Publications by authors named "Daniel M Spevack"

59 Publications

Variations in Mitral Valve Leaflet and Scallop Anatomy on Three-Dimensional Transesophageal Echocardiography.

J Am Soc Echocardiogr 2021 Jul 24. Epub 2021 Jul 24.

Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, New York. Electronic address:

Background: Textbook depictions of the mitral valve (MV) often illustrate it as composed of a single nonscalloped anterior leaflet, with the posterior leaflet having three symmetric and evenly spaced scallops. However, common variations in this anatomy have been noted in autopsy series for decades. Improved cardiac imaging with three-dimensional transesophageal echocardiography (TEE) now affords the ability to detect variations in scallop anatomy in vivo. The aims of this study were to catalog variations in mitral anatomy and to examine for association with mitral regurgitation in patients referred for clinical three-dimensional TEE.

Methods: Three-dimensional transesophageal echocardiographic images of the MV from 107 subjects were reviewed for MV variations. Three-dimensional analysis software was used to characterize mitral leaflet anatomy and assess the relative sizes of posterior leaflet scallops.

Results: Variations from the classic MV configuration were seen in 58.9%. Symmetric variations in the posterior leaflet (dominant P2 scallop, accessory P2 scallop, absent P2 scallop, and dichotomous P2 scallop) were seen in 33.6% of the study group. Asymmetric variants in the posterior leaflet (fused P1 and P2, fused P2 and P3, commissural scallop, accessory scallops, dichotomous P1 or P3, and dominant P2 or P3) were seen in 24.3%. Indentations or folds in the anterior leaflet were noted in 5.6%. Leaflet variations were not associated with patient demographics, indication for TEE, mitral regurgitation, mitral annular dimensions, or Carpentier class.

Conclusions: Mitral leaflet morphologic variants were well characterized using three-dimensional TEE. Variants are common and were present with a frequency consistent with autopsy series. Mitral scallop variations were not associated with mitral regurgitation.
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http://dx.doi.org/10.1016/j.echo.2021.07.010DOI Listing
July 2021

Comparison of Surgical Embolectomy and Veno-arterial Extracorporeal Membrane Oxygenation for Massive Pulmonary Embolism.

Semin Thorac Cardiovasc Surg 2021 Jun 19. Epub 2021 Jun 19.

Section of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York.

Massive pulmonary embolism (MPE) is associated with a 20-50% mortality rate with guideline directed therapy. MPE treatment with surgical embolectomy (SE) or venoarterial extracorporeal membrane oxygenation (VA-ECMO) have shown promising results. In the context of a surgical management strategy for MPE, a comparison of outcomes associated with VA-ECMO or SE was performed. A retrospective review of a single institution cardiac surgery database was performed, identifying MPE treated with SE or VA-ECMO between 2005-2020. Primary outcome was in-hospital survival. 59 MPE [27 (46.8%) VA-ECMO vs 32 (54.2%) SE] were identified. All presented with elevated cardiac biomarkers, tachycardia (mean heart rate 113 ± 20 beats/minute), hypotension (mean systolic blood pressure 85 ± 22 mm Hg) and vasopressors requirement, without significant differences between cohorts. Preoperative CPR was performed in 37.3% (22/59), without a significant difference between cohorts. More VA-ECMO presented with questionable neurologic status (GCS ≤ 4) [9/27 (33.3%) vs 2/32 (6.2%), P = 0.008] and more VA-ECMO failed thrombolysis [8/27 (29.6) vs 2/32 (6.3), P = 0.014]. All presented with severe RV dysfunction, by discharge all had normalization of echocardiographic RV function. Overall mortality was 10.2%, with a trend toward higher mortality among VA-ECMO [14.9% (4/27) vs 6.3% (2/32) P = 0.14]. CPR was independently associated with death (OR 10.8, P = 0.02) whereas treatment modality was not (OR 0.24). In an extremely unstable MPE population VA-ECMO and SE were safely performed with low mortality while achieving RV recovery. Adverse outcomes were more closely associated with preoperative CPR than with treatment modality.
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http://dx.doi.org/10.1053/j.semtcvs.2021.06.011DOI Listing
June 2021

Pacing at accelerated heart rate during echocardiography-guided atrioventricular optimisation following cardiac resynchronisation therapy.

Arch Med Sci Atheroscler Dis 2020 10;5:e230-e236. Epub 2020 Sep 10.

Department of Cardiology, Westchester Medical Centre and New York Medical College, Valhalla, New York, USA.

Introduction: Although echo-guided atrioventricular optimisation (AVO) is standardly performed at rest, this approach may not provide optimal AV synchrony during daily activities.

Material And Methods: The AVO protocol at one of two hospital campuses had been modified to be performed while pacing at an accelerated heart rate. We tested if this approach would improve the yield from AVO compared to the other campus, where AVO was performed at the intrinsic sinus rate.

Results: Between campuses, no significant differences were seen in demographics, chamber sizes, left ventricular ejection fraction, and diastolic function grade. Those having AVO at C2 were more likely to demonstrate "fusion prone" physiology (36% vs. 9%; = 0.006) and were more likely to display either "truncation- or fusion-prone" physiology (58% vs. 27%; = 0.007).

Conclusions: When AVO was performed at an accelerated heart rate, patients with "truncation-prone" or "fusion-prone" physiology were identified more readily.
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http://dx.doi.org/10.5114/amsad.2020.98928DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717446PMC
September 2020

Mechanistic validation of the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging Guidelines for the assessment of diastolic dysfunction in heart failure with reduced ejection fraction.

Cardiovasc Ultrasound 2020 Oct 16;18(1):42. Epub 2020 Oct 16.

Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden.

Background: The American Society for Echocardiography/European Association of Cardiovascular Imaging (ASE/EACVI) 2016 guidelines for assessment of diastolic dysfunction (DD) are based primarily on the effects of diastolic dysfunction on left ventricular filling hemodynamics. However, these measures do not provide quantifiable mechanistic information about diastolic function. The Parameterized Diastolic Filling (PDF) formalism is a validated theoretical framework that describes DD in terms of the physical properties of left ventricular filling.

