Publications by authors named "James A Goldstein"

116 Publications

Extent of coronary atherosclerosis and ischemic myocardium foment sudden cardiac death.

Catheter Cardiovasc Interv 2022 02;99(3):812-813

Department of Cardiovascular Medicine, Beaumont Health System, Royal Oak, Michigan, USA.

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http://dx.doi.org/10.1002/ccd.30130DOI Listing
February 2022

Hemodynamic Complications of Right Ventricular Infarction: Role of the Right Atrium.

JACC Case Rep 2021 Aug 4;3(9):1174-1176. Epub 2021 Aug 4.

Department of Cardiovascular Medicine, Beaumont Health System, Royal Oak, Michigan, USA.

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http://dx.doi.org/10.1016/j.jaccas.2021.02.045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8353557PMC
August 2021

Hemodynamic compromise in pulmonary embolism: "A tale of two ventricles".

Catheter Cardiovasc Interv 2021 02;97(2):299-300

Department of Cardiovascular Medicine, Beaumont Health System, Royal Oak, Michigan, USA.

In acute pulmonary embolism (PE), low cardiac output (CO)-hypotension results from disparate ventricular conditions: The left ventricle (LV) is under-filled and contracting vigorously, whereas the right ventricle (RV) is failing and dilated. The proximate cause of LV preload deprivation is thrombus-induced pulmonary vascular obstruction; abruptly increased pulmonary vascular resistance (PVR) induces acute RV systolic dysfunction which further compromises trans-pulmonary flow. "Escalation of Care" interventions (thrombolytics and aspiration thrombectomy) improve systemic hemodynamics by increasing LV preload delivery directly by reducing PVR and indirectly by relief of the strained failing RV.
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http://dx.doi.org/10.1002/ccd.29497DOI Listing
February 2021

Disparate impact of severe aortic and mitral regurgitation on left ventricular dilation.

Catheter Cardiovasc Interv 2021 05 20;97(6):1301-1308. Epub 2021 Jan 20.

Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, Royal Oak, Michigan, USA.

In asymptomatic severe aortic (AR) and mitral regurgitation (MR), left ventricular (LV) dimension criteria were established to guide timing of valve replacement to prevent irreversible LV dysfunction. Given both lesions are primary LV volume overload ''leaks'', it might be expected that both lesions would induce similar impact on the LV and result in equivalent dimension criteria for intervention. However, the dimension-based intervention criteria for AR versus MR (developed through natural history studies), differ markedly. The pathophysiological foundations for such discordance have neither been fully elucidated nor emphasized. This case-based treatise compares the two regurgitant lesions with respect to: (a) ''total regurgitant circuits''; (b) ''driving pressures'' resulting in LV volume overload from each respective ''leak''; and (c) volume and afterload wall stresses imposed on the LV.Key points The ''total circuits'' of volume overload differ: The AR circuit includes the LV and systemic vasculature, whereas MR includes the LV ejecting into the left atrium/pulmonary veins and systemic circulation. The ''driving pressure'' of regurgitation and afterload are high with AR and low with MR. Differing ''total circuits'' and ''driving pressures'' impose disparate wall stresses upon the LV. Parallel and serial sarcomere replication occurs in AR, while only serial replication occurs in MR. It therefore follows that for regurgitation of similar severities, AR results in greater LV dilation at the point of irreversible myocardial dysfunction compared to MR. These considerations may explain, at least in part, the disparate dimension criteria employed for valve intervention for severe AR vs MR.
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http://dx.doi.org/10.1002/ccd.29455DOI Listing
May 2021

A novel strategy to prevent contrast nephropathy: "Continuous hemodiafiltration".

Catheter Cardiovasc Interv 2020 11;96(6):1182-1183

Department of Cardiovascular Medicine, Beaumont Hospital, Royal Oak, Michigan, USA.

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http://dx.doi.org/10.1002/ccd.29356DOI Listing
November 2020

Mechanically supported PCI for ischemic cardiomyopathy reawakening of hibernating myocardium.

Catheter Cardiovasc Interv 2020 10;96(4):771-772

Beaumont Hospital, Royal Oak, MI, USA.

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http://dx.doi.org/10.1002/ccd.29304DOI Listing
October 2020

Impella RP for treatment of right ventricular shock: Appropriate unloading never gets old.

Catheter Cardiovasc Interv 2020 08;96(2):382-383

Department of Cardiovascular Medicine, Beaumont Health System, Royal Oak, Michigan.

Rapid restoration of hemodynamics is key to successful shock management. The failing right ventricular (RV) is resilient and recovers if hemodynamics are supported while the underlying insulting cause is alleviated. Inotropic/vasopressor drugs constitute a "double-edged sword" that augment hemodynamics, but exacerbate myocardial and multiorgan injury. Impella RP mechanical support for RV shock stabilizes hemodynamics and is associated with favorable clinical outcomes.
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http://dx.doi.org/10.1002/ccd.29165DOI Listing
August 2020

2-Year Outcomes After Stenting of Lipid-Rich and Nonrich Coronary Plaques.

