Publications by authors named "Hilmi Alnsasra"

20 Publications

  • Page 1 of 1

Association of Aspirin Treatment With Cardiac Allograft Vasculopathy Progression and Adverse Outcomes After Heart Transplantation.

J Card Fail 2021 May;27(5):542-551

Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota. Electronic address:

Background: Enhanced platelet reactivity may play a role in cardiac allograft vasculopathy (CAV) progression. The use of antiplatelet agents after heart transplantation (HT) has been inconsistent and although aspirin (ASA) is often a part of the medication regimen after HT, limited evidence is available on its benefit.

Methods And Results: CAV progression was assessed by measuring the difference in plaque volume and plaque index between the last follow-up and the baseline coronary intravascular ultrasound examination. Overall, 529 HT recipients were retrospectively analyzed (337 had ≥2 intravascular ultrasound studies). The progression in plaque volume (P = .007) and plaque index (P = .002) was significantly attenuated among patients treated with early ASA (within the first year after HT). Over a 6.7-year follow-up, all-cause mortality was lower with early ASA compared with late or no ASA use (P < .001). No cardiac deaths were observed in the early ASA group, and the risk of CAV-related graft dysfunction was significantly lower in this group (P = .03). However, the composite of all CAV-related events (cardiac death, CAV-related graft dysfunction, or coronary angioplasty) was not significantly different between the groups (P = .16).

Conclusions: Early ASA use after HT may delay CAV progression and decrease mortality and CAV-related graft dysfunction, but does not seem to affect overall CAV-associated events.
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http://dx.doi.org/10.1016/j.cardfail.2021.01.019DOI Listing
May 2021

Identifying patients with atrial fibrillation with a single CHADS-VASC risk factor who are at higher risk of stroke.

Ir J Med Sci 2021 Apr 12. Epub 2021 Apr 12.

Chief Physician's Office, Clalit Health Services, Clalit Research Institute, Tel Aviv, Israel.

Aims: Management of patients with a single CHADS-VASc score risk factor is controversial. We attempt to identify the "truly low risk" AF patients who will not benefit from oral anticoagulation (OAC) treatment.

Methods: Retrospective cohort analysis, all incident non-valvular AF (NVAF) cases between 2004 and 2015, and age 21 and older, with up to one thromboembolic risk factor besides sex (CHADS-VASc score of up to 1 for men and up to 2 for women). A "low risk" score was created for these patients using a logistic regression model on the incidence of stroke within 30-2500 days following the NVAF diagnosis.

Results: We identified 15,621 patients. Average age was 53.7 ± 12.3 years, 56.6% male. Mean follow-up was 5.5 years. Significant predictors of ischemic stroke were age 65-74 and diabetes (2 points each), hypertension, vascular disease, and chronic kidney disease stage 2-3 (1 point each). Stroke incidence ranged from 0.8% for score 0 and up to 3.4% for scores ≤ 2. Odds ratio for stroke among patient group with a score ≤ 2 was 4.3 (2.9-6.6) compared with score 0. Our risk score's area-under-the-curve (AUC) for prediction of stroke was 0.68 (0.65-0.71), compared with 0.60 (0.57-0.62) for the CHADS-VASc score, within this low-risk group.

Conclusion: Patients considered at low or intermediate risk using traditional risk stratification schemes, with ≥ 2 points using this proposed low-risk index (65-74 years old, diabetics or a combination of chronic renal failure and an additional risk factor), had an overall stroke risk that may justify anticoagulation therapy.
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http://dx.doi.org/10.1007/s11845-021-02618-yDOI Listing
April 2021

Pericardiocentesis induced right ventricular changes in patients with and without pulmonary hypertension.

Echocardiography 2021 Apr 9. Epub 2021 Apr 9.

MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA.

Background: Pericardial effusion drainage in patients with significant pulmonary hypertension (PH) has been questioned because of hemodynamic collapse concern, mainly because of right ventricular (RV) function challenging assessment. We aimed to assess RV function changes related to pericardiocentesis in patients with and without PH.