Aims: We hypothesized that PDF analysis can provide mechanistic insight into the mechanical properties governing higher grade DD.

Methods: Patients referred for echocardiography showing reduced left ventricular ejection fraction (< 45%) were prospectively classified into DD grade according to 2016 ASE/EACVI guidelines. Serial E-waves acquired during free breathing using pulsed wave Doppler of transmitral blood flow were analyzed using the PDF formalism.

Results: Higher DD grade (grade 2 or 3, n = 20 vs grade 1, n = 30) was associated with increased chamber stiffness (261 ± 71 vs 169 ± 61 g/s, p < 0.001), increased filling energy (2.0 ± 0.9 vs 1.0 ± 0.5 mJ, p < 0.001) and greater peak forces resisting filling (median [interquartile range], 18 [15-24] vs 11 [8-14] mN, p < 0.001). DD grade was unrelated to chamber viscoelasticity (21 ± 4 vs 20 ± 6 g/s, p = 0.32). Stiffness was inversely correlated with ejection fraction (r = - 0.39, p = 0.005).

Conclusions: Higher grade DD was associated with changes in the mechanical properties that determine the physics of poorer left ventricular filling. These findings provide mechanistic insight into, and independent validation of the appropriateness of the 2016 guidelines for assessment of DD.
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http://dx.doi.org/10.1186/s12947-020-00224-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7568361PMC
October 2020

Survival and Right Ventricular Function After Surgical Management of Acute Pulmonary Embolism.

J Am Coll Cardiol 2020 08;76(8):903-911

Division of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York.

Background: Acute pulmonary embolism (PE) is associated with high morbidity and mortality because of right ventricular (RV) failure. There is evidence suggesting surgical therapy (surgical embolectomy or venoarterial extracorporeal membrane oxygenation [ECMO]) is safe and effective.

Objectives: The aim of this study was to assess the safety and efficacy of surgical management of acute PE.

Methods: Surgical embolectomy and/or venoarterial ECMO were compared, between 2005 and 2019, for massive PE (MPE) versus high-risk submassive PE (SMPE). RV recovery was defined as improvements in central venous pressure, pulmonary artery systolic pressure, RV/left ventricular ratio, and RV fractional area change.

Results: One hundred thirty-six patients with PE (92 with SMPE and 44 with MPE) were identified. Patients with MPE more often presented with syncope (59.1% [26 of 44] vs. 25.0% [23 of 92]; p = 0.0003), Glasgow Coma Scale score ≤4 (22.7% [10 of 44] vs. 0% [0 of 92]), and failed thrombolysis (18.2% [8 of 44] vs. 4.3% [3 of 92]; p = 0.008). Pre-operative cardiopulmonary resuscitation occurred in 43.2% of patients with MPE (19 of 44). Most patients with SMPE were treated with embolectomy (98.9% [91 of 92]), while ECMO was used more in those with MPE (ECMO in 40.9% [18 of 44], embolectomy in 59.1% [26 of 44]). RV function improved as measured by central venous pressure (from 23.4 ± 4.9 to 10.5 ± 3.1 mm Hg), pulmonary artery systolic pressure (from 60.6 ± 14.2 to 33.8 ± 10.7 mm Hg), RV/left ventricular ratio (from 1.19 ± 0.33 to 0.87 ± 0.23; p < 0.005), and fractional area change (from 26.8 to 41.0; p < 0.005). Mortality was 4.4% (6 of 136; SMPE, 1.1% [1 of 92]; MPE, 11.6% [5 of 44]). Subgroup analysis showed morbidity and mortality were highly associated with pre-operative cardiopulmonary resuscitation.

Conclusions: Surgical management of patients with MPE and high-risk SMPE is safe and highly effective at achieving RV recovery.
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http://dx.doi.org/10.1016/j.jacc.2020.06.065DOI Listing
August 2020

Treatment of Peripheral Pulmonary Artery Stenosis.

Cardiol Rev 2021 May-Jun 01;29(3):115-119

From the Department of Medicine, Cardiology Division, New York Medical College, Westchester Medical Center, Valhalla, NY.

Peripheral pulmonary artery stenosis (PAS) is an abnormal narrowing of the pulmonary vasculature and can form anywhere within the pulmonary artery tree. PAS is a congenital or an acquired disease, and its severity depends on the etiology, location, and number of stenoses. Most often seen in infants and young children, some symptoms include shortness of breath, fatigue, and tachycardia. Symptoms can progressively worsen over time as right ventricular pressure increases, leading to further complications including pulmonary artery hypertension and systolic and diastolic dysfunctions. The current treatment options for PAS include simple balloon angioplasty, cutting balloon angioplasty, and stent placement. Simple balloon angioplasty is the most basic therapeutic option for proximally located PAS. Cutting balloon angioplasty is utilized for more dilation-resistant PAS vessels and for more distally located PAS. Stent placement is the most effective option seen to treat the majority of PAS; however, it requires multiple re-interventions for serial dilations and is generally reserved for PAS vessels that are resistant to angioplasty.
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http://dx.doi.org/10.1097/CRD.0000000000000300DOI Listing
February 2020

Heightened risk of cardiac events following percutaneous coronary intervention for cocaine-associated myocardial infarction.

Arch Med Sci 2020 31;16(1):66-70. Epub 2019 Dec 31.

Division of Cardiology, Department of Medicine, Westchester Medical Centre, New York Medical College, Valhalla, New York, USA.

Introduction: Several works have suggested heightened risk for cardiac events in cocaine users following percutaneous coronary intervention (PCI). Such studies have generally been performed in small, poorly defined samples and have not utilised optimal control groups. We aimed to define the short-term risk for death or recurrent myocardial infarction (MI) when PCI was performed for myocardial infarction in subjects presenting with urine toxicology positive for cocaine in relation to subjects testing negative for cocaine use.

