Publications by authors named "Eyal Ben Assa"

53 Publications

Age-specific mortality risk of mild diastolic dysfunction among hospitalized patients with preserved ejection fraction.

Int J Cardiol 2021 Mar 26. Epub 2021 Mar 26.

Department of Cardiology, Tel Aviv Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Israel; Department of Cardiology, Montefiore Medical Center, Bronx, NY, USA. Electronic address:

Background: The conveyed risk of mild diastolic dysfunction (MDD) according to age had not been thoroughly studied. We aimed to investigate the mortality-risk of MDD by age-groups among inpatients with preserved ejection fraction (EF), and determine ranges of diastolic function parameters by prognosis.

Methods: In a single-center retrospective study we identified inpatients who underwent echocardiography between 2012 and 2018 and had preserved EF without significant valvulopathies. Propensity scores were used to adjust for baseline characteristics and main diagnoses at discharge. Comparisons for all-cause mortality between MDD and normal diastolic function were conducted by age groups. Using classification and regression trees (CART) modeling we determined age-specific cut-offs according to outcome.

Results: The cohort consisted of 15,777 inpatients. Mortality rate during a 33.9-months median follow-up was 21.6%. MDD was associated with increased mortality risk among all ages up to 90 years, thereafter no difference was detected. Adjusted hazard ratios inversely related to age - 1.99(95%CI 1.25-3.16, p = 0.004), 1.82(95%CI1.46-2.26, p < 0.001), 1.88(95%CI1.64-2.15, p < 0.001), 1.78(95%CI1.59-2.01, p < 0.001), and 1.32(95%CI0.95-1.83, p = 0.093), for 18-44, 45-59, 60-74, 75-89, and ≥90 years, respectively (Pinteraction = 0.009). New cut-offs of E/e' for ages 75-89(16), e' lateral for ages ≥90(6 cm/s), e' septal for ages 60-74(5 cm/s), and E/A ratio for ages 18-44(1.5), predicted outcome more accurately than guidelines-based recommendations. The remaining cut-offs were not better predictors compared to guidelines-based recommendations.

Conclusions: MDD is a consequential finding at all ages up to 90 years among inpatients with preserved EF, although its significance decreases with age. Diastolic function of several age-groups may be better delineated by cut-offs that presage adverse prognoses. Helsinki committee approval number: 0170-17-TLV.
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http://dx.doi.org/10.1016/j.ijcard.2021.03.054DOI Listing
March 2021

Natural History of Moderate Aortic Stenosis with Preserved and Low Ejection Fraction.

J Am Soc Echocardiogr 2021 Feb 27. Epub 2021 Feb 27.

Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Tel Aviv Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Electronic address:

Background: There is a shortage of data concerning the natural history of patients with moderate aortic stenosis (AS). The aim of this study was to assess the effect of moderate AS on mortality in the general population and in the subgroups of patients with moderate AS and reduced ejection fractions (EF) and patients with moderate AS and low aortic valve gradients. The study was not designed to address the applicability of treatment in this population.

Methods: Outcomes were compared between patients with moderate AS and a propensity-matched cohort (1:3 ratio) without AS. The primary outcome was survival until end of follow-up.

Results: Among approximately 40,000 patients who underwent echocardiographic evaluations between 2011 and 2016, 952 had moderate AS. Median follow-up duration was 181 weeks (interquartile range, 179-182 weeks) for the entire cohort and 174 weeks (interquartile range, 169-179 weeks) for the propensity-matched groups. Propensity matching successfully balanced most preexisting clinical differences. Increased mortality was observed in the group of patients with moderate AS before propensity matching and persisted following propensity matching (median survival 4.1 vs 5.2 years, P = .008). Survival rates and corresponding standard errors at 1, 2, 3, and 5 years were 80 ± 1% versus 82 ± 0.7%, 70 ± 1.5% versus 74 ± 0.8%, 62 ± 1.7% versus 66 ± 0.9%, and 47 ± 2.4% versus 52 ± 1.3%, respectively. A survival difference was similarly observed for the subgroup analyses of moderate AS and reduced ejection fraction (P = .028) and moderate AS and low aortic valve gradients (P = .039).

Conclusions: Moderate AS is associated with increased mortality. The increased mortality was also observed in the subgroups of patients with either reduced ejection fraction or low aortic valve gradients.
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http://dx.doi.org/10.1016/j.echo.2021.02.014DOI Listing
February 2021

Mixed Valvular Disease Following Transcatheter Aortic Valve Replacement: Quantification and Systematic Differentiation Using Clinical Measurements and Image-Based Patient-Specific In Silico Modeling.

J Am Heart Assoc 2020 03 28;9(5):e015063. Epub 2020 Feb 28.

Institute for Medical Engineering and Science Massachusetts Institute of Technology Cambridge MA.

Background Mixed valvular disease (MVD), mitral regurgitation (MR) from pre-existing disease in conjunction with paravalvular leak (PVL) following transcatheter aortic valve replacement (TAVR), is one of the most important stimuli for left ventricle (LV) dysfunction, associated with cardiac mortality. Despite the prevalence of MVD, the quantitative understanding of the interplay between pre-existing MVD, PVL, LV, and post-TAVR recovery is meager. Methods and Results We quantified the effects of MVD on valvular-ventricular hemodynamics using an image-based patient-specific computational framework in 72 MVD patients. Doppler pressure was reduced by TAVR (mean, 77%; N=72; <0.05), but it was not always accompanied by improvements in LV workload. TAVR had no effect on LV workload in 22 patients, and LV workload post-TAVR significantly rose in 32 other patients. TAVR reduced LV workload in only 18 patients (25%). PVL significantly alters LV flow and increases shear stress on transcatheter aortic valve leaflets. It interacts with mitral inflow and elevates shear stresses on mitral valve and is one of the main contributors in worsening of MR post-TAVR. MR worsened in 32 patients post-TAVR and did not improve in 18 other patients. Conclusions PVL limits the benefit of TAVR by increasing LV load and worsening of MR and heart failure. Post-TAVR, most MVD patients (75% of N=72; <0.05) showed no improvements or even worsening of LV workload, whereas the majority of patients with PVL, but without that pre-existing MR condition (60% of N=48; <0.05), showed improvements in LV workload. MR and its exacerbation by PVL may hinder the success of TAVR.
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http://dx.doi.org/10.1161/JAHA.119.015063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7335548PMC
March 2020

Effect of Residual Interatrial Shunt on Migraine Burden After Transcatheter Closure of Patent Foramen Ovale.

JACC Cardiovasc Interv 2020 02;13(3):293-302

Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Objectives: This study sought to evaluate the long-term effect of transcatheter patent foramen ovale (PFO) closure on migraineurs with and without aura and examine the effect of residual right-to-left shunt.

