Publications by authors named "Cynthia C Taub"

60 Publications

Echocardiography Abnormal Findings and Laboratory Operations during the COVID-19 Pandemic at a High Volume Center in New York City.

Healthcare (Basel) 2020 Dec 3;8(4). Epub 2020 Dec 3.

Department of Medicine, Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA.

(1) Background: This study sought to explore how the novel coronavirus (COVID-19) pandemic affected the echocardiography (TTE) laboratory operations at a high volume medical center in New York City. Changes in cardiac imaging study volume, turn-around time, and abnormal findings were analyzed and compared to a pre-pandemic period. (2) Methods: Volume of all cardiac imaging studies and TTE reports between 11 March 2020 to 5 May 2020 and the same calendar period in 2019 were retrospectively identified and compared. (3) Results: During the pandemic, our center experienced a 46.72% reduction in TTEs, 82.47% reduction in transesophageal echocardiograms, 83.16% reduction in stress echo, 70.32% reduction in nuclear tests, 46.25% reduction in calcium score, 73.91% reduction in coronary computed tomography angiography, and 87.23% reduction in cardiac magnetic resonance imaging. TTE findings were overall similar between 2020 and 2019 (all ≥ 0.05), except for a significantly higher right ventricular systolic pressure in 2020 (39.8 ± 14.2 vs. 34.6 ± 11.2 mmHg, = 0.012). (4) Conclusions: Despite encountering an influx of critically ill patients, our hospital center experienced a reduction in the number of cardiac imaging studies, which likely represents a change in both patient mindset and physician management approach.
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http://dx.doi.org/10.3390/healthcare8040534DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7761727PMC
December 2020

State of the Art: Imaging for Myocardial Viability: A Scientific Statement From the American Heart Association.

Circ Cardiovasc Imaging 2020 Jul 13;13(7):e000053. Epub 2020 Jul 13.

A substantial proportion of patients with acute myocardial infarction develop clinical heart failure, which remains a common and major healthcare burden. It has been shown that in patients with chronic coronary artery disease, ischemic episodes lead to a global pattern of cardiomyocyte remodeling and dedifferentiation, hallmarked by myolysis, glycogen accumulation, and alteration of structural proteins. These changes, in conjunction with an impaired global coronary reserve, may eventually become irreversible and result in ischemic cardiomyopathy. Moreover, noninvasive imaging of myocardial scar and hibernation can inform the risk of sudden cardiac death. Therefore, it would be intuitive that imaging of myocardial viability is an essential tool for the proper use of invasive treatment strategies and patient prognostication. However, this notion has been challenged by large-scale clinical trials demonstrating that, in the modern era of improved guideline-directed medical therapies, imaging of myocardial viability failed to deliver effective guidance of coronary bypass surgery to a reduction of adverse cardiac outcomes. In addition, current available imaging technologies in this regard are numerous, and they target diverse surrogates of structural or tissue substrates of myocardial viability. In this document, we examine these issues in the current clinical context, collect current evidence of imaging technology by modality, and inform future directions.
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http://dx.doi.org/10.1161/HCI.0000000000000053DOI Listing
July 2020

Saddle pulmonary embolism and thrombus-in-transit straddling the patent foramen ovale 28 days after COVID symptom onset.

Echocardiography 2020 08 31;37(8):1296-1299. Epub 2020 Jul 31.

Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.

We present a late presentation of saddle pulmonary embolism and thrombus-in-transit straddle the patent foramen on patient who successfully recovered from severe acute respiratory syndrome coronavirus-2 (COVID-19) pneumonia. Seven days postdischarge (ie, 28 days after initial COVID-19 symptom onset), she was readmitted to hospital for severe dyspnea. Computer tomography angiogram and echocardiography confirmed the diagnosis. Severe pro-inflammatory and pro-thrombotic states with endothelial involvement have been reported associated with severe COVID-19 infection. However, the duration of hypercoagulable state has not yet known. This case highlights the risk of thromboembolic phenomena for prolonged periods of times after recovering from COVID-19 pneumonia.
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http://dx.doi.org/10.1111/echo.14796DOI Listing
August 2020

A self-resolving, post-traumatic aortopulmonary shunt.

Echocardiography 2020 05 10;37(5):781-783. Epub 2020 Apr 10.

Non-invasive Cardiology, Cardiovascular Imaging, Montefiore Hospital, Albert Einstein College of Medicine, Bronx, NY, USA.

A 34-year-old Hispanic man sustained a stab wound to his chest complicated with hemopericardium and pericardial tamponade. He underwent emergent clamshell thoracotomy as well as repair to the pulmonary artery. A transthoracic echocardiogram showed no evidence of intracardiac shunt. Two months later, a new murmur was noted, with a transthoracic echocardiogram revealing high-velocity flow between the left coronary sinus and the main pulmonary artery, with which a coronary computed tomography angiogram concurred. A transesophageal echocardiogram was performed which revealed an aortopulmonic fistula from the left coronary sinus of Valsalva, approximately 1cm anterior to the ostium of the left main coronary artery, to the main pulmonary artery just distal to the pulmonic valve. Pulmonary insufficiency was minimal. The main pulmonary artery was dilated, measuring 3.2 cm by coronary computed tomography angiogram. Right ventricular systolic function was normal. Right and left heart catheterizations were performed to further assess hemodynamics and coronary anatomy; pulmonary artery pressures were 16/8 mm Hg. Aortopulmonary fistula was seen on aortogram. Surgery was deferred in view of lack of symptoms and uncertainty in its natural history in the setting of traumatic etiology. A repeat transthoracic echocardiogram at six-month follow-up showed spontaneous closure of the fistula.
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http://dx.doi.org/10.1111/echo.14654DOI Listing
May 2020

Clinical Characteristics of Young Patients With Heart Failure With Reduced Ejection Fraction in a Racially Diverse Cohort.