Material And Methods: Our institutional electronic health record (EHR) was queried for all subjects with urine toxicology performed for cocaine exposure within 5 days before or after having elevated troponin-T assay between 1/1/08 and 12/31/13. Query results were cross-referenced with our institutional cardiology database to identify the sample who had PCI on the same admission as the cocaine test. Subsequent readmission for MI was assessed from the EHR, and deaths were identified from the National Death Index.

Results: PCI had been performed in 380 subjects who tested negative for cocaine and 44 subjects who tested positive. In the cocaine-positive group, incidences of death or MI at 30 days and 1 year were 18% and 23%, respectively. Those who tested positive for cocaine had increased odds (odds ratio (OR) = 2.3, 95% confidence interval (CI): 1.0-5.1, = 0.04) for death or MI at 30 days post PCI, after adjustment for age, sex, prior MI, and comorbidity index. Although the odds for events 1-year post PCI were not increased (OR = 2.0, 95% CI: 0.9-4.3), the -value approached significance in this small sample ( = 0.09).

Conclusions: This retrospective study suggests that PCI performed in cocaine-associated myocardial infarction comes with a high 30-day and one-year risk. Further prospective studies are needed to better define this risk and to lend insight into better management strategies.
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http://dx.doi.org/10.5114/aoms.2020.91287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6963151PMC
December 2019

Pulmonary Artery Denervation as an Innovative Treatment for Pulmonary Hypertension With and Without Heart Failure.

Cardiol Rev 2021 Mar-Apr 01;29(2):89-95

From the Department of Medicine, Cardiology Division, Westchester Medical Center and New York Medical College, Valhalla, NY.

Pulmonary hypertension (PH) is categorized into 5 groups based on etiology. The 2 most prevalent forms are pulmonary arterial hypertension (PAH) and PH due to left heart disease (PH-LHD). Therapeutic options do exist for PAH to decrease symptoms and improve functional capacity; however, the mortality rate remains high and clinical improvements are limited. PH-LHD is the most common cause of PH; however, no treatment exists and the use of PAH-therapies is discouraged. Pulmonary artery denervation (PADN) is an innovative catheter-based ablation technique targeting the afferent and efferent fibers of a baroreceptor reflex in the main pulmonary artery (PA) trunk and its bifurcation. This reflex is involved in the elevation of the PA pressure seen in PH. Since 2013, both animal trials and human trials have shown the efficacy of PADN in improving PAH, including improved hemodynamic parameters, increased functional capacity, decreased PA remodeling, and much more. PADN has been shown to decrease the rate of rehospitalization, PH-related complications, and death, and is an overall safe procedure. PADN has also been shown to be effective for PH-LHD. Additional therapeutic mechanisms and benefits of PADN are discussed along with new PADN techniques. PADN has shown efficacy and safety as a potential treatment option for PH.
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http://dx.doi.org/10.1097/CRD.0000000000000299DOI Listing
February 2020

The left ventricular ejection fraction: new insights into an old parameter.

Hosp Pract (1995) 2019 Dec 10;47(5):221-230. Epub 2019 Nov 10.

Cardiology Division, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA.

Accurate evaluation of cardiac function has become increasingly important as the treatment of cardiac disease has become more complex. At the same time, technological advances allow greater accuracy and precision in cardiac measurements. Measurement of left ventricular ejection fraction (LVEF) has been a pillar of cardiac evaluation. Several noninvasive modalities are available to assess LVEF; each has advantages and limitations. This review examines various modalities used to measure LVEF and focuses on the relative strengths and weaknesses of each modality. In some clinical settings, however, LVEF may be too insensitive to convey subtle changes in LV contractility. In certain clinical situations, use of LVEF may be an insufficient measure of left ventricular systolic function. Global longitudinal strain is one such parameter that has shown promise for detecting subtle reductions in left ventricular contractility in subjects with chemotherapy-induced cardiotoxicity.
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http://dx.doi.org/10.1080/21548331.2019.1687247DOI Listing
December 2019

Severely blunted early heart rate response during treadmill exercise is associated with above average exercise capacity.

Arch Med Sci Atheroscler Dis 2019 18;4:e167-e173. Epub 2019 Jul 18.

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

Introduction: Chronotropic response with exercise is evaluated by peak heart rate (HR) achieved. Since most of the exercise-related chronotropic response occurs early after exercise is initiated, we investigated whether the HR achieved with a standard dose of exercise (Bruce stage 2) is associated with exercise capacity. We hypothesized that those with a blunted or disproportionate HR response at this exercise dose would have reduced exercise capacity compared to those with a typical HR response.

Material And Methods: We reviewed 3,084 consecutive normal maximal treadmill stress echocardiographic reports acquired from individual adults over a 1.5-year period. We examined for association between stage 2 Bruce HR with age and sex-adjusted exercise capacity.

Results: After adjustment for age and sex, Bruce stage 2 HR was inversely associated (β = -0.08, < 0.01) with exercise duration. Thus for every additional 10 beats per minute achieved in stage 2, exercise duration was generally shortened by about 45 s. Most of the subjects (92%) who had a stage 2 Bruce HR response below the 10th percentile had above average or average exercise capacity for their age and sex.

Conclusions: Lower Bruce stage 2 HR was associated with increased exercise capacity. Severely blunted HR response was associated with above average exercise capacity. Caution should therefore be exercised in attributing exercise intolerance to a blunted HR response when making a diagnosis of chronotropic incompetence.
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http://dx.doi.org/10.5114/amsad.2019.86758DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6704761PMC
July 2019

Prevalence of myocardial infarction with non-obstructive coronary arteries (MINOCA) amongst acute coronary syndrome in patients with antiphospholipid syndrome.

Int J Cardiol Heart Vasc 2019 Mar 1;22:148-149. Epub 2019 Feb 1.