Background: Many studies reported improvement in migraine symptoms after PFO closure, yet randomized trials failed to reach its clinical endpoints.

Methods: The study retrospectively analyzed data from 474 patients who underwent transcatheter PFO closure at Massachusetts General Hospital. Patients completed a migraine burden questionnaire at baseline and at follow-up. Migraine severity is reported as migraine frequency (days/month), average duration (min), and migraine burden (days × min/month). Improvement following closure was defined as complete abolishment of symptoms or >50% reduction in migraine burden.

Results: A total of 110 migraineurs who underwent PFO closure were included; 77.0% had aura and 23.0% were without aura, and 91.0% had a cryptogenic stroke. During long-term median follow-up of 3.2 (interquartile range: 2.1 to 4.9) years, there was a significant improvement in migraine symptoms in migraineurs with or without aura. Migraine burden was reduced by >50% in 87.0% of patients, and symptoms were completely abolished in 48%. Presence of aura was associated with abolishment of migraine (odds ratio: 4.30; 95% confidence interval: 1.50 to 12.30; p = 0.006). At 6 months after PFO closure, residual right-to-left shunt was present in 26% of patients. Absence of right-to-left shunt was associated with improvement in migraine burden by >50% (odds ratio: 4.60; 95% confidence interval: 1.30 to 16.10; p = 0.017).

Conclusions: Long-term follow-up after transcatheter PFO closure was associated with significant improvement in migraine burden. Aura was a predictor of abolishing symptoms. Absence of residual right-to-left shunt was a predictor of significant reduction in migraine burden.
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http://dx.doi.org/10.1016/j.jcin.2019.09.042DOI Listing
February 2020

Author's reply to: Worsening of mitral regurgitation following transcatheter aortic valve replacement.

Int J Cardiol 2020 03 30;302:42. Epub 2019 Nov 30.

Cardiology Division, Tel Aviv Sourasky Medical Center, Sackler faculty of Medicine, Tel Aviv, Israel. Electronic address:

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http://dx.doi.org/10.1016/j.ijcard.2019.11.145DOI Listing
March 2020

Thirty-day readmissions after transcatheter versus surgical mitral valve repair in high-risk patients with mitral regurgitation: Analysis of the 2014-2015 Nationwide readmissions databases.

Catheter Cardiovasc Interv 2020 09 23;96(3):664-674. Epub 2019 Dec 23.

Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Objective: Determine the rates, reasons, predictors, and costs of 30-day readmissions following transcatheter mitral valve repair (TMVR) versus surgical mitral valve repair (SMVR) in the United States.

Background: Data on 30-day readmissions after TMVR are limited.

Methods: High-risk patients with mitral regurgitation (MR) undergoing TMVR or SMVR were identified from the 2014-2015 Nationwide Readmissions Databases. Multivariable stepwise regression models were used to identify independent predictors of 30-day readmission. Risk of 30-day readmission was compared between the two groups using univariate and propensity score adjusted regression models.

Results: Among 8,912 patients undergoing mitral valve repair during 2014-2015 (national estimate 17,809), we identified 7,510 (84.7%) that underwent SMVR and 1,402 (15.3%) that underwent TMVR. Thirty-day readmission rates after SMVR and TMVR were 10.7% and 11.7%, respectively (unadjusted OR 1.11, 95% CI 0.89-1.39, p = .35). After propensity score adjustment, TMVR was associated with a lower risk of 30-day readmissions compared with SMVR (adjusted OR 0.70, 95% CI 0.51-0.95, p = .02). Heart failure and arrhythmias were the leading cardiac reasons for readmission. Anemia and fluid and electrolyte disorder were independent predictors of 30-day readmission after TMVR. Demographics, comorbidities, and length of stay were independent predictors of 30-day readmission after SMVR.

Conclusions: One in 10 patients are readmitted within 30 days following TMVR or SMVR. Approximately half of the readmissions are for cardiac reasons. The predictors of 30-day readmission are different among patients undergoing TMVR and SMVR, but can be easily screened for to identify patients at highest risk for readmission.
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http://dx.doi.org/10.1002/ccd.28647DOI Listing
September 2020

Association of Pulmonary Hypertension With Clinical Outcomes of Transcatheter Mitral Valve Repair.

JAMA Cardiol 2020 01;5(1):47-56

Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston.

Importance: Pulmonary hypertension (pHTN) is associated with increased risk of mortality after mitral valve surgery for mitral regurgitation. However, its association with clinical outcomes in patients undergoing transcatheter mitral valve repair (TMVr) with a commercially available system (MitraClip) is unknown.

Objective: To assess the association of pHTN with readmissions for heart failure and 1-year all-cause mortality after TMVr.

Design, Setting, And Participants: This retrospective cohort study analyzed 4071 patients who underwent TMVr with the MitraClip system from November 4, 2013, through March 31, 2017, across 232 US sites in the Society of Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapy registry. Patients were stratified into the following 4 groups based on invasive mean pulmonary arterial pressure (mPAP): 1103 with no pHTN (mPAP, <25 mm Hg [group 1]); 1399 with mild pHTN (mPAP, 25-34 mm Hg [group 2]); 1011 with moderate pHTN (mPAP, 35-44 mm Hg [group 3]); and 558 with severe pHTN (mPAP, ≥45 mm Hg [group 4]). Data were analyzed from November 4, 2013, through March 31, 2017.

Interventions: Patients were stratified into groups before TMVr, and clinical outcomes were assessed at 1 year after intervention.

Main Outcomes And Measures: Primary end point was a composite of 1-year mortality and readmissions for heart failure. Secondary end points were 30-day and 1-year mortality and readmissions for heart failure. Linkage to Centers for Medicare & Medicaid Services administrative claims was performed to assess 1-year outcomes in 2381 patients.

Results: Among the 4071 patients included in the analysis, the median age was 81 years (interquartile range, 73-86 years); 1885 (46.3%) were women and 2186 (53.7%) were men. The composite rate of 1-year mortality and readmissions for heart failure was 33.6% (95% CI, 31.6%-35.7%), which was higher in those with pHTN (27.8% [95% CI, 24.2%-31.5%] in group 1, 32.4% [95% CI, 29.0%-35.8%] in group 2, 36.0% [95% CI, 31.8%-40.2%] in group 3, and 45.2% [95% CI, 39.1%-51.0%] in group 4; P < .001). Similarly, 1-year mortality (16.3% [95% CI, 13.4%-19.5%] in group 1, 19.8% [95% CI, 17.0%-22.8%] in group 2, 22.4% [95% CI, 18.8%-26.1%] in group 3, and 27.8% [95% CI, 22.6%-33.3%] in group 4; P < .001) increased across pHTN groups. The association of pHTN with mortality persisted despite multivariable adjustment (hazard ratio per 5-mm Hg mPAP increase, 1.05; 95% CI, 1.01-1.09; P = .02).