Crit Pathw Cardiol 2019 06;18(2):80-85

Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.

Background: Information on the clinical and echocardiographic characteristics of young patients with heart failure with reduced ejection fraction is scant, especially among racially diverse populations.

Methods: Patients admitted to Montefiore Medical Center between 2000 and 2016 with heart failure and ejection fraction of <40% were categorized as young (18-39 years), middle-aged (40-64 years), and elderly (≥65 years). Multivariable Cox regression models were used to evaluate mortality risk.

Results: A total of 1032 young, 8336 middle-aged, and 13,315 elderly patients were included. Median follow-up was 36 (14-69) months. The young group had more black individuals, lower socioeconomic scores, larger left ventricular chambers, but lower N-terminal pro b-type natriuretic peptide levels (P < 0.001). Better survival outcomes were observed in the young compared to the middle-aged [hazard ratio (HR), 1.52; 95% confidence interval (CI), 1.31-1.77] and elderly (HR, 3.19; 95% CI, 2.75-3.70). After multivariable adjustments, only β-blockers were associated with a significant reduction of mortality in young patients (HR, 0.33; 95% CI, 0.22-0.51).

Conclusion: In conclusion, young patients with heart failure with reduced ejection fraction have distinct demographic, clinical, and echocardiographic characteristics. They had lower socioeconomic status yet received more aggressive treatments and had lower mortality rates. Only β-blockers were associated with improved survival in young patients from our cohort.
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http://dx.doi.org/10.1097/HPC.0000000000000172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6553968PMC
June 2019

Racial differences of heart failure with midrange ejection fraction (HFmrEF): a large urban centre-based retrospective cohort study in the USA.

BMJ Open 2019 05 1;9(4):e026479. Epub 2019 May 1.

Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.

Objectives: We aimed to study the racial differences in clinical presentations, survival outcomes and outcome predictors among patients with heart failure (HF) with midrange ejection fraction (HFmrEF, EF 40%-49%).

Design: This is a retrospective study.

Setting: Adults with HF diagnosis at Montefiore Medical Center, Bronx, New York between 2008 and 2012, with an inpatient echocardiogram showing left ventricular ejection fraction of 40%-49% were included as HFmrEF population.

Participants: 1,852 HFmrEF patients are included in the study (56% male, mean age 67 years). There were 493 (26.5%) non-Hispanic whites, 541 (29.2%) non-Hispanic black, 489 (26.4%) Hispanics and 329 (17.8%) other racial populations.

Outcome Measures: Cumulative probabilities of all-cause mortality among different racial groups were estimated and multivariable adjusted Cox proportional regressions were performed to assess predictors of mortality.

Results: Among the HFmrEF patients, white patients were older and were less likely to be on guideline-directed medications. Blacks had a lower prevalence of prior myocardial infarction comparing to other groups. Hispanics had more chronic diseases and yet better survival comparing to whites and blacks after adjustment for age, sex and comorbidities. Distinct sets of survival predictors were revealed in individual racial groups. Baseline use of mineralocorticoid receptor antagonist (MRA) was associated with lower mortality among HFmrEF patients in general (HR 0.61, 95% CI 0.37 to 0.99).

Conclusions: There are significant racial/ethnic differences in clinical phenotypes, survival outcomes and mortality predictors of HFmrEF. Furthermore, the use of MRA predicted a reduced mortality in HFmrEF patients.
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http://dx.doi.org/10.1136/bmjopen-2018-026479DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6501992PMC
May 2019

A risk score for predicting atrial fibrillation in individuals with preclinical diastolic dysfunction: a retrospective study in a single large urban center in the United States.

BMC Cardiovasc Disord 2019 02 27;19(1):47. Epub 2019 Feb 27.

Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Jack D. Weiler Hospital, 1825 Eastchester Rd, Bronx, NY, 10461, USA.

Background: Left ventricular diastolic dysfunction has been shown to associate with increased risk of atrial fibrillation (AF). We aimed to examine the predictors of AF in individuals with preclinical diastolic dysfunction (PDD) - diastolic dysfunction without clinical heart failure - and develop a risk score in this population.

Methods: Patients underwent echocardiogram from December 2009 to December 2015 showing left ventricular ejection fraction (LVEF) ≥ 50% and grade 1 diastolic dysfunction, without clinical heart failure, valvular heart disease or AF were included. Outcome was defined as new onset AF. Cumulative probabilities were estimated and multivariable adjusted competing-risks regression analysis was performed to examine predictors of incident AF. A predictive score model was constructed.

Results: A total of 9591 PDD patients (mean age 66, 41% men) of racial/ethnical diversity were included in the study. During a median follow-up of 54 months, 455 (4.7%) patients developed AF. Independent predictors of AF included advanced age, male sex, race, hypertension, diabetes, and peripheral artery disease. A risk score including these factors showed a Wolber's concordance index of 0.65 (0.63-0.68, p <  0.001), suggesting a good discrimination.

Conclusions: Our study revealed a set of predictors of AF in PDD patients. A simple risk score predicting AF in PDD was developed and internally validated. The scoring system could help clinical risk stratification, which may lead to prevention and early treatment strategies.
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http://dx.doi.org/10.1186/s12872-019-1024-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6391831PMC
February 2019

Addressing maternal mortality: the pregnant cardiac patient.

Am J Obstet Gynecol 2019 02 29;220(2):167.e1-167.e8. Epub 2018 Sep 29.

Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY.

Cardiac disease in pregnancy is the number one indirect cause of maternal mortality in the United States. We propose a triad solution that includes universal screening for cardiovascular disease in pregnancy and postpartum women, patient education, and institution of a multidisciplinary cardiac team. Additionally, we emphasize essential elements to maximize care for the pregnant cardiac patient based on our experience at our institution in Bronx, NY.
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http://dx.doi.org/10.1016/j.ajog.2018.09.035DOI Listing
February 2019

Coronary Computed Tomography Angiography Versus Stress Echocardiography in Acute Chest Pain: A Randomized Controlled Trial.