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

Antiphospholipid antibody syndrome (APLS) is well known to cause thrombotic events and premature atherosclerosis leading to coronary artery occlusion. The association of non-thrombotic acute myocardial infarctions (AMI) with APLS is not as clearly delineated. The objective of this study was to determine the relative prevalence of myocardial infarction with non obstructive coronary arteries (MINOCA) compared to MI from vaso-occlusive disease amongst patients with known APLS at our institution. Out of 575 patients with positive antiphospholipid antibodies, cardiac catheterizations were performed in 40 patients presented with AMI and had cardiac catheterizations. MINOCA was found in 8 patients. We found that MINOCA is common in patients with APLS presenting with ACS and that spasm may also play a role in AMI in patients with APLS.
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http://dx.doi.org/10.1016/j.ijcha.2018.12.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6360345PMC
March 2019

Cardiac structure and function with and without metabolic syndrome: the Echocardiographic Study of Latinos (Echo-SOL).

BMJ Open Diabetes Res Care 2018 13;6(1):e000484. Epub 2018 Aug 13.

Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.

Objective: We assessed the hypothesis that metabolic syndrome is associated with adverse changes in cardiac structure and function in participants of the Echocardiographic Study of Latinos (Echo-SOL).

Methods: Non-diabetic Echo-SOL participants were included in this cross-sectional analysis. Metabolic syndrome was defined according to the American Heart Association/National Heart, Lung, and Blood Institute 2009 Joint Scientific Statement. Survey multivariable linear regression analyses using sampling weights were used adjusting for multiple potential confounding variables. Additional analysis was stratified according to the presence/absence of obesity (body mass index (BMI) ≥25 kg/m) and the presence/absence of metabolic syndrome.

Results: Within Echo-SOL, 1260 individuals met inclusion criteria (59% female; mean age 55.2 years). Compared with individuals without metabolic syndrome, those with metabolic syndrome had lower medial and lateral E' velocities (-0.4 cm/s, (SE 0.1), p=0.0002; -0.5 cm/s (0.2), p=0.02, respectively), greater E/E' (0.5(0.2), p=0.01) and worse two-chamber left ventricular longitudinal strain (0.9%(0.3), p=0.009), after adjusting for potential confounding variables. Increased left ventricular mass index (9.8 g/m (1.9), p<0.0001 and 7.5 g/m (1.7), p<0.0001), left ventricular end-diastolic volume (11.1 mL (3.0), p=0.0003 and 13.3 mL (2.7), p<0.0001), left ventricular end-systolic volume (5.0 mL (1.4), p=0.0004 and 5.7 mL (1.3) p<0.0001) and left ventricular stroke volume (10.2 mL (1.8), p<0.0001 and 13.0 mL (2.0), p<0.0001) were observed in obese individuals with and without metabolic syndrome compared with individuals with normal weight without metabolic syndrome. In sensitivity analyses, individuals with normal weight (BMI <25 kg/m) and metabolic syndrome had worse left ventricular global longitudinal strain (2.1%(0.7), p=0.002) and reduced left ventricular ejection fraction (-3.5%(1.4), p=0.007) compared with normal-weight individuals without metabolic syndrome.

Conclusions: In a sample of US Hispanics/Latinos metabolic syndrome was associated with worse left ventricular systolic and diastolic function. Adverse changes in left ventricular size and function were observed in obese individuals with and without metabolic syndrome but decreased left ventricular function was also present in normal-weight individuals with metabolic syndrome.
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http://dx.doi.org/10.1136/bmjdrc-2017-000484DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6091897PMC
August 2018

Association of Transthoracic Echocardiography Findings and Long-Term Outcomes in Patients Undergoing Workup of Stroke.

J Stroke Cerebrovasc Dis 2018 Nov 30;27(11):2943-2950. Epub 2018 Jul 30.

Department of Medicine, Montefiore Medical Center-Albert Einstein College of Medicine, Bronx, New York.

Background: Transthoracic echocardiography (TTE) has become routine as part of initial stroke workup to assess for sources of emboli. Few studies have looked at other TTE findings such as ejection fraction, wall motion abnormalities, valve disease, pulmonary hypertension and left ventricular hypertrophy and their association with various subtypes of stroke, long-term outcomes of recurrent stroke, and all-cause mortality.

Methods And Results: Computed tomography and magnetic resonance imaging brain imaging and TTE reports were reviewed for 2464 consecutive patients referred for TTE as part of a workup for acute stroke between 1/1/01 and 9/30/07. Study patients were 67 ± 15years, 60% female, 75% minorities and had hypertension (76%), diabetes (41%), chronic kidney disease (27%) and atrial fibrillation (18%). On TTE, a mass, thrombus, or vegetation was identified in only 4 cases (0.2%), whereas a clinically significant abnormality (ejection fraction < 50%, left ventricle or right ventricle wall motion abnormalities, severe valve disease, pulmonary hypertension, or left ventricular hypertrophy) was identified in 16%. Those with an abnormal TTE had increased risk for death at 10years (hazard ratio [HR] 1.8; 95% confidence interval [CI]: 1.6, 2.0; P < .01), although risk for readmission with stroke was not increased. Abnormal TTE remained associated with increased risk of death at 10years after adjustment for age, sex, race, and cardiovascular risk factors (HR 1.4; 95% CI: 1.2, 1.7; P < .01).

Conclusions: TTE performed as part of an initial workup for stroke had minimal yield for identifying sources of embolism. Clinically important abnormalities found on TTE were independently associated with increased long-term mortality, but not recurrent stroke.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2018.06.023DOI Listing
November 2018

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

Clinical Course of Sarcoidosis in World Trade Center-Exposed Firefighters.

Chest 2018 01 21;153(1):114-123. Epub 2017 Oct 21.