Conclusions And Relevance: These findings suggest that pHTN is associated with increased mortality and readmission for heart failure in patients undergoing TMVr using the MitraClip system for severe mitral regurgitation. Further efforts are needed to determine whether earlier intervention before pHTN develops will improve clinical outcomes.
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http://dx.doi.org/10.1001/jamacardio.2019.4428DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6902209PMC
January 2020

Experimental Investigation of the Effect of Heart Rate On Flow in the Left Ventricle in Health and Disease -- Aortic Valve Regurgitation.

J Biomech Eng 2019 Nov 1. Epub 2019 Nov 1.

Department of Mechanical, Industrial & Aerospace Engineering, Concordia University, 1455 Blvd. De Maisonneuve W., Montréal, Québec, Canada H3G 1M8.

There is much debate in the literature surrounding the effects of heart rate on aortic regurgitation (AR). Despite the contradictory information, it is still widely believed that an increase in heart rate is beneficial due to the disproportionate shortening of the duration of diastole relative to systole, permitting less time for the left ventricle to fill from regurgitation. This in vitro work investigates how a change in heart rate affects the left ventricular fluid dynamics in the absence and presence of acute AR. Considering fluid dynamic factors, an increase in heart rate was observed to have a limited benefit in the case of mild AR and a detrimental effect for more severe AR. With increasing heart rate, mild AR was associated with a decrease in regurgitant volume, a negligible change in regurgitant volume per diastolic second and a limited reduction in the fraction of retained regurgitant inflow. More severe AR was accompanied by an increase in both regurgitant volume and the fraction of retained regurgitant inflow, implying a less effective pumping efficiency and a longer relative residence time of blood in the ventricle. Globally, the left ventricle's capacity to compensate for the increase in energy dissipation associated with an increase in heart rate diminishes considerably with severity, a phenomenon which may be exploited further as a method of noninvasive assessment of the severity of AR. These findings may affect the clinical belief that tachycardia is preferred in acute AR and should be investigated further in the clinical setting.
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http://dx.doi.org/10.1115/1.4045400DOI Listing
November 2019

Ventricular stroke work and vascular impedance refine the characterization of patients with aortic stenosis.

Sci Transl Med 2019 09;11(509)

Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02142, USA.

Aortic stenosis (AS) management is classically guided by symptoms and valvular metrics. However, the natural history of AS is dictated by coupling of the left ventricle, aortic valve, and vascular system. We investigated whether metrics of ventricular and vascular state add to the appreciation of AS state above valve gradient alone. Seventy patients with severe symptomatic AS were prospectively followed from baseline to 30 days after transcatheter aortic valve replacement (TAVR). Quality of life (QOL) was assessed using the Kansas City Cardiomyopathy Questionnaire. Left ventricular stroke work (SW) and vascular impedance spectrums were calculated noninvasively using in-house models based on central blood pressure waveforms, along with hemodynamic parameters from echocardiograms. Patients with higher preprocedural SW and lower vascular impedance were more likely to experience improved QOL after TAVR. Patients fell into two categories: those who did and those who did not exhibit increase in blood pressure after TAVR. In patients who developed hypertension (19%), vascular impedance increased and SW remained unchanged (impedance at zeroth harmonic: , from 3964.4 to 4851.8 dyne·s/cm, = 0.039; characteristic impedance: , from 376.2 to 603.2 dyne·s/cm, = 0.033). SW dropped only in patients who did not develop new hypertension after TAVR (from 1.58 to 1.26 J; < 0.001). Reduction in valvular pressure gradient after TAVR did not predict change in SW ( = 0.213; = 0.129). Reduction of SW after TAVR may be an important metric in management of AS, rather than relying solely on the elimination of transvalvular pressure gradients.
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http://dx.doi.org/10.1126/scitranslmed.aaw0181DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7401937PMC
September 2019

Aortic regurgitation assessment by cardiovascular magnetic resonance imaging and transthoracic echocardiography: intermodality disagreement impacting on prediction of post-surgical left ventricular remodeling.

Int J Cardiovasc Imaging 2020 Jan 14;36(1):91-100. Epub 2019 Aug 14.

Department of Medicine (Cardiovascular Division), Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA.

Transthoracic echocardiography (TTE) is the primary clinical imaging modality for the assessment of patients with isolated aortic regurgitation (AR) in whom TTE's linear left ventricular (LV) dimension is used to assess disease severity to guide aortic valve replacement (AVR), yet TTE is relatively limited with regards to its integrated semi-quantitative/qualitative approach. We therefore compared TTE and cardiovascular magnetic resonance (CMR) assessment of isolated AR and investigated each modality's ability to predict LV remodeling after AVR. AR severity grading by CMR and TTE were compared in 101 consecutive patients referred for CMR assessment of chronic AR. LV end-diastolic diameter and end-systolic diameter measurements by both modalities were compared. Twenty-four patients subsequently had isolated AVR. The pre-AVR estimates of regurgitation severity by CMR and TTE were correlated with favorable post-AVR LV remodeling. AR severity grade agreement between CMR and TTE was moderate (ρ = 0.317, P = 0.001). TTE underestimated CMR LV end-diastolic and LV end-systolic diameter by 6.6 mm (P < 0.001, CI 5.8-7.7) and 5.9 mm (P < 0.001, CI 4.1-7.6), respectively. The correlation of post-AVR LV remodeling with CMR AR grade (ρ = 0.578, P = 0.004) and AR volumes (R = 0.664, P < 0.001) was stronger in comparison to TTE (ρ = 0.511, P = 0.011; R = 0.318, P = 0.2). In chronic AR, CMR provides more prognostic relevant information than TTE in assessing AR severity. CMR should be considered in the management of chronic AR patients being considered for AVR.
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http://dx.doi.org/10.1007/s10554-019-01682-xDOI Listing
January 2020

Clinical impact of post procedural mitral regurgitation after transcatheter aortic valve replacement.

Int J Cardiol 2020 01 1;299:215-221. Epub 2019 Aug 1.

Cardiology Division, Tel Aviv Sourasky Medical Center, Sackler faculty of Medicine, Tel Aviv, Israel. Electronic address:

Background: While the impact of mitral regurgitation (MR) prior to transcatheter aortic valve replacement (TAVR) has been intensively studied, the implications of post-procedural MR on outcome are unknown. We investigated the clinical and physiological impact of significant MR after TAVR.