JACC Cardiovasc Imaging 2018 09 13;11(9):1288-1297. Epub 2018 Jun 13.

Department of Radiology, Division of Cardiothoracic Imaging, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York; Department of Internal Medicine, Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.

Objectives: This study sought to compare early emergency department (ED) use of coronary computed tomography angiography (CTA) and stress echocardiography (SE) head-to-head.

Background: Coronary CTA has been promoted as the early ED chest pain triage imaging method of choice, whereas SE is often overlooked in this setting and involves no ionizing radiation.

Methods: The authors randomized 400 consecutive low- to intermediate-risk ED acute chest pain patients without known coronary artery disease and a negative initial serum troponin level to immediate coronary CTA (n = 201) or SE (n = 199). The primary endpoint was hospitalization rate. Secondary endpoints were ED and hospital length of stay. Safety endpoints included cardiovascular events and radiation exposure.

Results: Mean patient age was 55 years, with 43% women and predominantly ethnic minorities (46% Hispanics, 32% African Americans). Thirty-nine coronary CTA patients (19%) and 22 SE patients (11%) were hospitalized at presentation (difference 8%; 95% confidence interval: 1% to 15%; p = 0.026). Median ED length of stay for discharged patients was 5.4 h (interquartile range [IQR]: 4.2 to 6.4 h) for coronary CTA and 4.7 h (IQR: 3.5 to 6.0 h) for SE (p < 0.001). Median hospital length of stay was 58 h (IQR: 50 to 102 h) for coronary CTA and 34 h (IQR: 31 to 54 h) for SE (p = 0.002). There were 11 and 7 major adverse cardiovascular events for coronary CTA and SE, respectively (p = 0.47), over a median 24 months of follow-up. Median/mean complete initial work-up radiation exposure was 6.5/7.7 mSv for coronary CTA and 0/0.96 mSv for SE (p < 0.001).

Conclusions: The use of SE resulted in the hospitalization of a smaller proportion of patients with a shorter length of stay than coronary CTA and was safe. SE should be considered an appropriate option for ED chest pain triage (Stress Echocardiography and Heart Computed Tomography [CT] Scan in Emergency Department Patients With Chest Pain; NCT01384448).
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http://dx.doi.org/10.1016/j.jcmg.2018.03.024DOI Listing
September 2018

Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Prior Coronary Artery Bypass Grafting: Trends in Utilization and Propensity-Matched Analysis of In-Hospital Outcomes.

Circ Cardiovasc Interv 2018 04;11(4):e006179

From the Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (T.G., C.C.T., G.W., M.J.G.); Division of Cardiology, Massachusetts General Hospital, Boston (S.K., I.I., S.E.); Division of Cardiology, Warren Alpert Medical School, Brown University, Providence, RI (D.K., H.D.A., J.D.A.,); Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (K.G., C.S.R.); Division of Cardiovascular Medicine, Case Western Reserve University School of Medicine, Cleveland, OH (A.K.); Division of Cardiology, New York University Langone Medical Center (P.A.V.); Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles, CA (G.C.F); Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX (N.S.K.); and Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.).

Background: A significant proportion of patients requiring aortic valve replacement (AVR) have undergone prior coronary artery bypass grafting (CABG). Reoperative heart surgery is associated with increased risk. Data on relative utilization and comparative outcomes of transcatheter (TAVR) versus surgical AVR (SAVR) in patients with prior CABG are limited.

Methods And Results: We queried the 2012 to 2014 National Inpatient Sample databases to identify isolated AVR hospitalizations in adults with prior CABG. In-hospital outcomes of TAVR versus SAVR were compared using propensity-matched analysis. Of 147 395 AVRs, 15 055 (10.2%) were in patients with prior CABG. The number of TAVRs in patients with prior CABG increased from 1615 in 2012 to 4400 in 2014, whereas the number of SAVRs decreased from 2285 to 1895 (<0.001). There were 3880 records in each group in the matched cohort. Compared with SAVR, TAVR was associated with similar in-hospital mortality (2.3% versus 2.4%; =0.71) but lower incidence of myocardial infarction (1.5% versus 3.4%; <0.001), stroke (1.4% versus 2.7%; <0.001), bleeding complications (10.6% versus 24.6%; <0.001), and acute kidney injury (16.2% versus 19.3%; <0.001). Requirement for prior permanent pacemaker was higher in the TAVR cohort, whereas the incidence of vascular complications and acute kidney injury requiring dialysis was similar in the 2 groups. Average length of stay was shorter in patients undergoing TAVR.

Conclusions: TAVR is being increasingly used as the preferred modality of AVR in patients with prior CABG. Compared with SAVR, TAVR is associated with similar in-hospital mortality but lower rates of in-hospital complications in this important subset of patients.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.117.006179DOI Listing
April 2018

Clip, Slip, and Grip: Impact on Left Atrial Strain.

Circ Cardiovasc Imaging 2018 03;11(3):e007491

From the Division of Cardiology, Montefiore Medical Center, Bronx, NY.

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http://dx.doi.org/10.1161/CIRCIMAGING.118.007491DOI Listing
March 2018

ACC/AATS/AHA/ASE/EACTS/HVS/SCA/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for the Treatment of Patients With Severe Aortic Stenosis: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Valve Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons.

J Am Soc Echocardiogr 2018 02 16;31(2):117-147. Epub 2017 Dec 16.