Bureau of Health Services, Fire Department of the City of New York, Brooklyn, NY; Pulmonary Division, Department of Medicine, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY. Electronic address:

Background: Sarcoidosis is believed to represent a genetically primed, abnormal immune response to an antigen exposure or inflammatory trigger, with both genetic and environmental factors playing a role in disease onset and phenotypic expression. In a population of firefighters with post-World Trade Center (WTC) 9/11/2001 (9/11) sarcoidosis, we have a unique opportunity to describe the clinical course of incident sarcoidosis during the 15 years postexposure and, on average, 8 years following diagnosis.

Methods: Among the WTC-exposed cohort, 74 firefighters with post-9/11 sarcoidosis were identified through medical records review. A total of 59 were enrolled in follow-up studies. For each participant, the World Association of Sarcoidosis and Other Granulomatous Diseases organ assessment tool was used to categorize the sarcoidosis involvement of each organ system at time of diagnosis and at follow-up.

Results: The incidence of sarcoidosis post-9/11 was 25 per 100,000. Radiographic resolution of intrathoracic involvement occurred in 24 (45%) subjects. Lung function for nearly all subjects was within normal limits. Extrathoracic involvement increased, most prominently joints (15%) and cardiac (16%) involvement. There was no evidence of calcium dysmetabolism. Few subjects had ocular (5%) or skin (2%) involvement, and none had beryllium sensitization. Most (76%) subjects did not receive any treatment.

Conclusions: Extrathoracic disease was more prevalent in WTC-related sarcoidosis than reported for patients with sarcoidosis without WTC exposure or for other exposure-related granulomatous diseases (beryllium disease and hypersensitivity pneumonitis). Cardiac involvement would have been missed if evaluation stopped after ECG, 48-h recordings, and echocardiogram. Our results also support the need for advanced cardiac screening in asymptomatic patients with strenuous, stressful, public safety occupations, given the potential fatality of a missed diagnosis.
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http://dx.doi.org/10.1016/j.chest.2017.10.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026251PMC
January 2018

Does ischemic burden on stress testing influence patient survival in subjects with known severe multi-vessel CAD?

Am J Cardiovasc Dis 2017 15;7(2):48-52. Epub 2017 Apr 15.

Montefiore Medical Center/Albert Einstein College of MedicineBronx, NY, USA.

Background: Ischemic burden observed during stress testing has been postulated to predict prognosis irrespective of anatomic atherosclerotic burden observed on angiography. However, it is not known if the stress test result influences the long-term prognosis of subjects with diffuse coronary artery disease. We sought to determine the prognostic importance of stress test false negativity amongst patients with severe multi-vessel coronary artery disease (CAD) undergoing stress testing in the previous decade.

Methods: We selected subjects from the dates of 1/1/2000 to 12/31/2005 who underwent a nuclear stress test (MPI) or stress echocardiogram (SE) within six months of a coronary angiogram demonstrating severe, multi-vessel CAD. We excluded those with a prior MI, PCI, CABG, resting wall motion abnormality, or perfusion defect at rest. Determination of patient death during the followup period was performed using the U.S. social security index.

Results: 139 subjects (MPI 81, SE 58) were studied; stress tests were positive for ischemia in 80%. Rates of death were similar at 1 year (MPI 9%, SE 5%, -value 0.44), 5 years (MPI 20%, SE 14%, -value 0.36) and 10 years (MPI 30%, SE 26%, -value 0.63). Using multivariate analysis, mortality at each time period was not affected by stress test positivity.

Conclusion: Amongst subjects with diffuse and severe atherosclerosis with preserved ventricular function, ischemic burden on stress testing did not influence short or long-term survival.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5435604PMC
April 2017

Comparison of Echocardiographic Measures in a Hispanic/Latino Population With the 2005 and 2015 American Society of Echocardiography Reference Limits (The Echocardiographic Study of Latinos).

Circ Cardiovasc Imaging 2016 Jan;9(1)

From the Departments of Internal Medicine (W.T.Q., J.A.L., A.D., C.J.R.) and Public Health Sciences (K.S., C.J.R.), Wake Forest School of Medicine, Winston-Salem, NC; San Diego School of Medicine, University of California (M.A.A.); Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (J.C., F.G.); Department of Psychology, University of Miami, FL (B.E.H.); Department of Medicine - Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL (S.J.S.); Department of Medicine, University of Arizona, Tucson (A.A.D.); and Department of Medicine, Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY (D.M.S.).

Background: Reference limits for echocardiographic quantification of cardiac chambers in Hispanics are not well studied.

Methods And Results: We examined the reference values of left atrium and left ventricle (LV) structure in a large ethnically diverse Hispanic cohort. Two-dimensional transthoracic echocardiography was performed in 1818 participants of the Echocardiographic Study of Latinos (ECHO-SOL). Individuals with body mass index ≥30 kg/m(2), hypertension, diabetes mellitus, coronary artery disease, and atrial fibrillation were excluded leaving 525 participants defined as healthy reference cohort. We estimated 95th weighted percentiles of LV end systolic volume, LV end diastolic volume, relative wall and septal thickness, LV mass, and left atrial volume. We then used upper reference limits of the 2005 and 2015 American Society of Echocardiography (ASE) and 95th percentile of reference cohort to classify the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) target population into abnormal and normal. Reference limits were also calculated for each of 6 Hispanic origins. Using ASE 2015 defined reference values, we categorized 7%, 21%, 57%, and 17% of men and 18%, 29%, 60%, and 26% of women as having abnormal LV mass index, relative, septal, and posterior wall thickness, respectively. Conversely, 10% and 11% of men and 4% and 2% of women were classified as having abnormal end-diastolic volume and internal diameter by ASE 2015 cutoffs, respectively. Similar differences were found when we used 2005 ASE cutoffs. Several differences were noted in distribution of cardiac structure and volumes among various Hispanic/Latino origins. Cubans had highest values of echocardiographic measures, and Central Americans had the lowest.