Methods: Clinical and echocardiographic data of 486 patients who underwent TAVR between March 2009 and December 2014 were evaluated. Clinical endpoints included overall mortality and combined endpoint of mortality, heart failure re-hospitalization and new atrial fibrillation. Echocardiographic parameters were analyzed at baseline, 30-day and 6-month after TAVR.

Results: MR severity improved in 25%, worsened in 19% and did not change in 56% of patients 30-days post TAVR (p = 0.3). Post TAVR MR grade ≥ moderate was present in 16.1%. Predictive accuracy of post TAVR MR was low (AUC = 0.63). Median follow-up was 4.3 years (interquartile range, 2.5 to 6.1). Post TAVR MR grade ≥ moderate was associated with increased mortality and combined cardiac events (p = 0.013 and p < 0.001) even when adjusted for all clinical and echo parameters and when analyzed with propensity score matching. In patients with MR ≥ moderate, LV filling pressure and RV hemodynamics worsened 6 months post TAVR, while improving in patients with less significant post procedural MR.

Conclusion: Post procedural, but not pre-procedural MR grade ≥ moderate was independently associated with mortality and adverse cardiac events after TAVR. Significant MR post TAVR resulted in adverse LV and RV remodeling and poor hemodynamic. Our study strengthens the rational for initiating early treatment to reduce post TAVR MR.
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http://dx.doi.org/10.1016/j.ijcard.2019.07.092DOI Listing
January 2020

Forced diuresis with matched hydration during transcatheter aortic valve implantation for Reducing Acute Kidney Injury: a randomized, sham-controlled study (REDUCE-AKI).

Eur Heart J 2019 10;40(38):3169-3178

Department of Cardiology, Tel-Aviv Medical Center Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 weizman st, Tel-Aviv, Israel.

Aims: Acute kidney injury (AKI) is a common complication following transcatheter aortic valve implantation (TAVI) and is associated with increased risk for short- and long-term mortality. In patients undergoing percutaneous coronary intervention (PCI), forced diuresis with matched hydration has been shown to reduce the incidence of AKI by ∼50%. The aim of the present study was to evaluate whether forced diuresis with matched intravenous hydration reduces AKI in patients undergoing TAVI.

Methods And Results: Reducing Acute Kidney Injury (REDUCE-AKI) was a single-centre, prospective, randomized, double-blind sham-controlled clinical trial, designed to examine the effect of an automated matched saline infusion with urine output for the prevention of AKI in patients undergoing TAVI. A total of 136 TAVI patients were randomized, 68 in each group. Mean age was 83.9 ± 5 years and 41.2% were males. There were no differences in baseline characteristics between the two groups. The rate of AKI was not statistically different between the groups (25% in the active group vs. 19.1% in the sham group, P = 0.408). There was a significant increase in long-term mortality in the active group (27.9% vs. 13. 2% HR 3.744, 95% CI 1.51-9.28; P = 0.004). The study was terminated prematurely by the Data Safety Monitoring Board for futility and a possible signal of harm.

Conclusions: Unlike in PCI, forced diuresis with matched hydration does not prevent AKI in patients undergoing TAVI, and might be associated with increased long-term mortality. Future studies should focus on understanding the mechanisms behind these findings.

Clinicaltrials.gov Registration: NCT01866800, 30 April 2013.
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http://dx.doi.org/10.1093/eurheartj/ehz343DOI Listing
October 2019

A Mechanical Approach for Smooth Surface Fitting to Delineate Vessel Walls in Optical Coherence Tomography Images.

IEEE Trans Med Imaging 2019 06 29;38(6):1384-1397. Epub 2018 Nov 29.

Automated analysis of vascular imaging techniques is limited by the inability to precisely determine arterial borders. Intravascular optical coherence tomography (OCT) offers unprecedented detail of artery wall structure and composition, but does not provide consistent visibility of the outer border of the vessel due to the limited penetration depth. Existing interpolation and surface fitting methods prove insufficient to accurately fill the gaps between the irregularly spaced and sometimes unreliably identified visible segments of the vessel outer border. This paper describes an intuitive, efficient, and flexible new method of 3D surface fitting and smoothing suitable for this task. An anisotropic linear-elastic mesh is fit to irregularly spaced and uncertain data points corresponding to visible segments of vessel borders, enabling the fully automated delineation of the entire inner and outer borders of diseased vessels in OCT images for the first time. In a clinical dataset, the proposed smooth surface fitting approach had great agreement when compared with human annotations: areas differed by just 11 ± 11% (0.93 ± 0.84 mm), with a coefficient of determination of 0.89. Overlapping and non-overlapping area ratios were 0.91 and 0.18, respectively, with a sensitivity of 90.8 and specificity of 99.0. This spring mesh method of contour fitting significantly outperformed all alternative surface fitting and interpolation approaches tested. The application of this promising proposed method is expected to enhance clinical intervention and translational research using OCT.
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http://dx.doi.org/10.1109/TMI.2018.2884142DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6541545PMC
June 2019

Optimized Computer-Aided Segmentation and Three-Dimensional Reconstruction Using Intracoronary Optical Coherence Tomography.

IEEE J Biomed Health Inform 2018 07;22(4):1168-1176

We present a novel and time-efficient method for intracoronary lumen detection, which produces three-dimensional (3-D) coronary arteries using optical coherence tomographic (OCT) images. OCT images are acquired for multiple patients and longitudinal cross-section (LOCS) images are reconstructed using different acquisition angles. The lumen contours for each LOCS image are extracted and translated to 2-D cross-sectional images. Using two angiographic projections, the centerline of the coronary vessel is reconstructed in 3-D, and the detected 2-D contours are transformed to 3-D and placed perpendicular to the centerline. To validate the proposed method, 613 manual annotations from medical experts were used as gold standard. The 2-D detected contours were compared with the annotated contours, and the 3-D reconstructed models produced using the detected contours were compared to the models produced by the annotated contours. Wall shear stress (WSS), as dominant hemodynamics factor, was calculated using computational fluid dynamics and 844 consecutive 2-mm segments of the 3-D models were extracted and compared with each other. High Pearson's correlation coefficients were obtained for the lumen area (r = 0.98) and local WSS (r = 0.97) measurements, while no significant bias with good limits of agreement was shown in the Bland-Altman analysis. The overlapping and nonoverlapping areas ratio between experts' annotations and presented method was 0.92 and 0.14, respectively. The proposed computer-aided lumen extraction and 3-D vessel reconstruction method is fast, accurate, and likely to assist in a number of research and clinical applications.
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http://dx.doi.org/10.1109/JBHI.2017.2762520DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6042877PMC
July 2018

Prevention of post procedural acute kidney injury in the catheterization laboratory in a real-world population.