Methods: Consecutive patients with symptomatic moderate-to-large pericardial effusion who had either echocardiographic or clinical signs of cardiac tamponade and who underwent pericardiocentesis from 2013 to 2018 were included. RV speckle-tracking echocardiography analysis was performed before and after pericardiocentesis. Patients were stratified by significant PH (pulmonary artery systolic pressure [PASP] ≥50 mm Hg).

Results: The study cohort consisted of 76 patients, 23 (30%) with PH. In patients with PH, both end-diastolic and end-systolic areas (EDA, ESA) increased significantly after pericardiocentesis (22.6 ± 8.0 cm -26.4 ± 8.4 cm , P = .01) and (15.9 ± 6.3 cm -18.7 ± 6.5 cm , P = .02), respectively. However, RV function indices including fractional area change (FAC: 30.6 ± 13.7%-29.1 ± 8.8%, P = .61) and free-wall longitudinal strain (FWLS: -16.7 ± 6.7 to -15.9 ± 5.0, P = .50) remained unchanged postpericardiocentesis. In contrast, in the non-PH group, after pericardiocentesis, EDA increased significantly (20.4 ± 6.2-22.4 ± 5.9 cm , P = .006) but ESA did not (14.9 ± 5.7 vs 15.0 ± 4.6 cm , P = .89), and RV function indices improved (FAC 27.9 ± 11.7%-33.1 ± 8.5%, P = .003; FWLS -13.6 ± 5.4 to -17.2 ± 3.9%, P < .001).

Conclusion: Quantification of RV size and function can improve understanding of echocardiographic and hemodynamic changes postpericardiocentesis, which has the potential to guide management of PH patients with large pericardial effusion.
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http://dx.doi.org/10.1111/echo.15046DOI Listing
April 2021

Tricuspid valve injury after heart transplantation: how to monitor for rejection?

Eur Heart J Cardiovasc Imaging 2021 Feb 23. Epub 2021 Feb 23.

MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA.

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http://dx.doi.org/10.1093/ehjci/jeab035DOI Listing
February 2021

Comparison of Outcomes with or without Beta-Blocker Therapy After Acute Myocardial Infarction in Patients Without Heart Failure or Left Ventricular Systolic Dysfunction (from the Acute Coronary Syndromes Israeli Survey [ACSIS]).

Am J Cardiol 2021 03 12;143:1-6. Epub 2021 Jan 12.

Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel.

The contemporary benefit of routine beta-blocker therapy following myocardial infraction in the absence of heart failure or left ventricular systolic dysfunction is unclear. We investigated the impact of beta-blockers on post myocardial infarction outcome in patients without heart failure or left ventricular systolic dysfunction among patients enrolled in the biennial Acute Coronary Syndrome Israeli Surveys. MACE rates at 30 days and overall mortality at one year were compared among patients discharged on beta-blockers versus not, after multivariate analysis to adjust for baseline differences. Between the years 2000 to 2016, data from 15.211consecutive ACS patients were collected. Of 7,392 patients who met the inclusion criteria, 6007 (79.9%) were discharged on beta-blocker therapy. Prescription of beta-blockers at discharge increased modestly from 32% to 38% over the 16-year period. The 30-day MACE rates were similar in patients on vs. not on beta-blockers at discharge (9.0% and 9.5%, respectively). One year survival did not differ significantly between those on vs. not on beta-blockers (HR 0.8, 95% CI 0.58 to 1.11, p = 0.18).In conclusion, beta-blocker therapy did not affect 30 days MACE or 1-year survival after myocardial infarction in patients without heart failure or reduced ejection fraction.
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http://dx.doi.org/10.1016/j.amjcard.2020.12.044DOI Listing
March 2021

Impact of Sirolimus as a Primary Immunosuppressant on Myocardial Fibrosis and Diastolic Function Following Heart Transplantation.

J Am Heart Assoc 2021 Jan 16;10(1):e018186. Epub 2020 Dec 16.

Department of Cardiovascular Diseases Mayo Clinic Rochester MN.