Conclusions: This is the first large study that provides normal reference values for cardiac structure. It further demonstrates that a considerable segment of Hispanic/Latinos residing in the United States may be classified as having abnormal measures of cardiac chambers when 2015 and 2005 ASE reference cutoffs are used.
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http://dx.doi.org/10.1161/CIRCIMAGING.115.003597DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4696402PMC
January 2016

Left ventricular early inflow-outflow index: a novel echocardiographic indicator of mitral regurgitation severity.

J Am Heart Assoc 2015 Jun 12;4(6):e000781. Epub 2015 Jun 12.

Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (A.S., M.J.G., D.M.S.).

Background: No gold standard currently exists for quantification of mitral regurgitation (MR) severity. Classification by echocardiography is based on integrative criteria using color and spectral Doppler and anatomic measurements. We hypothesized that a simple Doppler left ventricular early inflow-outflow index (LVEIO), based on flow velocity into the left ventricle (LV) in diastole and ejected from the LV in systole, would add incrementally to current diagnostic criteria. LVEIO was calculated by dividing the mitral E-wave velocity by the LV outflow velocity time integral.

Methods And Results: Transthoracic echocardiography reports from Montefiore Medical Center and its referring clinics from July 1, 2011, to December 31, 2011 (n=11 235) were reviewed. The MR severity reported by a cardiologist certified by the National Board of Echocardiography was used as a reference standard. Studies reporting moderate or severe MR (n=550) were reanalyzed to measure effective regurgitant orifice area by the proximal isovelocity surface area method, vena contracta width, MR jet area, and left-sided chamber volumes. LVEIO was 9.3±3.9, 7.0±3.2, and 4.2±1.7 among those with severe, moderate, and insignificant MR, respectively (ANOVA P<0.001). By receiver operating characteristic analysis, area under the curve for LVEIO was 0.92 for severe MR. Those with LVEIO ≥8 were likely to have severe MR (likelihood ratio 26.5), whereas those with LVEIO ≤4 were unlikely to have severe MR (likelihood ratio 0.11). LVEIO performed better in those with normal LV ejection fraction (≥50%) compared with those with reduced LV ejection fraction (<50%) (area under the curve 0.92 versus 0.80, P<0.001). By multivariate logistic regression analysis, LVEIO was independently associated with severe MR when compared with vena contracta width, MR jet area, and effective regurgitant orifice area measured by the proximal isovelocity surface area method.

Conclusion: LVEIO is a simple-to-use echocardiographic parameter that accurately identifies severe MR, particularly in patients with normal LV ejection fraction.
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http://dx.doi.org/10.1161/JAHA.113.000781DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4599519PMC
June 2015

Coronary Computed Tomography Angiography Versus Radionuclide Myocardial Perfusion Imaging in Patients With Chest Pain Admitted to Telemetry: A Randomized Trial.

Ann Intern Med 2015 Aug;163(3):174-83

Background: The role of coronary computed tomography angiography (CCTA) in the management of symptomatic patients suspected of having coronary artery disease is expanding. However, prospective intermediate-term outcomes are lacking.

Objective: To compare CCTA with conventional noninvasive testing.

Design: Randomized, controlled comparative effectiveness trial. (ClinicalTrials.gov: NCT00705458).

Setting: Telemetry-monitored wards of an inner-city medical center.

Patients: 400 patients with acute chest pain (mean age, 57 years); 63% women; 54% Hispanic and 37% African-American; and low socioeconomic status.

Intervention: CCTA or radionuclide stress myocardial perfusion imaging (MPI).

Measurements: The primary outcome was cardiac catheterization not leading to revascularization within 1 year. Secondary outcomes included length of stay, resource utilization, and patient experience. Safety outcomes included death, major cardiovascular events, and radiation exposure.

Results: Thirty (15%) patients who had CCTA and 32 (16%) who had MPI underwent cardiac catheterization within 1 year. Fifteen (7.5%) and 20 (10%) of these patients, respectively, did not undergo revascularization (difference, -2.5 percentage points [95% CI, -8.6 to 3.5 percentage points]; hazard ratio, 0.77 [CI, 0.40 to 1.49]; P = 0.44). Median length of stay was 28.9 hours for the CCTA group and 30.4 hours for the MPI group (P = 0.057). Median follow-up was 40.4 months. For the CCTA and MPI groups, the incidence of death (0.5% versus 3%; P = 0.12), nonfatal cardiovascular events (4.5% versus 4.5%), rehospitalization (43% versus 49%), emergency department visit (63% versus 58%), and outpatient cardiology visit (23% versus 21%) did not differ. Long-term, all-cause radiation exposure was lower for the CCTA group (24 versus 29 mSv; P < 0.001). More patients in the CCTA group graded their experience favorably (P = 0.001) and would undergo the examination again (P = 0.003).

Limitation: This was a single-site study, and the primary outcome depended on clinical management decisions.

Conclusion: The CCTA and MPI groups did not significantly differ in outcomes or resource utilization over 40 months. Compared with MPI, CCTA was associated with less radiation exposure and with a more positive patient experience.

Primary Funding Source: American Heart Association.
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http://dx.doi.org/10.7326/M14-2948DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4703121PMC
August 2015

Outcomes in patients with various forms of aortic stenosis including those with low-flow low-gradient normal and low ejection fraction.

Am J Cardiol 2014 Oct 17;114(7):1069-74. Epub 2014 Jul 17.