Int J Cardiol 2017 Jan 11;226:42-47. Epub 2016 Oct 11.

Department of Cardiology, Tel Aviv Medical Center, Israel; Sackler School of Medicine, Tel Aviv University, Israel. Electronic address:

Background: Radiologists and cardiologists have a remarkably different approach to the clinical importance and to the need for prophylactic treatment of contrast-induced acute kidney injury (CI-AKI).

Objectives: To evaluate the efficacy of forced diuresis with matched controlled hydration (FMH) in a real-world, high risk population.

Methods: This is an investigator-driven, single-center, retrospective analysis of prospectively collected data. A total of 150 consecutive patients undergoing coronary angiography, angioplasty or TAVR who were treated with FMH were compared to a matched historical control cohort.

Results: In the FMH treated patients, eGFR improved following the procedure from 37ml/min per 1.73m at baseline to 39ml/min per 1.73m (p<0.001); the net creatinine decreased from 1.85mg/dl to 1.78mg/dl (p<0.001). Among the matched control group, eGFR deteriorated from a baseline value of 36.7ml/min per 1.73m to 33.2ml/min per 1.73m post procedurally (p<0.001); the net creatinine increased from 1.88mg/dl to 2.14mg/dl (p<0.001). The incidence of post procedural AKI was substantially lower in the FMH treated group (2.7%) compared to the control group (26.7%). By multivariable analysis FMH treatment was independently correlated with reduced incidence of post procedural AKI compared with the control group (OR 0.06, p<0.001). Contrast volume did not correlate with AKI in neither univariate nor multivariate analyses.

Conclusions: In patients undergoing coronary angiography, angioplasty or TAVR, who are considered high risk to develop post procedural AKI, forced diuresis with matched controlled hydration resulted in a significant net creatinine decrease, eGFR increase and a decrease in the incidence of AKI.
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http://dx.doi.org/10.1016/j.ijcard.2016.10.028DOI Listing
January 2017

Elimination of Transcoarctation Pressure Gradients Has No Impact on Left Ventricular Function or Aortic Shear Stress After Intervention in Patients With Mild Coarctation.

JACC Cardiovasc Interv 2016 09;9(18):1953-65

Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts; Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Objectives: This study sought to investigate the impact of transcatheter intervention on left ventricular function and aortic hemodynamics in patients with mild coarctation of the aorta (COA).

Background: The optimal method and timing of transcatheter intervention for COA remains unclear, especially when the severity of COA is mild (peak-to-peak transcoarctation pressure gradient <20 mm Hg). Debate rages regarding the risk/benefit ratio of intervention versus long-term effects of persistent minimal gradient in this heterogeneous population with differing blood pressures, ventricular function, and peripheral perfusion.

Methods: We developed a unique computational fluid dynamics and lumped parameter modeling framework based on patient-specific hemodynamic input parameters and validated it against patient-specific clinical outcomes (before and after intervention). We used clinically measured hemodynamic metrics and imaging of the aorta and the left ventricle in 34 patients with mild COA to make these correlations.

Results: Despite dramatic reduction in the transcoarctation pressure gradient (catheter and Doppler echocardiography pressure gradients reduced by 75% and 47.3%, respectively), there was only modest effect on aortic flow and no significant impact on aortic shear stress (the maximum time-averaged wall shear stress in descending aorta was reduced 5.1%). In no patient did transcatheter intervention improve left ventricular function (e.g., stroke work and normalized stroke work were reduced by only 4.48% and 3.9%, respectively).

Conclusions: Transcatheter intervention that successfully relieves mild COA pressure gradients does not translate to decreased myocardial strain. The effects of the intervention were determined to the greatest degree by ventricular-vascular coupling hemodynamics and provide a novel valuable mechanism to evaluate patients with COA that may influence clinical practice.
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http://dx.doi.org/10.1016/j.jcin.2016.06.054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5402700PMC
September 2016

When Virchow Meets Da Vinci: Correlating Thrombogenesis With Intracardiac Flow Dynamics.

Circ Cardiovasc Imaging 2016 09;9(9):e005438

From the Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge (E.B.-A.); Department of Medicine, Cardiovascular Division (E.B.-A., W.J.M.) and Department of Radiology (W.J.M.), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.

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http://dx.doi.org/10.1161/CIRCIMAGING.116.005438DOI Listing
September 2016

Steroid therapy and conduction disturbances after transcatheter aortic valve implantation.

Cardiovasc Ther 2016 Oct;34(5):325-9

Interventional Cardiology, Tel-Aviv Medical Center, Tel-Aviv, Israel.

Background: Direct mechanical compression of the frame struts on the adjacent bundle branch with local inflammatory reaction might cause conduction system disturbances and need for pacemaker implantation following transcatheter aortic valve implantation (TAVI). We assessed the impact of preprocedural anti-inflammatory steroid therapy on the occurrence of conduction disturbances following TAVI.

Methods And Results: From a cohort of 324 patients who underwent transfemoral TAVI, 39 (12%) were pretreated with steroids because of iodine allergy (n=29) or active obstructive pulmonary disease (n=10). We compared the rate of occurrence of new conduction disturbances and pacemaker implantation between TAVI patients with (n=39) and without (n=285) steroid treatment, using Cox logistic regression estimates and proportional hazards models. The overall occurrence of new conduction defects and the need for new pacemaker implantation were similar among steroid and non-steroid-treated patients (38.4% vs 37.5% and 25.6% vs 25.3%, respectively). New conduction disturbances were more prevalent in patients treated with CoreValve prosthesis, low implantation, and smaller aortic annulus diameter (P<.001, P<.001, and P=.006, respectively). Thirty-day mortality and complication rates were similar between the groups.

Conclusion: Although safe, steroid treatment prior to TAVI failed to reduce the incidence of new conduction defects and the need for pacemaker implantation.
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http://dx.doi.org/10.1111/1755-5922.12202DOI Listing
October 2016

Norton scale for predicting prognosis in elderly patients undergoing trans-catheter aortic valve implantation: A historical prospective study.

J Cardiol 2016 06 28;67(6):519-25. Epub 2016 Feb 28.

Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Department of Cardiology, Tel Aviv Medical Center, Tel-Aviv, Israel. Electronic address:

Background: The Norton scale is traditionally used to assess the risk of pressure ulcers. However, recent studies have shown its prognostic utilization in elderly patients with diverse medical conditions. The association between low admission Norton scale scores (ANSS), complications, and mortality in elderly patients following trans-catheter aortic valve implantation (TAVI) has never been studied. We aimed to determine if low ANSS (≤16) is associated with complications and 30-day and 1-year mortality in elderly patients undergoing TAVI.