Background Myocardial fibrosis is an important contributor for development of diastolic dysfunction. We investigated the impact of sirolimus as primary immunosuppression on diastolic dysfunction and fibrosis progression among heart transplantation recipients. Methods and Results In 100 heart transplantation recipients who were either treated with a calcineurin inhibitor (CNI) (n=51) or converted from CNI to sirolimus (n=49), diastolic function parameters were assessed using serial echocardiograms and right heart catheterizations. Myocardial fibrosis was quantified on serial myocardial biopsies. After 3 years, lateral e' increased within the sirolimus group but decreased in the CNI group (0.02±0.04 versus -0.02±0.04 m/s delta change; =0.003, respectively). Both pulmonary capillary wedge pressure and diastolic pulmonary artery pressure significantly decreased in the sirolimus group but remained unchanged in the CNI group (-1.50±2.59 versus 0.20±2.20 mm Hg/year; =0.02; and -1.72±3.39 versus 0.82±2.59 mm Hg/year; =0.005, respectively). A trend for increased percentage of fibrosis was seen in the sirolimus group (8.48±3.17 to 10.10±3.0%; =0.07) as compared with marginally significant progression in the CNI group (8.76±3.87 to 10.56±4.34%; =0.04). The percent change in fibrosis did not differ significantly between the groups (1.62±4.67 versus 1.80±5.31%, respectively; =0.88). Conclusions Early conversion to sirolimus is associated with improvement in diastolic dysfunction and filling pressures as compared with CNI therapy. Whether this could be attributed to attenuation of myocardial fibrosis progression with sirolimus treatment warrants further investigation.
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http://dx.doi.org/10.1161/JAHA.120.018186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955460PMC
January 2021

Mitral inflow obstruction by a descending thoracic aortic aneurysm.

Eur Heart J Cardiovasc Imaging 2021 May;22(6):e77

Department of Cardiology, MedStar Heart and Vascular Institute, Washington, D.C. 20010, USA.

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http://dx.doi.org/10.1093/ehjci/jeaa291DOI Listing
May 2021

Effects of mTOR inhibitor-related proteinuria on progression of cardiac allograft vasculopathy and outcomes among heart transplant recipients.

Am J Transplant 2021 02 21;21(2):626-635. Epub 2020 Jul 21.

Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.

We have previously described the use of sirolimus (SRL) as primary immunosuppression following heart transplantation (HT). The advantages of this approach include attenuation of cardiac allograft vasculopathy (CAV), improvement in glomerular filtration rate (GFR), and reduced malignancy. However, in some patients SRL may cause significant proteinuria. We sought to investigate the prognostic value of proteinuria after conversion to SRL. CAV progression and adverse clinical events were studied. CAV progression was assessed by measuring the Δ change in plaque volume (PV) and plaque index (PI) per year using coronary intravascular ultrasound. Proteinuria was defined as Δ urine protein ≥300 mg/24 h at 1 year after conversion to SRL. Overall, 137 patients were analyzed (26% with proteinuria). Patients with proteinuria had significantly lower GFR (P = .005) but similar GFR during follow-up. Delta PV (P < .001) and Δ PI (P = .001) were significantly higher among patients with proteinuria after adjustment for baseline characteristics. Multivariate Cox regression analysis showed higher all-cause mortality (hazard ratio 3.8; P = .01) with proteinuria but similar risk of CAV-related events (P = .61). Our results indicate that proteinuria is a marker of baseline renal dysfunction, and that HT recipients who develop proteinuria after conversion to SRL have less attenuation of CAV progression and higher mortality risk.
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http://dx.doi.org/10.1111/ajt.16155DOI Listing
February 2021

Predictors and Clinical Outcomes of Vasoplegia in Patients Bridged to Heart Transplantation With Continuous-Flow Left Ventricular Assist Devices.

J Am Heart Assoc 2019 11 8;8(22):e013108. Epub 2019 Nov 8.

Department of Cardiovascular Diseases Mayo Clinic Rochester MN.