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

Low-flow low-gradient aortic stenosis with normal ejection fraction (LFLGNEF AS) is a newly characterized poorly understood entity within the AS spectrum. Whether LFLGNEF AS has a worse prognosis than typical AS remains controversial. We retrospectively identified 4,546 individual patients with any type of AS on echocardiogram from 2003 through 2013 and categorized them into 5 cohorts: (1) mild AS, (2) moderate AS, (3) severe AS, (4) LFLGNEF AS (ejection fraction≥55%), and (5) low-flow low-gradient low ejection fraction AS (LFLGLEF AS; ejection fraction<55%). Survival analysis was used to compare outcomes of LFLGNEF AS with those of the other cohorts. AS was classified as mild in 591 patients, moderate in 2,358, severe in 500, LFLGNEF in 776, and LFLGLEF in 318. The study group had a mean age of 80.5 years, 61% were women, and the patients were followed for 2.26±1.16 years. Among subjects managed without valve replacement, total mortality for the LFLGNEF AS group was lower compared with that in both the severe AS and the LFLGLEF AS groups (p=0.007 and p<0.001, respectively). The prognosis for LFLGNEF AS was worse, however, compared with those with mild and moderate AS (p<0.001, both). In conclusion, no survival differences were found among AS types among those who received valve replacement. The survival rate in LFLGNEF is better than that in severe AS or LFLGLEF but is worse than that in mild or moderate AS. Valve replacement seems reasonable to pursue in select patients.
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http://dx.doi.org/10.1016/j.amjcard.2014.07.020DOI Listing
October 2014

Evaluation of the cardiac chambers on axial CT: comparison with echocardiography.

J Comput Assist Tomogr 2014 Jan-Feb;38(1):53-60

From the *Departments of Radiology, †Medicine, Division of Cardiology, ‡Medicine, and §Family and Social Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY.

Objective: To evaluate qualitative and simple quantitative measures of all 4 cardiac chamber sizes on computed tomography (CT) in comparison with transthoracic echocardiography (TTE).

Methods: We retrospectively identified 104 adults with electrocardiographically gated cardiac CT and TTE within 3 months. Axial early diastolic (75% R-R) CT images were reviewed for qualitative chamber enlargement, and each chamber was measured linearly. Transthoracic echocardiography was reviewed for linear, area, and volume measurements. Interrater agreement was calculated using Cohen κ and Pearson correlation.

Results: There were significant correlations between linear left atrium and left ventricle sizes by CT and TTE (r = 0.686 and r = 0.709, respectively). Correlations for right atrium and right ventricle measurements were lower (r = 0.447 and r = 0.492, respectively). Agreement between CT and TTE for qualitative chamber enlargement was poor (highest κ = 0.35). Computed tomography sensitivity was ≤ 62% for enlargement of all chambers.

Conclusions: Linear CT measurements of left-sided chamber sizes correlate well with TTE. Right heart measurements and qualitative assessments agreed poorly with TTE.
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http://dx.doi.org/10.1097/RCT.0b013e3182a75fbeDOI Listing
March 2014

Rationale and design of a randomized trial comparing initial stress echocardiography versus coronary CT angiography in low-to-intermediate risk emergency department patients with chest pain.

Echocardiography 2014 Jul 23;31(6):744-50. Epub 2013 Dec 23.

Department of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.

Background: Comparative effectiveness research (CER) has become a major focus of cardiovascular disease investigation to optimize diagnosis and treatment paradigms and decrease healthcare expenditures. Acute chest pain is a highly prevalent reason for evaluation in the Emergency Department (ED) that results in hospital admission for many patients and excess expense. Improvement in noninvasive diagnostic algorithms can potentially reduce unnecessary admissions.

Objective: To compare the performance of treadmill stress echocardiography (SE) and coronary computed tomography angiography (CTA) in ED chest pain patients with low-to-intermediate risk of significant coronary artery disease.

Design: This is a single-center, randomized controlled trial (RCT) comparing SE and CTA head-to-head as the initial noninvasive imaging modality. The primary outcome measured is the incidence of hospitalization. The study is powered to detect a reduction in admissions from 28% to 15% with a sample size of 400. Secondary outcomes include length of stay in the ED/hospital and estimated cost of care. Safety outcomes include subsequent visits to the ED and hospitalizations, as well as major adverse cardiovascular events at 30 days and 1 year. Patients who do not meet study criteria or do not consent for randomization are offered entry into an observational registry.

Conclusions: This RCT will add to our understanding of the roles of different imaging modalities in triaging patients with suspected angina. It will increase the CER evidence base comparing SE and CTA and provide insight into potential benefits and limitations of appropriate use of treadmill SE in the ED.
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http://dx.doi.org/10.1111/echo.12464DOI Listing
July 2014

Echocardiographic left ventricular end-diastolic pressure volume loop estimate predicts survival in congestive heart failure.

J Card Fail 2013 Apr 25;19(4):251-9. Epub 2013 Mar 25.

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

Background: The left ventricular end-diastolic pressure-volume relationship (LV-EDPVR) is a measure of LV distensibility, conveying the size the LV will assume at a given LV end-diastolic pressure (LV-EDP). Measurement of LV-EDPVR requires invasive testing with specialized equipment. Echocardiography can be used to measure LV end-diastolic volume (EDV) and to grossly estimate LV-EDP noninvasively. We therefore hypothesized that categorization of patients based on these parameters to create an estimate of the end-diastolic pressure-volume loop position (EDPVE) could predict congestive heart failure (CHF) prognosis.

Methods And Results: Echocardiograms from 968 CHF clinic patients were reviewed. LV-EDP was considered to be elevated if mitral filling pattern was pseudo-normal or restrictive. EDPVE was categorized into 3 groups. EDPVE was considered to have evidence of rightward shift if the LV was severely dilated (>97 mL/m(2)). EDPVE was considered to have evidence of leftward shift if the LV was normal size (<76 mL/m(2)) and there was Doppler evidence of increased LV-EDP. Patients who did not meet criteria for leftward or rightward shift were classified as "intermediate." Using the intermediate group for comparison, those with evidence of leftward shift in EDPVE had increased mortality (hazard ratio [HR] 1.77; 95% confidence interval [CI]: 1.23-2.54). Rightward shift only correlated with increased mortality in those older than age 70 years. Leftward shift remained an independent predictor of mortality even after adjusting for LV ejection fraction, atrial fibrillation, mitral regurgitation, and Doppler indices of diastolic dysfunction.