The American College of Cardiology collaborated with the American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Valve Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons to develop and evaluate Appropriate Use Criteria (AUC) for the treatment of patients with severe aortic stenosis (AS). This is the first AUC to address the topic of AS and its treatment options, including surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). A number of common patient scenarios experienced in daily practice were developed along with assumptions and definitions for those scenarios, which were all created using guidelines, clinical trial data, and expert opinion in the field of AS. The 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines(1) and its 2017 focused update paper (2) were used as the primary guiding references in developing these indications. The writing group identified 95 clinical scenarios based on patient symptoms and clinical presentation, and up to 6 potential treatment options for those patients. A separate, independent rating panel was asked to score each indication from 1 to 9, with 1-3 categorized as "Rarely Appropriate," 4-6 as "May Be Appropriate," and 7-9 as "Appropriate." After considering factors such as symptom status, left ventricular (LV) function, surgical risk, and the presence of concomitant coronary or other valve disease, the rating panel determined that either SAVR or TAVR is Appropriate in most patients with symptomatic AS at intermediate or high surgical risk; however, situations commonly arise in clinical practice in which the indications for SAVR or TAVR are less clear, including situations in which 1 form of valve replacement would appear reasonable when the other is less so, as do other circumstances in which neither intervention is the suitable treatment option. The purpose of this AUC is to provide guidance to clinicians in the care of patients with severe AS by identifying the reasonable treatment and intervention options available based on the myriad clinical scenarios with which patients present. This AUC document also serves as an educational and quality improvement tool to identify patterns of care and reduce the number of rarely appropriate interventions in clinical practice.
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http://dx.doi.org/10.1016/j.echo.2017.10.020DOI Listing
February 2018

Circumferential strain acquired by CMR early after acute myocardial infarction adds incremental predictive value to late gadolinium enhancement imaging to predict late myocardial remodeling and subsequent risk of sudden cardiac death.

J Interv Card Electrophysiol 2017 Dec 15;50(3):211-218. Epub 2017 Nov 15.

Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA.

Purpose: Late adverse myocardial remodeling after acute myocardial infarction (AMI) is strongly associated with sudden cardiac death (SCD). Cardiac magnetic resonance (CMR) performed early after AMI can predict late remodeling and SCD risk with moderate accuracy. This study assessed the ability of CMR-measured circumferential strain (CS) to add incremental predictive information to late gadolinium enhancement (LGE).

Methods: Patients with an AMI and LVEF < 50% were screened for inclusion. A total of 27 patients, totaling 432 myocardial segments, prospectively underwent CMR 7 ± 5 days after percutaneous coronary intervention (PCI). LGE, microvascular obstruction (MVO), and myocardial CS were measured for each segment. The primary endpoint was late segmental adverse remodeling defined as segmental wall motion score (WMS) > 1 measured by echocardiography 3 months after PCI.

Results: A total of 141 segments experienced the primary endpoint at 3 months. The mean LGE volume was higher in these segments, but LGE was also present in many segments with normal WMS (40 ± 28 versus 20 ± 26%, p < 0.01). Segments that met the primary endpoint also showed greater impairment of CS. Segments with both LGE > 17% and impaired CS >- 7.2% on CMR were more likely to experience late adverse remodeling (73%) as compared to segments with neither (9%, p < 0.001) or one abnormal parameter (36%, p < 0.001). CS >- 7.2% also added incremental accuracy to LGE > 17% for predicting late adverse remodeling (AUC 0.81 from 0.70, p < 0.001).

Conclusions: When performed early after AMI, LGE is a moderate predictor of late remodeling and CS is a powerful predictor of late myocardial remodeling. When combined, they can predict late remodeling, a surrogate of SCD, with high accuracy.
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http://dx.doi.org/10.1007/s10840-017-0296-9DOI Listing
December 2017

Cardiovascular outcomes of pregnancy in Marfan's syndrome patients: A literature review.

Congenit Heart Dis 2018 Mar 23;13(2):203-209. Epub 2017 Oct 23.

Montefiore Medical Center, Bronx, New York, USA.

Aims: Pregnancy in patients with Marfan's syndrome (MFS) carries an increased risk of cardiovascular complications, resulting in increased maternal and fetal mortality and morbidity. Literature on MFS pregnant patients is relatively sparse, and there has yet to be a concrete consensus on the management of this unique patient population. The purpose of our paper is to provide a literature review of case reports and studies on MFS during pregnancy (published between 2005 and 2015) and to explore cardiovascular outcomes of patients with MFS.

Methods And Results: Of the 852 women in our review, there were 1112 pregnancies, with an aortic dissection rate of 7.9% and mortality of 1.2%. Data demonstrated a trend that patients whose aortic diameter ≥40 mm had a greater rate of dissection than MFS patients whose aortic diameter <40 mm (Fisher's exact test, P = .0504). Fetal outcome included a 5.6% mortality rate and 41% of births were cesarean deliveries and of those reported, 75% secondary to cardiac emergencies.

Conclusions: Patients with MFS, especially those whose initial aortic diameters ≥40 mm, planning a pregnancy or currently pregnant should be carefully counseled about the maternal and fetal risks throughout pregnancy. MFS patients whose aortic diameters ≥40 mm should be advised to ideally await pregnancy until prophylactic aortic surgery. As MFS varies in its phenotypic expression, each patient's risk of adverse cardiac events should be assessed individually through a joint Maternal Fetal Medicine and Cardiology Center.
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http://dx.doi.org/10.1111/chd.12546DOI Listing
March 2018

Association of Chronic Kidney Disease With In-Hospital Outcomes of Transcatheter Aortic Valve Replacement.

JACC Cardiovasc Interv 2017 10;10(20):2050-2060

Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts. Electronic address:

Objectives: This study sought to determine the association of chronic kidney disease (CKD) with in-hospital outcomes of transcatheter aortic valve replacement (TAVR).

Background: CKD is a known independent risk factor for worse outcomes after surgical aortic valve replacement (SAVR). However, data on outcomes of patients with CKD undergoing TAVR are limited, especially in those on chronic dialysis.

Methods: The authors used data from the 2012 to 2014 National Inpatient Sample database to identify all patients ≥18 years of age who underwent TAVR. International Classification of Diseases-Ninth Revision-Clinical Modification codes were used to identify patients with no CKD, CKD (without chronic dialysis), or end-stage renal disease (ESRD) on long-term dialysis. Multivariable logistic regression models were constructed using generalized estimating equations to examine in-hospital outcomes.