Background The presence of a durable left ventricular assist device (LVAD) is associated with increased risk of vasoplegia in the early postoperative period following heart transplantation (HT). However, preoperative predictors of vasoplegia and its impact on survival after HT are unknown. We sought to examine predictors and outcomes of patients who develop vasoplegia after HT following bridging therapy with an LVAD. Methods and Results We identified 94 patients who underwent HT after bridging with continuous-flow LVAD from 2008 to 2018 at a single institution. Vasoplegia was defined as persistent low vascular resistance requiring ≥2 intravenous vasopressors within 48 hours after HT for >24 hours to maintain mean arterial pressure >70 mm Hg. Overall, 44 patients (46.8%) developed vasoplegia after HT. Patients with and without vasoplegia had similar preoperative LVAD, echocardiographic, and hemodynamic parameters. Patients with vasoplegia were significantly older; had longer LVAD support, higher preoperative creatinine, longer cardiopulmonary bypass time, and higher Charlson comorbidity index; and more often underwent combined organ transplantation. In a multivariate logistic regression model, older age (odds ratio: 1.08 per year; =0.010), longer LVAD support (odds ratio: 1.06 per month; =0.007), higher creatinine (odds ratio: 3.9 per 1 mg/dL; =0.039), and longer cardiopulmonary bypass time (odds ratio: 1.83 per hour; =0.044) were independent predictors of vasoplegia. After mean follow-up of 4.0 years after HT, vasoplegia was associated with increased risk of all-cause mortality (hazard ratio: 5.20; 95% CI, 1.71-19.28; =0.003). Conclusions Older age, longer LVAD support, impaired renal function, and prolonged intraoperative CPB time are independent predictors of vasoplegia in patients undergoing HT after LVAD bridging. Vasoplegia is associated with worse prognosis; therefore, detailed assessment of these predictors can be clinically important.
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http://dx.doi.org/10.1161/JAHA.119.013108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6915279PMC
November 2019

Diastolic Pulmonary Gradient as a Predictor of Right Ventricular Failure After Left Ventricular Assist Device Implantation.

J Am Heart Assoc 2019 08 14;8(16):e012073. Epub 2019 Aug 14.

Department of Cardiovascular Diseases Mayo Clinic Rochester MN.

Background Diastolic pulmonary gradient (DPG) was proposed as a better marker of pulmonary vascular remodeling compared with pulmonary vascular resistance (PVR) and transpulmonary gradient (TPG). The prognostic significance of DPG in patients requiring a left ventricular assist device (LVAD) remains unclear. We sought to investigate whether pre-LVAD DPG is a predictor of survival or right ventricular (RV) failure post-LVAD. Methods and Results We retrospectively reviewed 268 patients who underwent right heart catheterization before LVAD implantation from 2007 to 2017 and had pulmonary hypertension because of left heart disease. Patients were dichotomized using DPG ≥7 mm Hg, PVR ≥3 mm Hg, or TPG ≥12 mm Hg. The associations between these parameters and all-cause mortality or RV failure post LVAD were assessed with Cox proportional hazards regression and Kaplan-Meier analyses. After a mean follow-up time of 35 months, elevated DPG was associated with increased risk of RV failure (hazard ratio [HR]: 3.30; P=0.004, for DPG ≥7 versus DPG <7), whereas elevated PVR (HR 1.85, P=0.13 for PVR ≥3 versus PVR <3) or TPG (HR 1.47, P=0.35, for TPG ≥12 versus TPG <12) were not associated with the development of RV failure. Elevated DPG was not associated with mortality risk (HR 1.16, P=0.54, for DPG ≥7 versus DPG <7), whereas elevated PVR, but not TPG, was associated with higher mortality risk (HR 1.55; P=0.026, for PVR ≥3 versus PVR <3). Conclusions Among patients with pulmonary hypertension because of left heart disease requiring LVAD support, elevated DPG was associated with RV failure but not survival, while elevated PVR predicted mortality post LVAD implantation.
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http://dx.doi.org/10.1161/JAHA.119.012073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6759881PMC
August 2019

Incidence of Malignancies in Patients Treated With Sirolimus Following Heart Transplantation.