Conclusion: EDPVE is a strong predictor of CHF survival which is independent of LV ejection fraction and traditional Doppler indices of LV diastolic function.
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http://dx.doi.org/10.1016/j.cardfail.2013.02.003DOI Listing
April 2013

Administration of perflutren contrast agents during transthoracic echocardiography is not associated with a significant increase in acute mortality risk.

Cardiology 2012 18;122(2):119-25. Epub 2012 Jul 18.

Albert Einstein College of Medicine, Bronx, NY 10467, USA.

Background: Despite the 2008 revision of a previously issued black box warning of the US Food and Drug Administration against the use of perflutren ultrasound contrast agents, the warning still reports fatalities having occurred following their administration. We sought to assess 1-day mortality associated with contrast use across a wide range of clinical settings and co-morbidities.

Methods: We conducted a retrospective study involving 96,705 transthoracic echocardiograms (TTE) in 63,189 adults at our institution between July 2003 and June 2008. A contrast agent was used in 2,518 TTE during this time. The primary outcome was total mortality within 1 day of TTE.

Results: Death occurred in 10 patients (0.44%) in the contrast group and in 421 patients (0.69%) in the non-contrast group (p = 0.14). In a multivariate model, use of contrast enhancement was not associated with increased mortality (p = 0.67) after adjustment for age, gender, race, patient location, ejection fraction, and the presence of various co-morbidities. Cause of death analysis did not identify any cases where contrast played a likely role.

Conclusion: Definity contrast use during TTE was not associated with increased acute mortality risk. Contrast administration during TTE should not be withheld when the additional information obtained could potentially improve patient management.
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http://dx.doi.org/10.1159/000338731DOI Listing
November 2012

Long-term echocardiographic changes in left ventricular size and function following surgery for severe mitral regurgitation.

Med Sci Monit 2012 Apr;18(4):CR209-14

Albert Einstein College of Medicine, Bronx, NY, USA.

Background: Chronic mitral regurgitation (MR) results in a state of chronic left ventricular (LV) volume overload, resulting in compensatory dilatation. Mitral valve (MV) surgery for regurgitation reduces LV preload but increases LV afterload. Few data are available documenting subsequent changes in LV size and function over time following MV surgery for severe regurgitation in unselected populations.

Material/methods: Pre- and postoperative echocardiograms (n=454) acquired from 108 consecutive patients with chronic MR who underwent MV surgery were analyzed.

Results: LV diastolic diameter was 4 mm smaller on postoperative compared to preoperative exams, whereas LV fractional shortening (FS) was unchanged. Linear regression analysis showed no change in LV diastolic diameter over time postoperatively, whereas LV FS increased over time following surgery. Improvement in LV FS occurred at an average rate of 1.6% per year (95% CI, 0.2-2.9). Subgroups were small, but the same secular trends were generally noted in groups with or without coronary artery bypass graft surgery (CABGS) and in those with or without mitral leaflet disease.

Conclusions: Following MV surgery for MR, LV diastolic diameter reduces by 2 mm at the time of surgery, but then remains stable over time. Improvement in LV function over time postoperatively was only seen in those without concomitant CABGS, possibly related to less baseline myocardial scarring in this group.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3560836PMC
http://dx.doi.org/10.12659/msm.882620DOI Listing
April 2012

Prinzmetal's angina in patients with antiphospholipid syndrome.

Coron Artery Dis 2011 Dec;22(8):537-9

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

Antiphospholipid syndrome (APS) is an acquired hypercoagulable disease that is associated with both arterial and venous thrombosis. It is known to cause a spectrum of cardiovascular manifestations including myocardial infarction, stroke, valvular abnormalities, as well as vascular and intracardiac thrombosis. The pathogenesis of myocardial infarction and angina due to APS is thought to be due to coronary thrombosis. Coronary vasospasm without thrombosis can produce myocardial ischemia and chest pain, this is known as Prinzmetal's angina. To our knowledge, Prinzmetal's angina is not known to be associated with APS. In our clinical practice, we came across two cases of APS in which the patients presented with angina and were found to have coronary vasospasm without thrombosis. The finding of these two uncommon diagnoses in multiple individuals raises the possibility that these disorders are associated.
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http://dx.doi.org/10.1097/MCA.0b013e32834d3378DOI Listing
December 2011

Changes in cardiac geometry and function after gastric bypass surgery.

J Am Coll Cardiol 2011 Oct;58(18):1924; author reply 1924

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http://dx.doi.org/10.1016/j.jacc.2011.04.048DOI Listing
October 2011

Predictors of cardiac hepatopathy in patients with right heart failure.

Med Sci Monit 2011 Oct;17(10):CR537-41

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

Background: Some patients with right heart failure develop cardiac hepatopathy (CH). The pathophysiology of CH is thought to be secondary to hepatic venous congestion and arterial ischemia. We sought to define the clinical and hemodynamic characteristics associated with CH.

Material/methods: A retrospective cross sectional analysis was performed in which subjects were identified from our institutional cardiology database if echocardiography showed either right ventricular (RV) hypokinesis or dilatation, and was performed within 30 days of right heart catheterization. A chart review was then performed to identify patient clinical characteristics and to determine if the patients had underlying liver disease. Subjects with non-cardiac causes for hepatopathy were excluded.

Results: In 188 included subjects, etiology for right heart dysfunction included left heart failure (LHF), shunt, pulmonary hypertension, mitral- tricuspid- and pulmonic valvular disease. On multivariate analysis, higher RV diastolic pressure and etiology for RV dysfunction other than LHF were both associated with CH. Low cardiac output was associated with CH only amongst those without LHF.

Conclusions: CH is most often seen in subjects with elevated RV diastolic pressure suggesting a congestive cause in most cases. CH associated with low cardiac output in patients without LHF suggests that low flow may be contributing to the patophysiology in some cases.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3539469PMC
http://dx.doi.org/10.12659/msm.881977DOI Listing
October 2011
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