J Am Coll Cardiol 2020 03;75(12):1371-1382

Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Montefiore Medical Center, Bronx, New York.

Background: Autopsy studies suggest that implanting stents in lipid-rich plaque (LRP) may be associated with adverse outcomes.

Objectives: The purpose of this study was to evaluate the association between LRP detected by near-infrared spectroscopy (NIRS) and clinical outcomes in patients with coronary artery disease treated with contemporary drug-eluting stents.

Methods: In this prospective, multicenter registry, NIRS was performed in patients undergoing coronary angiography and possible percutaneous coronary intervention (PCI). Lipid core burden index (LCBI) was calculated as the fraction of pixels with the probability of LRP >0.6 within a region of interest. MaxLCBI was defined as the maximum LCBI within any 4-mm-long segment. Major adverse cardiac events (MACE) included cardiac death, myocardial infarction, definite or probable stent thrombosis, or unplanned revascularization or rehospitalization for progressive angina or unstable angina. Events were subcategorized as culprit (treated) lesion-related, nonculprit (untreated) lesion-related, or indeterminate.

Results: Among 1,999 patients who were enrolled in the COLOR (Chemometric Observations of Lipid Core Plaques of Interest in Native Coronary Arteries Registry), PCI was performed in 1,621 patients and MACE occurred in 18.0% of patients, of which 8.3% were culprit lesion-related, 10.7% were nonculprit lesion-related, and 3.1% were indeterminate during 2-year follow-up. Complications from NIRS imaging occurred in 9 patients (0.45%), which resulted in 1 peri-procedural myocardial infarction and 1 emergent coronary bypass. Pre-PCI NIRS imaging was obtained in 1,189 patients, and the 2-year rate of culprit lesion-related MACE was not significantly associated with maxLCBI (hazard ratio of maxLCBI per 100: 1.06; 95% confidence interval: 0.96 to 1.17; p = 0.28) after adjusting clinical and procedural factors.

Conclusions: Following PCI with contemporary drug-eluting stents, stent implantation in NIRS-defined LRPs was not associated with increased periprocedural or late adverse outcomes compared with those without significant lipid.
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http://dx.doi.org/10.1016/j.jacc.2020.01.044DOI Listing
March 2020

Cardiac tamponade in the interventional era: A paradigm shift in etiology and outcomes.

Catheter Cardiovasc Interv 2020 02;95(3):387-388

Division of Cardiology, William Beaumont Hospital, Royal Oak, Michigan.

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http://dx.doi.org/10.1002/ccd.28764DOI Listing
February 2020

Hemodynamics of constrictive pericarditis and restrictive cardiomyopathy.

Catheter Cardiovasc Interv 2020 05 6;95(6):1240-1248. Epub 2020 Jan 6.

Veterans Administration Long Beach Health Care System, University of California, Irvine, California.

Constrictive pericarditis (CP) and restrictive cardiomyopathy (RCM) are indolent disabling diseases of diastolic function. The two conditions share common pathophysiologic features, resulting in similar and overlapping clinical presentations, echocardiographic findings, and hemodynamic characteristics. However, their clinical course differs, as CP is surgically curable whereas RCM is a chronic condition managed medically. Separating these two entities is based on delineation of anatomic and physiologic derangements employing multimodality hemodynamic interrogation by advanced imaging techniques (Echo-Doppler, CT, and especially MRI) combined with sophisticated invasive hemodynamics.
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http://dx.doi.org/10.1002/ccd.28692DOI Listing
May 2020

Urgent mechanical circulatory support and transcatheter mitral valve repair for refractory hemodynamic compromise.

Catheter Cardiovasc Interv 2019 Nov 27;94(6):886-892. Epub 2019 Aug 27.

Beaumont Health System, Royal Oak, Michigan.

Patients presenting with hemodynamic instability attributable to left ventricular systolic dysfunction and concomitant severe mitral regurgitation (MR) are increasingly recognized and pose complex management challenges. Surgical therapy is typically precluded owing to prohibitive mortality. The role of percutaneous mechanical circulatory support in such cases is well established; however, such interventions may be neither sufficient to achieve optimal stability nor prove definitive. The advent of novel catheter-based mitral repair modalities now offers primary decisive therapeutic intervention. Three cases of cardiogenic shock with severe MR illustrate the salutary hemodynamic and clinical responses to percutaneous mechanical support and valve repair by mitral clip.
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http://dx.doi.org/10.1002/ccd.28439DOI Listing
November 2019

Ultrasound-accelerated thrombolysis (USAT) versus standard catheter-directed thrombolysis (CDT) for treatment of pulmonary embolism: A retrospective analysis.