J Am Coll Cardiol 2019 06;73(21):2676-2688

Department of Cardiovascular Diseases and Health Sciences Research and the William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota. Electronic address:

Background: Malignancy is a major cause of late post-heart transplantation (HT) mortality. Sirolimus (SRL) exerts antiproliferative properties and its long-term use in HT as primary immunosuppression (IS) is associated with decreased mortality risk that is not fully explained by attenuation of cardiac allograft vasculopathy progression.

Objectives: This study sought to examine whether conversion from calcineurin inhibitor (CNI)-based to SRL-based IS was associated with decreased risk of malignancy post-HT.

Methods: Overall, 523 patients underwent HT between 1994 and 2016 at a single institution. The main outcomes included incidence of overall de novo malignancies (excluding non-melanoma skin cancers [NMSCs]), post-transplantation lymphoproliferative disorders (PTLD), and first and subsequent primary occurrences of NMSC post-HT.

Results: The study identified 307 patients on SRL-based and 216 on CNI-based maintenance IS. Over a median follow-up of 10 years after HT, overall de novo malignancies (non-NMSC) occurred in 31% of CNI patients and in 13% of SRL patients (adjusted hazard ratio [HR]: 0.34; 95% confidence interval [CI]: 0.18 to 0.62; p < 0.001). The incidence of the first NMSC was similar in the SRL and CNI groups (HR: 0.92; 95% CI: 0.66 to 1.28; p = 0.62). However, conversion to SRL was significantly associated with a decreased risk of subsequent primary occurrences of NMSC compared with that of CNI (adjusted HR: 0.44; 95% CI: 0.28 to 0.69; p < 0.001). The adjusted PTLD risk was significantly decreased in the SRL group (HR: 0.13; 95% CI: 0.03 to 0.59; p = 0.009). Late survival post-HT was markedly decreased in patients who developed non-NMSC, PTLD, or non-PTLD compared with patients who did not develop these malignancies, whereas NMSC had no significant effect on survival.

Conclusions: Conversion to SRL was associated with a decreased risk of all de novo malignancies, PTLD, and subsequent primary occurrences of NMSC after HT. These findings provided further explanation of the late survival benefit with long-term SRL use.
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http://dx.doi.org/10.1016/j.jacc.2019.03.499DOI Listing
June 2019

Dizziness in the Heartmate III patient.

Heart Lung 2019 Jul - Aug;48(4):320. Epub 2019 Apr 30.

Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.

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http://dx.doi.org/10.1016/j.hrtlng.2019.04.004DOI Listing
April 2019

Feasibility and safety of exclusive echocardiography-guided intravenous temporary pacemaker implantation.

J Echocardiogr 2019 09 13;17(3):157-161. Epub 2018 Nov 13.

Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 151, 84101, Beer Sheva, Israel.

Background: The standard approach for urgent trans-venous temporary cardiac pacemaker (TVTP) implantation is fluoroscopy guidance. The delay in activation of the fluoroscopy-room and the transfer of unstable patients may be life-threatening. Echocardiography-guided TP implantation may increase the safety of the patients by obviating the need for in-hospital transfer. We examined the feasibility and safety of echocardiography-guided vs. fluoroscopy-guided TVTP implantation.

Methods: From January 2015 to September 2017 data for consecutive patients who needed emergent TVTP implantation were retrospectively reviewed. Ultrasound-guided TVTP protocol that was introduced in our center in January 2015 involved ultrasound guidance for both central venous access and pacing lead positioning. Access sites included femoral, subclavian, or jugular veins. Electrodes were placed in the right ventricular apex by means of echocardiographic monitoring in intensive care unit or by fluoroscopic guidance. Endpoints were achievement of successful ventricular pacing and procedural complications.