Results: Of 41,025 patients undergoing TAVR from 2012 to 2014, 25,585 (62.4%) had no CKD, 13,750 (33.5%) had CKD, and 1,690 (4.1%) had ESRD. Compared with patients with no CKD, in-hospital mortality was significantly higher in patients with CKD or ESRD (3.8% vs. 4.5% vs. 8.3%; adjusted odds ratio [no CKD as reference]: 1.39 [95% confidence interval: 1.24 to 1.55] for CKD and 2.58 [95% confidence interval: 2.09 to 3.13] for ESRD). Patients with CKD or ESRD had a higher incidence of major adverse cardiovascular events (composite of death, myocardial infarction, or stroke), net adverse cardiovascular events (composite of major adverse cardiovascular events, major bleeding, or vascular complications), and pacemaker implantation compared with patients without CKD. Acute kidney injury (AKI) and AKI requiring dialysis were associated with several-fold higher risk-adjusted in-hospital mortality in patients in the no CKD and CKD groups. Moreover, the incidence of AKI and AKI requiring dialysis did not decline during the study period.

Conclusions: Patients with CKD or ESRD have worse in-hospital outcomes after TAVR. AKI is associated with higher in-hospital mortality in patients undergoing TAVR and the incidence of AKI has not declined over the years.
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http://dx.doi.org/10.1016/j.jcin.2017.07.044DOI Listing
October 2017

Regional Variation in Utilization, In-hospital Mortality, and Health-Care Resource Use of Transcatheter Aortic Valve Implantation in the United States.

Am J Cardiol 2017 Nov 10;120(10):1869-1876. Epub 2017 Aug 10.

Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts. Electronic address:

We queried the National Inpatient Sample database from 2012 to 2014 to identify all patients aged ≥18 years undergoing transcatheter aortic valve implantation (TAVI) in the United States. Regional differences in TAVI utilization, in-hospital mortality, and health-care resource use were analyzed. Of 41,025 TAVI procedures in the United States between 2012 and 2014, 10,390 were performed in the Northeast, 9,090 in the Midwest, 14,095 in the South, and 7,450 in the West. Overall, the number of TAVI implants per million adults increased from 24.8 in 2012 to 63.2 in 2014. The utilization of TAVI increased during the study period in all 4 geographic regions, with the number of implants per million adults being highest in the Northeast, followed by the Midwest, South, and West, respectively. Overall in-hospital mortality was 4.2%. Compared with the Northeast, risk-adjusted in-hospital mortality was higher in the Midwest (adjusted odds ratio [aOR] 1.26 [1.07 to 1.48]) and the South (aOR 1.61 [1.40 to 1.85]) and similar in the West (aOR 1.00 [0.84 to 1.18]). Average length of stay was shorter in all other regions compared with the Northeast. Among patients surviving to discharge, disposition to a skilled nursing facility or home health care was most common in the Northeast, whereas home discharge was most common in the West. Average hospital costs were highest in the West. In conclusion, we observed significant regional differences in TAVI utilization, in-hospital mortality, and health-care resource use in the United States. The findings of our study may have important policy implications and should provide an impetus to understand the source of this regional variation.
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http://dx.doi.org/10.1016/j.amjcard.2017.07.102DOI Listing
November 2017

Comparison of Predictors of Heart Failure With Preserved Versus Reduced Ejection Fraction in a Multiracial Cohort of Preclinical Left Ventricular Diastolic Dysfunction.

Am J Cardiol 2017 06 15;119(11):1815-1820. Epub 2017 Mar 15.

Division of Cardiology, Montefiore Medical Center, Bronx, New York. Electronic address:

Preclinical diastolic dysfunction (PDD) is a well-known but poorly understood risk factor for heart failure. We aimed to investigate risk factors contributing to progression of PDD to heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). Patients with echocardiogram from 2003 to 2008 with left ventricular ejection fraction ≥50%, grade I diastolic dysfunction, and free of clinical heart failure were included. The end point was incident HFpEF or HFrEF. Cumulative probabilities were estimated and multivariable adjusted Cox proportional hazards regressions were performed to examine predictors of incident HFpEF and HFrEF. In total, 7,878 patients with PDD (79.2% nonwhite) were included. At the end of follow-up (median 5.9 years), 146 patients developed HFrEF, and 635 patients developed HFpEF. The 10-year cumulative probabilities of HFrEF and HFpEF were 3.1% and 12.6%, respectively. Incidence of HFrEF was significantly lower in non-Hispanic blacks (2.2%) compared with non-Hispanic whites (4.5%). Age, diabetes, myocardial infarction, and renal disease were independent predictors of both HFrEF and HFpEF. Male gender, cerebrovascular accident, and low baseline left ventricular ejection fraction were associated with HFrEF only; whereas pulmonary disease, blood urea nitrogen, and anemia were predictors of HFpEF only. In conclusion, our results revealed a distinct set of predictors of HFrEF and HFpEF in patients with PDD and underscored a differential approach of risk stratification, prevention, and early treatment based on heart failure subtypes.
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http://dx.doi.org/10.1016/j.amjcard.2017.03.005DOI Listing
June 2017

Early Post-Operative Coronary Thrombosis Following Repair of a Proximal Coronary Artery Fistula.

J Clin Diagn Res 2016 Dec 1;10(12):OD17-OD18. Epub 2016 Dec 1.

Director, Non-invasive Cardiology, Montefiore/Einstein, Professor of Clinical Medicine, Albert Einstein College of Medicine , Bronx, New York, USA .