Methods: The medical charts of elderly (≥70 years) TAVI patients at the Tel-Aviv Medical Center, a tertiary medical center, were studied for the following measurements: ANSS, demographics, co-morbidities, complications during hospitalization, and 30-day and 1-year mortality. Complications included: an atrio-ventricular block, stroke, and vascular complications.

Results: The cohort included 302 elderly patients: 179 (59.3%) were women; the mean age was 83.3±5.1 years. Following TAVI, 112 (37.1%) patients had complications other than pressure ulcers, 10 (3.3%) patients died within 30 days, and 42 (13.9%) patients died within one year. Overall, 36 (11.9%) patients had low ANSS. 1-year mortality rates were almost three times higher in patients with low ANSS relative to patients with high ANSS (27.8% vs. 12.0%; the relative risk 1.1; p=0.018). A stepwise logistic regression analysis showed that ANSS was independently inversely associated with 1-year mortality (p=0.018). Complications and 30-day mortality rates were similar in both groups.

Conclusions: Low ANSS are associated with 1-year mortality after TAVI. The Norton scale may therefore be used as an additional tool for elderly patient selection before TAVI.
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http://dx.doi.org/10.1016/j.jjcc.2016.01.017DOI Listing
June 2016

HbA1c Levels and Long-Term Mortality in Patients Undergoing Coronary Angiography.

Cardiology 2016 1;134(2):101-6. Epub 2016 Mar 1.

Department of Cardiology, Cardiovascular Research Center, Tel Aviv Medical Center, affiliated to Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objectives: Previous studies investigating the prognostic value of HbA1c in patients undergoing coronary angiography reported a mixed pattern of results. Therefore, we aimed to better define the prognostic power of HbA1c among coronary catheterized patients.

Methods: Patients undergoing coronary angiography (n = 3,749) were divided into four groups according to HbA1c levels (<5, 5-6, 6-7 and >7%). Cox regression models assessed long-term mortality after adjusting for multiple covariates.

Results: Baseline clinical profiles differed in HbA1c groups, with a higher prevalence of comorbidities in the groups with higher HbA1c levels. Median follow-up was 1,745 days (interquartile range 1,007-2,171). A J-shaped association curve was observed between HbA1c levels and all-cause mortality rates, with patients in the lowest and highest HbA1c groups suffering from significantly higher mortality rates compared to in-between groups (hazard ratio 1.9, 95% CI 1.32-2.74, p = 0.001, and hazard ratio 1.58, 95% CI 1.29-1.95, p < 0.001, for the lowest and highest HbA1c groups, respectively). This association persisted after adjustment for anemia, nutritional status, renal function, cardiovascular risk factors and inflammatory biomarkers.

Conclusions: HbA1c levels <5 or >7% are predictors of all-cause mortality in patients undergoing coronary angiography.
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http://dx.doi.org/10.1159/000444008DOI Listing
December 2016

Impact of Hemoglobin Drop, Bleeding Events, and Red Blood Cell Transfusions on Long-term Mortality in Patients Undergoing Transaortic Valve Implantation.

Can J Cardiol 2016 10 10;32(10):1239.e9-1239.e14. Epub 2015 Nov 10.

Department of Cardiology, Tel-Aviv Medical Center, Tel-Aviv and the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.

Background: Despite the minimally invasive nature of transcatheter aortic valve implantation (TAVI), the procedure is associated with several complications. We aimed to analyze the individual impact of bleeding events, hemoglobin (Hb) drop, and red blood cell (RBC) transfusions on prognosis and to evaluate the temporal trends in bleeding and RBC transfusions since the initiation of the TAVI program in our centre and onward.

Methods: Consecutive patients (n = 597) undergoing transfemoral TAVI were prospectively enrolled. Periprocedural Hb levels, RBC transfusions, and major/life-threatening bleeding events were documented and analyzed.

Results: In the entire cohort, mean Hb level decreased after TAVI (11.8 ± 1.4 to 9.5 ± 1.3 g/dL; P < 0.001). Major/life threatening bleeding occurred in 66 (10.1%) patients, and 179 (30%) patients received RBC transfusions. Major/life threatening bleeding was not independently associated with mortality when adjusted for Hb drop and RBC transfusion. Among patients with an Hb drop of < 3 g/dL, those who received RBC transfusions had a higher mortality (hazard ratio [HR], 1.9; confidence interval [CI], 95% CI, 1.2-2.9; P = 0.004). Among patients with an Hb drop of ≥ 3 g/dL, the Hb drop had no significant impact on survival (HR, 1.5; 95% CI, 0.7-2.9; P = 0.2); however, patients who received RBC transfusions had a significantly higher mortality (HR, 4.1; 95% CI, 2.2-7.7; P < 0.001). The use of RBC transfusions decreased gradually over the duration of the study.

Conclusions: An Hb drop is frequently observed after TAVI. RBC transfusions are strongly associated with increased long-term mortality in these patients, regardless of the degree of Hb drop or major bleeding.
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http://dx.doi.org/10.1016/j.cjca.2015.10.032DOI Listing
October 2016

Target Hemoglobin May Be Achieved with Intravenous Iron Alone in Anemic Patients with Cardiorenal Syndrome: An Observational Study.

Cardiorenal Med 2015 Oct 4;5(4):246-53. Epub 2015 Jul 4.

Department of Nephrology, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

Background: The treatment of anemia in patients with cardiorenal syndrome (CRS) is based mainly on intravenous (IV) iron therapy and/or erythropoiesis-stimulating agents (ESAs). There are concerns about the safety of ESAs due to a potentially higher risk for stroke and malignancy.

Objective: We aimed to explore whether IV iron alone is sufficient to improve anemia in CRS patients and to define the predictors of treatment response.

Methods: We retrospectively analyzed data of 81 CRS patient treated for anemia at our clinic. All patients received IV iron for 6 weeks. A subset of patients was additionally given subcutaneous ESAs. The end point was the improvement from baseline in hemoglobin (Hb) and ferritin levels at week 7.

Results: We retrieved the files of 81 patients; 34 received IV iron alone and 47 were given IV iron and ESAs (the combination group). The Hb levels significantly increased in both groups (in the IV iron alone group: 10.6 ± 1.1 to 11.9 ±1.1 g/dl, p < 0.001; in the combination group: 10.2 ± 0.9 to 12.4 ± 1.3 g/dl, p < 0.001), but more pronouncedly in the combination group (2.17 vs. 1.24 g/dl; p = 0.001). The platelet count decreased significantly in the IV iron alone group but was unchanged in the combination group. Eighty percent of patients attained a Hb target of 11 g/dl, with no significant difference between the two groups (73.5 vs. 85.1%; p = 0.197). Low baseline Hb was the only predictor of a favorable outcome to treatment.