Results: Sixty-six patients (17 echocardiography-guided and 49 fluoroscopy-guided) were included. There were no differences in pacing threshold between the echocardiography-guided group and the fluoroscopy-guided group (0.75 ± 0.58 mA vs. 0.57 ± 0.35 mA, p = 0.24). The access site for implantation was femoral vein in 27% for the fluoroscopy-guided vs. none for the echocardiography-guided approach (p = 0.015). One hematoma and one related infection occurred in the fluoroscopy-guided group. The need for electrode repositioning was observed in 1 patient in each group. There were no procedural-related deaths in either group.

Conclusions: Echocardiography-guided temporary cardiac pacing is a feasible and safe alternative to fluoroscopy-guided approach and significantly lowers the need for in-hospital transfer.
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http://dx.doi.org/10.1007/s12574-018-0406-4DOI Listing
September 2019

Net clinical benefit of anticoagulant treatments in elderly patients with nonvalvular atrial fibrillation: Experience from the real world.

Heart Rhythm 2019 01 18;16(1):31-37. Epub 2018 Aug 18.

Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel.

Background: Oral anticoagulation (OAC) is effective in stroke prevention in elderly patients with nonvalvular atrial fibrillation (AF), but older patients are also at higher risk of bleeding.

Objective: We aimed to examine whether OAC has net clinical benefit (NCB) in elderly patients with AF.

Methods: This is a retrospective cohort study of patients with AF, aged 75 years and older, who were diagnosed from January 1, 2013, through December 31, 2015. Incidences of stroke and intracranial hemorrhage (ICH) were estimated as the number of events per 100 person-years. The NCBs were estimated with respect to time in therapeutic range (TTR) (<60% or ≥60%) and treatment type (warfarin and low or high dose of direct oral anticoagulants [DOACs]).

Results: We included 11,760 patients, of whom 4982 (42.4%) were treated with OACs: 2042 (17.4%) with warfarin and 2940 (25.0%) with DOACs. Among patients treated with warfarin, those who achieved TTR ≥ 60% had a lower incidence of stroke (2.54 per 100 person-years vs 5.21 per 100 person-years; P = .01) but without a statistically significant lower incidence of ICH (0.68 per 100 person-years vs 1.10 per 100 person-years; P = .45) and a higher NCB (9.78 vs 6.52) than did those with TTR < 60%. Among patients treated with DOACs, patients treated with the high dose had a statistically significant similar incidence of stroke (8.40 per 100 person-years vs 9.81 per 100 person-years; P = .67), a statistically significant lower incidence of ICH (0.33 per 100 person-years vs 1.20 per 100 person-years; P = .02), and a higher NCB (4.42 vs 1.78) than did patients treated with the low dose.

Conclusion: A large proportion of elderly patients are not treated with OACs. We found that the NCB of OAC in the elderly is positive, with the highest benefit in elderly patients treated with warfarin who achieved TTR ≥ 60% or high dose of DOACs.
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http://dx.doi.org/10.1016/j.hrthm.2018.08.016DOI Listing
January 2019

High-grade atrioventricular block in patients with acute myocardial infarction. Insights from a contemporary multi-center survey.

J Electrocardiol 2018 May - Jun;51(3):386-391. Epub 2018 Mar 7.

Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

High-grade atrioventricular block (HAVB) is a frequent complication of acute myocardial infarction (AMI) and is associated with increased morbidity and mortality. We aimed to evaluate the incidence, predictors, and prognostic significance of HAVB in a contemporary cohort of patients with AMI, in the recent era of early reperfusion. Patients with acute coronary syndromes (n=11,487) during the years 2000-2010 were included. Patients were divided into two groups: with HAVB (n=308, 2.7%) and without HAVB (n=11,179, 97.3%). The incidence of HAVB decreased from 4.2% in 2000 to 2.1% in 2010 (p for trend<0.01). Patients with HAVB were more likely to develop in-hospital complications. Independent predictors of developing HAVB were older age, ST-elevation myocardial infarction (STEMI), smoking and Killip class≥2 on admission. 30-day and 1-year mortality rates were significantly higher in the HAVB as compared to the non-HAVB group (24% vs. 4.9%, p<0.01, 33.5% vs. 10%, p<0.01, respectively). Multivariable logistic regression analysis revealed that, HAVB was associated with increased 30-day (OR - 3.97; 95% CI - 1.96-8.04) and 1-year mortality risk (HR - 2.02; 95% CI - 1.3-3.1). Similar estimates were obtained for STEMI and non-STEMI (NSTEMI). In conclusion, although the incidence of HAVB decreased over the last decade, the associated morbidity and mortality are still high in these patients despite early reperfusion therapy.
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http://dx.doi.org/10.1016/j.jelectrocard.2018.03.003DOI Listing
March 2019