Patients with aneurysmal coronary artery fistulas are often a treatment challenge. We hereby, report a case of aneurysmal left main coronary artery to coronary sinus fistula repair, complicated by an early post-operative thrombosis of the left main coronary artery, necessitating an orthotropic heart transplant. Routine use of peri-procedural and long-term anti-coagulation is usually not a standard recommendation in these cases; however, early institution of the same may prevent flow stasis, thrombus formation and unfavourable outcomes pre- or post-operatively.
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http://dx.doi.org/10.7860/JCDR/2016/22368.9106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5296490PMC
December 2016

Predictors of Cardiac Rehabilitation Initiation and Adherence in a Multiracial Urban Population.

J Cardiopulm Rehabil Prev 2017 Jan;37(1):30-38

Montefiore Medical Center, Bronx, New York.

Background: Lack of initiation and adherence to cardiac rehabilitation (CR) remains a persistent problem. We sought to examine predictors of initiation, adherence, and completion of CR in a unique, minority predominant, urban population.

Methods: We included all patients who were first-time referred to the outpatient CR program at Montefiore Medical Center between 1997 and 2010. The indications for referral included acute myocardial infarction, coronary artery disease, heart failure, stable angina, and valvular heart disease. Adherence was defined as attendance of at least 18 sessions of CR, and completion was defined as attendance of 36 sessions. Multivariable logistic regression was utilized to examine the predictors of initiation, adherence, and completion of CR.

Results: A total of 590 patients were included (43.9% white and 56.1% nonwhite patients). Among 400 patients who initiated CR, 229 patients (57.3%) attended at least 18 sessions and 140 patients (35.0%) completed all sessions. Initiation of CR was less likely in patients who were nonwhite (OR = 0.66; 95% CI: 0.44-0.97; P = .04) and those who lacked insurance (OR = 0.54; 95% CI: 0.29-0.83; P = .04). Older age was associated with better adherence (OR = 1.04; 95% CI: 1.02-1.07; P < .001). Requirement of a copayment (OR = 0.57; 95% CI: 0.37-0.87; P = .01) was associated with poor adherence.

Conclusion: In a multiracial population, nonwhite patients and those who did not have insurance were less likely to initiate CR. Younger age and requirement of copayment were independent predictors for poor adherence. Increasing medical insurance coverage and eliminating copayment may improve the participation and adherence of CR.
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http://dx.doi.org/10.1097/HCR.0000000000000226DOI Listing
January 2017

A meta-analysis and meta-regression of long-term outcomes of transcatheter versus surgical aortic valve replacement for severe aortic stenosis.

Int J Cardiol 2016 Dec 6;225:234-243. Epub 2016 Oct 6.

Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic College of Medicine, Scottsdale, AZ, USA.

Background: Transcatheter aortic valve replacement (TAVR) has emerged as an alternative to surgical aortic-valve replacement (SAVR) for patients with severe symptomatic aortic stenosis (AS) who are at high operative risk. We sought to determine the long-term (≥1year follow-up) safety and efficacy TAVR compared with SAVR in patients with severe AS.

Methods: A comprehensive search of PubMed, EMBASE, Cochrane Central Register of Controlled Trials, conference proceedings, and relevant Web sites from inception through 10 April 2016.

Results: Fifty studies enrolling 44,247 patients met the inclusion criteria. The mean duration follow-up was 21.4months. No difference was found in long-term all-cause mortality (risk ratios (RR), 1.06; 95% confidence interval (CI) 0.91-1.22). There was a significant difference favoring TAVR in the incidence of stroke (RR, 0.82; 95% CI 0.71-0.94), atrial fibrillation (RR, 0.43; 95% CI 0.33-0.54), acute kidney injury (RR, 0.70; 95% CI 0.53-0.92), and major bleeding (RR, 0.57; 95% CI 0.40-0.81). TAVR had significant higher incidence of vascular complications (RR, 2.90; 95% CI 1.87-4.49), aortic regurgitation (RR, 7.00; 95% CI 5.27-9.30), and pacemaker implantation (PPM) (RR, 2.02; 95% CI 1.51-2.68). TAVR demonstrated significantly lower stroke risk compared to SAVR in high-risk patients (RR, 1.49; 95% CI 1.06-2.10); no differences in PPM implantation were observed in intermediate-risk patients (RR, 1.68; 95% CI 0.94-3.00). In a meta-regression analysis, the effect of TAVR baseline clinical features did not affect the long-term all-cause mortality outcome.

Conclusion: TAVR and SAVR showed similar long-term survival in patients with severe AS; with important differences in treatment-associated morbidity.
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http://dx.doi.org/10.1016/j.ijcard.2016.10.003DOI Listing
December 2016

Dynamic left ventricular changes in patients with gestational diabetes: A speckle tracking echocardiography study.

J Clin Ultrasound 2017 Jan 28;45(1):20-27. Epub 2016 Sep 28.

Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10467.

Purpose: The left ventricle (LV) undergoes physiologic remodeling in adaptation to the hemodynamic changes that occur in pregnancy. Speckle tracking echocardiography (STE) is a novel and reliable tool to evaluate subtle myocardial alterations that have been utilized to assess myocardial changes in patients with diabetes mellitus (DM) but not in patients with gestational DM (GDM). We seek to evaluate changes in LV function using STE in patients with GDM compared with women with normal pregnancy.

Methods: This was a single-center retrospective cohort study. A total of 312 pregnant patients that underwent transthoracic echocardiogram (TTE) between 2009 and 2014 were screened. After excluding patients with comorbidities or insufficient data, 90 women were included. TTE from the second and third trimester for each patient were then reviewed, and STE analysis was performed.

Results: Of the 90 subjects, 72 had normal pregnancies and 18 developed GDM. There was no difference in LV end-diastolic diameter (4.73 ± 0.40 versus 4.60 ± 0.56, p = 0.25), LV end-systolic diameter (3.12 ± 0.35 versus 2.91 ± 0.61, p = 0.152), or ejection fraction (62.26 ± 4.12 versus 63.50 ± 5.24, p = 0.314) between the two groups. Global longitudinal strain was lower (-19.8 ± 3.34 versus -17.2 ± 2.18, p < 0.001) in patients with GDM, while time-to-peak strain was greater (0.43 ± 0.05 versus 0.50 ± 0.06, p < 0.001). Circumferential and radial strains were preserved in both groups.