Conclusion: Our observational study suggests that IV iron treatment without ESAs may substantially raise the Hb level to ≥11 g/dl in CRS patients. This treatment strategy may reduce the use of ESAs and hence its potential adverse effects.
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http://dx.doi.org/10.1159/000433564DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4662275PMC
October 2015

Expediting Time from Symptoms to Medical Contact Utilizing a Telemedicine Call Center.

Telemed J E Health 2015 Oct 4;21(10):801-7. Epub 2015 Jun 4.

1 Department of Cardiology, Tel Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv, Israel .

Background: No definitive solution has been forthcoming for the often dangerously long interval between symptom onset and seeking medical care in the prehospital setting. We examined the implementation of telemedicine technology and characterization of its utilizers for its efficacy in reducing this possibly life-threatening time lag.

Materials And Methods: A retrospective observational study was performed on the working database of an operational telemedicine facility that included all subscribers. Time-to-contact measurements throughout 2012 were retrieved from its medical files, and data on age, gender, medical history, and main complaint were analyzed.

Results: Throughout 2012, 22,274 of a total of 46,556 calls (47.8%) were made ≤60 min from symptom onset. It is important that 26.9% of all calls (12,522/46,556) were made in <15 min. Significantly more males (10,794/22,229 [49%]) contacted in ≤60 min compared with females (11,480/24,327 [47%], p<0.03). Subjects <60 years of age (2,889/5,717 [51%]) called earlier than those >60 years (19,386/40,839 [47%], p<0.001). Patients with prior resuscitation and/or myocardial infarction contacted significantly more rapidly than those with other cardiac diseases. Over one-half of patients with cardiac complaints contacted the call center ≤60 min from symptom onset, as did those who suffered physical trauma, but not patients with gastrointestinal symptoms or pain elsewhere.

Conclusions: A telemedicine system with rapid accessibility to a professional call center and prompt triage thereafter could be an additional promising strategy for shortening the interval between symptom onset and call for medical assistance. Implementation of a widespread telemedicine infrastructure may bridge the unmet gap between occurrence of symptoms to initiation of medical treatment.
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http://dx.doi.org/10.1089/tmj.2014.0227DOI Listing
October 2015

Pericardial covered stent for coronary perforations.

Catheter Cardiovasc Interv 2015 Sep 8;86(3):400-4. Epub 2015 Jul 8.

Department of Cardiology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.

Objectives: To evaluate initial and long term results of coronary perforation treatment with pericardial covered stent.

Background: Iatrogenic coronary perforation is a rare life threatening complication of percutaneous coronary interventions (PCI) occurring in 0.1-0.8% of cases. Covered stents are the mainstay of therapy for coronary perforation. However, polytetrafluoroethylene covered stents are bulky with limited flexibility and thus may not be easy to deliver in difficult anatomy. Therefore, they are reserved to perforations in proximal or mid straight segments where their delivery is relatively easy. The pericardial covered stent is a highly deliverable fully covered stent that may be used to treat coronary perforations. Only a single case has been reported of the use of this stent in its previous version for the treatment of coronary perforation.

Methods: The electronic databases of four tertiary medical centers were retrospectively reviewed for cases of coronary perforations in which PCS was used. During a five years period, between 2008 and 2013, 18,364 patients underwent PCI in these centers. Nine cases of perforations for which balloon dilatation was not sufficient and pericardial covered stent was used were recorded.

Results: All nine cases were successfully treated with pericardial covered stent. Six of the patients underwent repeated angiography at 2-15 months, and in two of them instent restenosis that warranted repeated angioplasty was observed. One of them was catheterized for NSTEMI 3 months after the covered stent implantation, and stent thrombosis was demonstrated.

Conclusions: Pericardial covered stents offer a safe and effective therapy for coronary perforation when balloon inflation and reversal of anticoagulation are insufficient.
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http://dx.doi.org/10.1002/ccd.26011DOI Listing
September 2015

Outcomes of Transfemoral Transcatheter Aortic Valve Implantation in Patients With Previous Coronary Bypass.

Am J Cardiol 2015 Aug 9;116(3):431-5. Epub 2015 May 9.

Department of Cardiology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Patients with previous coronary artery bypass grafting (CABG) are considered to be at increased perioperative risk for a redo cardiac operation. In the era of transcatheter aortic valve implantation (TAVI), these patients constitute a considerable portion of those with severe aortic stenosis referred for TAVI. We evaluated the impact of previous CABG on transfemoral TAVI outcomes. Patients with severe symptomatic aortic stenosis (n = 515) who underwent transfemoral TAVI were divided according to the presence of history of CABG. Patients with previous valvular surgery were excluded (n = 12). TAVI clinical end points and adverse events were considered according to the Valve Academic Research Consortium 2 definitions. Survival was estimated using Cox regression models at the enter mode with the dependent variable defined as all-cause mortality. Of the total 503 patients who underwent TAVI, 91 (18.1%) had previous CABG. At baseline, patients with previous CABG were younger (80.8 vs 83.1 years, p <0.001), mostly men (85% vs 35%, p <0.001), had more cardiac and vascular co-morbidities, higher mean logistic EuroSCORE (32.8 vs 22; p <0.001), lower ejection fraction (53% vs 56%, p <0.001), and lower AV gradients and larger valve area. At a mean follow-up of 636 days, the overall Valve Academic Research Consortium 2-adjudicated end points did not differ. No differences in mortality were observed at 30 days, 6 months, and 1 year after TAVI (hazard ratio 1.34, p = 0.55, Cox regression). We conclude that patients with previous CABG who underwent TAVI do not have increased risk of periprocedural complications or mortality, although having distinct clinical features compared with the total TAVI population.
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http://dx.doi.org/10.1016/j.amjcard.2015.04.055DOI Listing
August 2015

Usefulness of urine output criteria for early detection of acute kidney injury after transcatheter aortic valve implantation.

Cardiorenal Med 2014 Dec 14;4(3-4):155-60. Epub 2014 Aug 14.

Department of Cardiology, Tel-Aviv University, Tel-Aviv, Israel.

Background: Previous studies demonstrated that acute kidney injury (AKI) following transcatheter aortic valve implantation (TAVI) is frequent and associated with adverse outcomes. However, these studies only applied the serum creatinine (sCr) criteria while ignoring the urine output criteria. We hypothesized that adding the urine output criteria might contribute to an earlier diagnosis of AKI.

