Increased intraluminal esophageal temperature has been correlated with risk of esophageal injury. The objective of this study was to compare esophageal temperature monitoring (ETM) using a multi-sensor temperature probe with 12 sensors to a single-sensor probe during catheter ablation for atrial fibrillation (AF).

Methods And Results: We compared the detection of intraluminal esophageal temperature rises in 543 patients undergoing RF ablation for AF with ETM. Esophageal endoscopy (EGD) was performed on all patients with maximum esophageal temperature ≥ 39°C. Esophageal lesions were classified by severity as mild or severe ulcerations. Four hundred fifty-five patients underwent RF ablation with single-sensor ETM and 88 patients with multi-sensor ETM. Thirty-nine percent of patients with single-sensor versus 75% with multi-sensor ETM reached a maximum detected esophageal temperature ≥ 39°C (P < 0.0001). Esophageal injury was detected by EGD in 29% of patients with maximum temperature ≥ 39°C by single-sensor versus 46% of patients with multi-sensor ETM (P = 0.021). Thirty-nine percent of patients with lesions in the single-sensor probe group had severe ulcerations compared to 33% of patients in the multi-sensor probe group (P = 0.641).

Conclusions: Intraluminal esophageal temperature ≥ 39°C is detected more frequently by the multi-sensor temperature probe versus the single-sensor probe, with more frequent esophageal injury and with comparable severity of injury. Despite detecting esophageal temperature rises in more patients, the multi-sensor probe may not have any measurable benefit compared to a single-sensor probe.
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http://dx.doi.org/10.1111/jce.12180DOI Listing
September 2013