Ethnic Diversity and Increasing Resistance Patterns of Hospitalized Community-Acquired Urinary Tract Infections in Southern Israel: A Prospective Study.

Isr Med Assoc J 2017 Sep;19(9):538-542

Division of Internal Medicine, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.

Background: Little is known about the incidence of urinary tract infections (UTI) in the dispersed Bedouin population. UTIs are routinely treated empirically according to local resistance patterns, which is important when evaluating the risk factors and antibiotic resistance patterns in the Bedouin population.

Objectives: To analyze risk factors, pathogens, and antibiotic resistance patterns of UTIs in the Bedouin population compared to the general population in southern Israel. To compare data from this study to that from a previous study conducted at our center.

Methods: We prospectively followed all patients hospitalized with community acquired UTIs during a 4 month period at Soroka Medical Center. We also compared results from this study to those from a study conducted in 2000.

Results: The study comprised 223 patients: 44 Bedouin (19.7%), 179 (80.3) non-Bedouin; 158 female (70.9%), 65 male (29.1). The Bedouin were younger (51.7 vs. 71.1 years of age, P < 0.001) and had a lower Charlson Comorbidity Index (2.25 vs. 4.87, P < 0.001). Enterobacteriaceae were the most common pathogens identified, and Escherichia coli (E. coli) was the most common with 156 (70%) strains identified, followed by Klebsiella spp. with 29 (13%), Proteus spp. with 18 (8%), pseudomonas with 9 (4%), and other bacteria including enterococci with 11 (5%). The prevalence of E. coli increased significantly from 56% in 2000 to 70% in this study. We also noted an increase in community acquired extended spectrum beta lactamase (ESBL) pathogens from 4.5% in 2000 to 25.5% in the present study. No statistically significant difference was observed between the Bedouin and general populations in the causal pathogens, resistance to antibiotics, length of therapy, and readmission rate within 60 days.

Conclusions: The Bedouin population hospitalized for UTIs is younger and presents with fewer co-morbidities. Isolated pathogens were similar to those found in the general population as was the presence of drug resistant infections. Overall, a substantial percentage of pathogens were resistant to standard first-line antibiotics, driving the need to change from empiric therapy to aminoglycoside therapy.
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September 2017

Contemporary Determinants of Delayed Benchmark Timelines in Acute Myocardial Infarction in Men and Women.

Am J Cardiol 2017 Nov 8;120(10):1715-1719. Epub 2017 Aug 8.

Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel. Electronic address:

Treatment delays in patients with acute myocardial infarction (AMI) are related to increased morbidity and mortality. Hence, identifying determinants of delay may help reduce time to treatment. Importantly, limited data suggest that there may be sex-related disparities in benchmark timelines. Although guidelines advocate the use of the first medical contact (FMC) rather than hospital admission as the moment from which delays to treatment should be monitored, the latter is still often used for quality purposes. We aimed to identify factors associated with treatment delays, with an emphasis on sex-related disparities. We reviewed data on 3,658 patients with AMI from 2 contemporary, consecutive multicenter surveys. Measured delays were FMC-to-electrocardiogram >10 minutes in ST-elevation MI (STEMI) and non-STEMI, FMC-to-primary percutaneous coronary intervention >90 minutes in STEMI, and invasive angiography >72 hours after admission in non-STEMI patients. Timely electrocardiogram was performed in 48% of patients with STEMI and in 39.8% of non-STEMI patients without significant sex-related differences. Independent determinants of delay included atypical chest pain (CP) and presentation during daytime. In patients with STEMI, 37.5% had primary percutaneous coronary intervention in less than 90 minutes without significant sex-related disparities. Independent determinants of delay included atypical CP, night presentation, and diabetes. In non-STEMI patients, independent determinants of delayed invasive approach were female sex, age >75 years, atypical CP, and renal failure. In conclusion, significant treatment delays in patients with AMI are still frequent in contemporary practice, highlighting the need for improvement and guidelines implementation. Predictors of delay identified in our study may facilitate targeting of interventions to improve adherence to guidelines.
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http://dx.doi.org/10.1016/j.amjcard.2017.07.085DOI Listing
November 2017