Methods: We included 143 patients with severe aortic stenosis who underwent transfemoral TAVI between December 2012 and April 2014. Urine output was assessed hourly for at least 24 h following TAVI, and sCr was assessed at least daily until discharge. Based on the Valve Academic Research Consortium-2 (VARC-2), AKI was determined using both sCr and urine output criteria. We compared the incidence of AKI and time to AKI diagnosis based on these two methods.

Results: The mean age was 81 ± 6 years (range 61-94) and 56% were male. AKI occurred in 27 (19%) patients, 13 (9%) of whom had AKI defined by sCr criteria. Twenty (14%) patients had AKI defined by urine output criteria, only 6 of whom had AKI also defined by sCr criteria. The use of urine output criteria resulted in earlier identification of AKI (18 ± 4 vs. 64 ± 57 h, p = 0.02) and was associated with lower sCr elevation in patients having AKI defined by only urine output criteria (0.03 ± 0.12 vs. 0.37 ± 0.06 mg/dl, p < 0.001).

Conclusion: The use of the VARC-2 urine output criteria significantly increased the incidence of AKI and shortened the time to AKI diagnosis.
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http://dx.doi.org/10.1159/000365936DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4299170PMC
December 2014

The obesity paradox in patients undergoing transcatheter aortic valve implantation.

Clin Cardiol 2015 Feb 2;38(2):76-81. Epub 2015 Feb 2.

Department of Cardiology, Tel-Aviv Medical Center and the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.

Background: Obesity is a major risk factor for cardiovascular morbidity and mortality. A considerable number of studies, however, showed better outcomes for overweight patients undergoing cardiovascular interventions-the so called obesity paradox.

Hypothesis: Increased body mass index (BMI) is independently associated with improved survival following transcatheter aortic valve implantation (TAVI).

Methods: We analyzed the data of 409 consecutive patients undergoing TAVI in our medical center. Patients were categorized into 4 groups according to BMI: underweight (≤18.4 kg/m(2) ), normal weight (18.5-24.9 kg/m(2) ), overweight (25-29.9 kg/m(2) ), and obese (≥30 kg/m(2) ). Procedure-related complications were recorded, as well as 30-day and 1-year all-cause mortality rates.

Results: Obese patients had a higher prevalence of comorbidities and higher incidence of vascular complications compared with the normal-weight patients (16% vs 7%, P = 0.013). Nevertheless, 30-day mortality was similar among the groups, whereas 1-year mortality was lower among the overweight and obese patients (BMI >25) (P = 0.038). After adjusting for differences in baseline characteristics, increase in BMI was found to be independently associated with improved survival following TAVI (hazard ratio: 0.94, confidence interval: 0.89-0.99, P = 0.043).

Conclusions: In our single-center study, obesity and overweight were independently associated with better outcome, supporting the obesity paradox in the TAVI population.
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http://dx.doi.org/10.1002/clc.22355DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6711073PMC
February 2015

Relation of in-hospital serum creatinine change patterns and outcomes among ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.

Clin Cardiol 2015 May 1;38(5):274-9. Epub 2015 Feb 1.

Department of Cardiology, Tel-Aviv University, Tel-Aviv, Israel.

Background: The worsening of serum creatinine (sCr) level is a frequent finding among ST-segment elevation MI (STEMI) patients undergoing primary percutaneous coronary intervention (PCI), associated with adverse short-term and long-term outcomes. No information is present, however, regarding the incidence and prognostic implications associated with an improvement in sCr levels throughout hospitalization, as compared with admission levels.

Hypothesis: Reversible renal impairment prior to PCI is not associated with adverse outcomes.

Methods: We retrospectively studied 1260 STEMI patients undergoing primary PCI. The incidence of in-hospital complications and long-term mortality was compared between patients having stable, worsened (>0.3 mg/dL increase), or improved (>0.3 mg/dL decrease) sCr levels throughout hospitalization.

Results: Overall, 127 patients (10%) had worsening in sCr levels, whereas 44 (3.5%) had an improvement of sCr compared with admission levels. Patients with worsening sCR had more complications during hospitalization, higher 30-day (13% vs 1%; P < 0.001) and up to 5-year all-cause mortality (28% vs 5%; P < 0.001) compared with those with stable sCR. No significant difference was found regarding complications and mortality between patients having an improvement in sCr and stable sCr. Compared with patients with stable sCr, the adjusted hazard ratio for all-cause mortality in patients with worsened sCr was 6.68 (95% confidence interval: 2.1-21.6, P = 0.002).

Conclusions: In STEMI patients undergoing primary PCI, renal impairment prior to PCI is a frequent finding. In contrast to post-PCI sCr worsening, this entity is not associated with adverse short-term and long-term outcomes.
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http://dx.doi.org/10.1002/clc.22384DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6711092PMC
May 2015

Periprocedural bleeding, acute kidney injury, and long-term mortality after transcatheter aortic valve implantation.

Can J Cardiol 2015 Jan 11;31(1):56-62. Epub 2014 Nov 11.

Department of Cardiology, Tel-Aviv Medical Center, and the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel. Electronic address:

Background: Acute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI) is frequent and is associated with adverse outcomes. Past studies have attributed AKI to impaired kidney function at baseline, amount of contrast medium used, major bleeding, and hemodynamic instability during the procedure. Because major bleeding might play a role in the development of AKI, we analyzed the relationship between periprocedural bleeding and the development of AKI and assessed the impact of these 2 important procedure-related complications on outcome.

Methods: Consecutive patients undergoing transfemoral TAVI for severe aortic stenosis were prospectively recruited. AKI and bleeding events during hospitalization were recorded, defined, and classified according to the Valve Academic Research Consortium 2 definitions. Logistic and Cox regression was used for predictor and survival analyses.

Results: We recruited 422 consecutive patients who underwent TAVI; the mean follow-up duration was 576 ± 400 days. AKI occurred in 66 (15.6%) patients. No patient required dialysis. Fifty patients (12%) had major or life-threatening bleeding. Periprocedural major or life-threatening bleeding was a strong predictor of the development of AKI (odds ratio, 3.19; 95% confidence interval [CI], 1.38-7.1; P = 0.006). Major bleeding was a strong independent predictor for both 30-day and long-term mortality (hazard ratio [HR], 6.67; 95% CI, 2.2-19.8; P = 0.001 and HR, 3.3, 95% CI, 1.2-9.0; P = 0.02, respectively), whereas AKI was not independently associated with increased mortality after TAVI.

Conclusions: In patients undergoing transfemoral TAVI, periprocedural bleeding is a strong risk factor for the development of AKI and a major determinant of short- and long-term mortality.
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http://dx.doi.org/10.1016/j.cjca.2014.11.006DOI Listing
January 2015