Conclusions: Although conventional TTE variables show preserved LV size and function, LV longitudinal strain suggests subclinical myocardial dysfunction in patients with GDM. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:20-27, 2017.
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http://dx.doi.org/10.1002/jcu.22399DOI Listing
January 2017

Sapien 3 versus Sapien XT prosthetic valves in transcatheter aortic valve implantation: A meta-analysis.

Int J Cardiol 2016 Oct 27;220:472-8. Epub 2016 Jun 27.

Wayne State University/Detroit Medical Center, Division of Cardiology, Detroit, MI 48226, USA.

Objectives: The S3 prosthetic valve was introduced to overcome several issues with its predecessor, the SXT, in transcatheter aortic valve implantation (TAVI), however, the clinical outcomes of this new model are not clearly defined. We performed a meta-analysis to compare the outcomes in Sapien 3 (S3) and Sapien XT (SXT) recipients.

Methods: A literature search through PUBMED and EMBASE was conducted. Articles that included at least one of the clinical outcomes of interest were included in the meta-analysis: moderate to severe paravalvular regurgitation (PVR), permanent pacemaker implantation (PPI), major vascular complications (MVC), cerebrovascular events (stroke and transient ischemic attack) (CVE), failure rate of device implantation, life-threatening, disabling or major bleeding, need for post-dilation and early all-cause-mortality.

Results: A total of 9 observational cohort studies were included. S3 was implanted in 945 and SXT in 1553 patients. S3 was associated with a lower incidence of moderate to severe PVR (1.6% vs 6.9%, p<0.0001), lower MVC (5.1% vs 8.9%, p=0.01) and less serious bleeding (8.1% vs 15.2%, p=0.003) compared to the SXT. Device deployment failure rate was lower in the S3 (1.2% vs 5.9%, p=0.004) and the S3 required less post-dilation (16.9% vs 26.9%, p=0.05). Rates of CVE, perioperative mortality and PPI were similar between the two valves.

Conclusions: Implantation of the S3 prosthetic valve results in lower rates of moderate to severe PVR, MVC, post-dilation and serious bleeding however it does not improve on the SXT in terms of CVE, PPI and early mortality.
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http://dx.doi.org/10.1016/j.ijcard.2016.06.159DOI Listing
October 2016

Iatrogenic Ventricular Septal Defect Following Transcatheter Aortic Valve Replacement: A Systematic Review.

Heart Lung Circ 2016 Oct 22;25(10):968-74. Epub 2016 Apr 22.

Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.

Background: Ventricular septal defects (VSD) are rarely reported as a complication following transcatheter aortic valve replacement (TAVR). We sought to characterise the patients, clinical management, and outcomes regarding this rare phenomenon.

Methods: Relevant articles were identified by a systematic search of MEDLINE and EMBASE databases from January, 2002 to September, 2015.

Results: A total of 18 case reports, including 20 patients, were identified. The median age was 83 years and six were male. Twelve were performed by trans-femoral approach. Pre-dilation was performed in 12 patients and post-dilation in four. Balloon expandable valves were used in the majority (85%) of cases. The clinical presentation varied from asymptomatic to progressive heart failure. The timing of the diagnosis also varied significantly from immediately post valve implantation to one year afterwards. There were two cases of Gerbode-type defect while the rest were inter-ventricular defects. The location was mostly membranous or perimembranous (79%) and adjacent to the valve landing zone. A total of seven interventions (one open surgery and six percutaneous closure) were performed. Four patients died during the same hospital admission. Sixteen survived past discharge (range 12 days to two years).

Conclusions: Ventricular septal defects post-TAVR were seen more with balloon expandable valves and with pre-dilation or post-dilation. Percutaneous treatment of the VSD was preferred over open cardiac surgery given the high surgical risk in this patient population. Some, but not all, patients survived TAVR and VSD and had a good prognosis for both patient groups with or without VSD closure.
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http://dx.doi.org/10.1016/j.hlc.2016.03.012DOI Listing
October 2016

Ventricular septal rupture complicating acute myocardial infarction in the modern era with mechanical circulatory support: a single center observational study.

Am J Cardiovasc Dis 2016 1;6(1):10-6. Epub 2016 Mar 1.

Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine Bronx, NY, USA.

Ventricular septal rupture (VSR) is a rare but devastating complication after acute myocardial infarction (AMI). While the incidence has decreased, the mortality rate from VSR has remained extremely high. The use of mechanical circulatory support with intra-aortic balloon pump (IABP) and extracorporal membrane oxygenation (ECMO) may be useful in providing hemodynamic stability and time for myocardial scarring. However, the optimal timing for surgical repair remains an enigma. Retrospective analysis of 14 consecutive patients diagnosed with VSR after AMI at Montefiore Medical Center between January 2009 and June 2015. A chart review was performed with analysis of baseline characteristics, hemodynamics, imaging, percutaneous interventions, surgical timing, and outcomes. The survival group had a higher systolic BP (145 vs 98, p<0.01), higher MAP (96 vs 76, p=0.03), and lower HR (75 vs 104, p=0.05). Overall surgical timing was 6.5 ± 3.7 days after indexed myocardial infarction with a significant difference between survivors and non-survivors (9.8 vs 4.3, p=0.01). The number of pre-operative days using IABP was longer in survivors (6.5 vs 3.2, p=0.36) as was post-operative ECMO use (4.5 vs 2 days, p=0.35). The overall 30-day mortality was 71.4% with a 60% surgical mortality rate. Hemodynamics at the time of presentation and a delayed surgical approach of at least 9 days showed significant association with improved survival. Percutaneous coronary intervention (PCI) was more common in non-survivors. The use of IABP in the pre-operative period and post-operative ECMO use likely provide a survival benefit.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4788724PMC
April 2016

Spontaneous Echocardiographic Contrast in the Left Atrium During Transcatheter Aortic Valve Replacement is Associated With Worse Outcomes.