Successful treatment of ventricular fibrillation storm triggered by short-long-short sequence; time to avoid managed ventricular pacing.

J Electrocardiol 2017 Nov - Dec;50(6):941-943. Epub 2017 Jun 8.

Department of Cardiology, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) is caused by ventricular tachyarrhythmia that can be effectively treated by implantable cardioverter defibrillator (ICD) therapy. We report of a 28-year-old man with HCM and a dual chamber ICD, originally implanted for primary prevention of SCD, (programmed to AAI(R)-DDD(R); managed ventricular pacing (MVP) mode, Medtronic Inc. St Paul, MN USA). He presented with recurrent ICD shocks due to ventricular fibrillation (VF) despite antiarrhythmic therapy. Careful assessment of the stored electrograms demonstrated a repetitive pattern of VF initiation following short-long-short sequences. Initially, activation of ventricular rate stabilization (VRS) algorithm failed to prevent recurrent VF. Ultimately, deactivation of MVP and reprogramming the device to DDD mode with VRS on, resulted in arrhythmia suppression and avoidance of ICD shocks. Physicians should be aware that although VRS function is available in MVP mode, it does not function in the AAI mode during MVP; in order to effectively treat short-long-short sequence induced ventricular arrhythmia by device programming.
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http://dx.doi.org/10.1016/j.jelectrocard.2017.06.005DOI Listing
August 2018

Swallow-induced syncope and carotid sinus hypersensitivity: Coincident or associated conditions?

J Electrocardiol 2017 Jul - Aug;50(4):523-525. Epub 2017 Mar 14.

Department of Cardiology, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Swallow induced syncope is a rare clinical condition which is thought to result from an abnormal vagal reflex leading to bradycardia and cerebral hypoperfusion. It mostly occurs in patients with organic or functional disorders of the esophagus, and often requires permanent pacemaker implantation, along with treatment of the underlying esophageal pathology. In the following case, we report of a 71-year-old male with achalasia post per oral endoscopic myectomy, who presented with syncope and documented AV-block while eating solid food. In addition, long sinus pauses were noted during carotid sinus massage, suggesting that the two distinct entities may be associated, and further supporting the mechanism of neurally mediated syncope in the pathophysiology of swallow-induced syncope.
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http://dx.doi.org/10.1016/j.jelectrocard.2017.03.011DOI Listing
May 2018

Two to one CRTD pacing: When the T wave and the P wave interact.

J Electrocardiol 2017 May - Jun;50(3):372-374. Epub 2016 Dec 29.

Cardiology Department, Soroka Medical Center, Beer-Sheva, Israel; Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.

We presented a unique phenomenon of 2:1 cardiac resynchronization therapy pacing due to T wave oversensing. Ultimately, by utilizing a unique feature of integrated bipolar sensing, we succeeded to eliminate the T wave oversensing signals, and restore 1:1 CRTD pacing. Importantly, this feature enabled us to overcome the T wave oversensing issue, without the need to decrease the ventricular sensitivity, which could potentially interfere with ventricular arrhythmia detection and appropriate shock delivery when required.
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http://dx.doi.org/10.1016/j.jelectrocard.2016.12.003DOI Listing
February 2018