J Invasive Cardiol 2016 Apr;28(4):152-7

Department of Internal Medicine, Mount Sinai Beth Israel, 1st avenue and 16th Street, New York, NY 10003 USA.

Objectives: Patients undergoing transcatheter aortic valve replacement (TAVR) often have spontaneous echocardiographic contrast (SEC) observed in the left atrium (LA). Mid-term prognosis of patients with SEC following TAVR is not well studied. We assessed the impact of SEC on outcomes after TAVR.

Methods: Medical records of 93 consecutive patients who underwent TAVR at a single center were reviewed retrospectively. The primary endpoint was defined as the composite of a cardioembolic event, death from any cause, and admission for decompensated heart failure within 3 months of TAVR.

Results: After excluding 3 patients who had procedural complications, 90 patients were included in the study. The mean age was 81 ± 8 years old and 50% were male. There were 12 patients with SEC in the LA (group 1) and 78 patients without SEC in the LA (group 2) during the TAVR procedure. Atrial fibrillation was more common in group 1 (50% vs 13%, respectively; P=.01) and diabetes was more common in group 2 (17% vs 53%, respectively; P=.03). The primary endpoint occurred in 22 patients (24%) and occurred more in group 1 (58% vs 19%, respectively; P<.01). On regression analysis, after adjusting for sex and STS score, SEC had a hazard ratio (HR) of 5.02 (95% confidence interval [CI], 1.96-12.9; P<.001) and STS ≥15 had an HR of 6.37 (95% CI, 2.02-20.1; P=.01). On survival analysis, group 1 had lower event-free survival compared with group 2 (log-rank P=.01).

Conclusion: SEC during TAVR procedure is a negative prognostic marker for death, cardioembolic events, or admission for decompensated heart failure in the first 3 months post procedure.
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April 2016

Impact of transcatheter aortic valve implantation on left atrial appendage flow velocities.

J Clin Ultrasound 2016 Jul 15;44(6):375-82. Epub 2016 Feb 15.

Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10467.

Purpose: Left atrial appendage (LAA) flow velocity has not been extensively studied in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to assess the impact of TAVI on LAA flow velocity.

Methods: Medical records of consecutive TAVI recipients were reviewed retrospectively. Patients with persistent atrial fibrillation were excluded. LAA velocities were measured before and after TAVI by transesophageal echocardiography.

Results: Sixty-one patients were included. Mean LAA emptying (EV) and filling (FV) flow velocity before TAVI were 33 ± 16 cm/s and 31 ± 14 cm/s, respectively. They increased to 37 ± 20 (p = 0.0036) and 33 ± 13 cm/s (p = 0.047) after TAVI in the whole population sample, but not in patients with normal flow AS. In low-flow, low-gradient (LFLG) AS patients, EV and FV increased from 36 ± 22 to 47 ± 30 cm/s (p < 0.01), and from 29 ± 12 to 40 ± 15 cm/s (p < 0.01), respectively, after TAVI. There was no difference between normal flow and LFLG AS patients in the number of patients who achieved EV ≥ 40 cm/s post-TAVI (35% versus 47%, p = 0.54, respectively).

Conclusions: LAA EV and FV were low prior to TAVI and increased significantly after TAVI only in patients with LFLG AS. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:375-382, 2016.
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http://dx.doi.org/10.1002/jcu.22347DOI Listing
July 2016

Mechanical valve obstruction: Review of diagnostic and treatment strategies.

World J Cardiol 2015 Dec;7(12):875-81

Jason Salamon, Jerson Munoz-Mendoza, Cynthia C Taub, Department of Cardiology, Montefiore Medical Center, Bronx, NY 10467, United States.

Prosthetic valve obstruction (PVO) is a rare but feared complication of mechanical valve replacement. Diagnostic evaluation should focus on differentiating prosthetic valve thrombosis (PVT) from pannus formation, as their treatment options differ. History of sub-optimal anti-coagulation and post-op time course to development of PVO are useful clinical characteristics in differentiating thrombus from pannus formation. Treatment of PVT is influenced by the patient's symptoms, valve location, degree of obstruction and thrombus size and may include thrombolysis or surgical intervention. Alternatively, pannus formation requires surgical intervention. The purpose of this article is to review the pathophysiology, epidemiology, diagnostic approach and treatment options for aortic and mitral valve PVO.
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http://dx.doi.org/10.4330/wjc.v7.i12.875DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4691813PMC
December 2015

Aortocavitary fistula as a complication of infective endocarditis and subsequent complete heart block in a patient with severe anemia.

J Community Hosp Intern Med Perspect 2015 11;5(6):29446. Epub 2015 Dec 11.

Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.

Infective endocarditis has different presentations depending on the involvement of valvular and perivalvular structures, and it is associated with high morbidity and mortality. Aortocavitary fistula is a rare complication. We introduce the case of a 48-year-old female with native valve endocarditis, complicated by aortocavitary fistula to the right atrium, and consequently presented with syncope.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4677595PMC
http://dx.doi.org/10.3402/jchimp.v5.29446DOI Listing
December 2015

Inferolateral ST-segment Elevation in Boerhaave Syndrome.

Am J Med 2016 Mar 18;129(3):e27-8. Epub 2015 Nov 18.

Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY. Electronic address:

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http://dx.doi.org/10.1016/j.amjmed.2015.09.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4799847PMC
March 2016

The Reply.

Am J Med 2015 Dec;128(12):e39

Department of Medicine, Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.

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http://dx.doi.org/10.1016/j.amjmed.2015.07.037DOI Listing
December 2015