Vasc Med 2019 06 27;24(3):234-240. Epub 2019 Mar 27.

1 Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, MI, USA.

Ultrasound-accelerated thrombolysis (USAT) is advocated in pulmonary embolism (PE) based on the hypothesis that adjunctive ultrasound provides superior clinical efficacy compared to standard catheter-directed thrombolysis (CDT). This retrospective study was designed to compare outcomes between the two modalities. We analyzed patients with computed tomography-diagnosed PE at our institution treated with either USAT or standard CDT. Efficacy parameters assessed included invasive pulmonary artery systolic pressure (PASP; pre- and 24 hours post-treatment), non-invasive right-to-left ventricle (RV/LV) ratio (pre- and post-treatment), and general clinical outcomes (length-of-stay, significant bleeding, and mortality). We analyzed 98 cases (62 USAT and 36 CDT), in whom massive PE was diagnosed in 7%, intermediate/high risk in 81%, and intermediate/low risk in 12%. Overall, 92% had bilateral clot and 40% saddle embolus. At 24 hours, PASP decreased similarly in both groups (CDT Δ14.7 mmHg, USAT Δ10.8 mmHg; p = 0.14). Post-treatment, CDT showed similar improvement in the RV/LV ratio (CDT Δ0.58 vs USAT Δ0.45; p = 0.07), despite the baseline ratio being greater in the CDT group, indicating more severe RV strain (1.56 ± 0.36 vs 1.40 ± 0.29; p = 0.01). Intensive care unit and hospital length-of-stays were similar in both groups. A trend toward lesser significant bleeding rates in the CDT group (8.3% vs 12.9%, p = 0.74) as well as improved survival-to-discharge (97.2% vs 91.9%, p = 0.66) was observed. Compared to USAT, standard CDT achieves similar beneficial effects on hemodynamics, RV/LV ratios, and clinical outcomes. These observations suggest that salutary clinical results may be achieved without the need for very expensive devices.
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http://dx.doi.org/10.1177/1358863X19838350DOI Listing
June 2019

Disparate Impact of Ischemic Injury on Regional Wall Dysfunction in Acute Anterior vs Inferior Myocardial Infarction.

Cardiovasc Revasc Med 2019 11 21;20(11):965-972. Epub 2018 Dec 21.

Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, MI, USA.

Background: Acute transmural ischemia should induce similar magnitude of wall motion abnormality (WMA) in both anterior myocardial infarction (AMI) and inferior (IMI). However, patients with AMI generally suffer more severe hemodynamic compromise.

Methods: This retrospective study compared WMA's in ST segment elevation MI patients undergoing primary reperfusion and subsequent cardiac MRI. Regional systolic wall motion and thickening were assessed in all segments throughout the left ventricle (LV).

Results: We analyzed 37 patients (AMI = 24 vs IMI = 13). Reperfusion success was achieved in all and there were no differences between groups in door-to-balloon time (AMI median 77 vs IMI 119 min, p = 0.085). Compared to IMI, in AMI LV ejection fraction was more depressed (37 ± 7.6% vs 51 ± 10.3%, P = 0.0006) and regional WMA more severe (total regional WMA score = 2.63 ± 0.53 vs IMI = 2.1 ± 0.52, P = 0.007). Regional dyskinesis was commonly observed in AMI patients but was rare in IMI (79% vs 7% of cases). Similarly, AMI manifested systolic thinning, whereas thickening was depressed but still present in IMI patients. Strikingly, WMA severity differed downstream relative to the origin of the infarct artery: In all AMI cases, WMA worsened from proximal anterior toward the distal apical zone; in IMI the pattern was reverse, with WMA consistently most severe in the basal segment of the inferior-posterior wall with preservation toward the apical distribution of the infarct vessel.

Conclusion: These results demonstrate a disparate impact of ischemic injury on mechanical performance of the anterior vs inferior-posterior walls. These findings may be attributable to differences between the walls in architecture, mechanics and coronary blood flow. These observations may have implications for myocardial salvage, remodeling and prognosis.
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http://dx.doi.org/10.1016/j.carrev.2018.12.016DOI Listing
November 2019

Low-dose systemic thrombolytic therapy for treatment of submassive pulmonary embolism: Clinical efficacy but attendant hemorrhagic risks.

Catheter Cardiovasc Interv 2019 02 14;93(3):506-510. Epub 2018 Dec 14.

Department of Cardiovascular Medicine, Diseases, Beaumont Health, Royal Oak, Michigan.

Objectives: The purpose of the present study is to evaluate the safety and efficacy of "low-dose" systemic thrombolytic therapy (TT) for treatment of patients with intermediate-high risk submassive pulmonary embolism (PE).

Background: TT is increasingly utilized in acute submassive PE. Strategies for TT include catheter-directed administration as well as traditional IV systemic therapy. Regardless of the route, most studies document the attendant significant bleeding complication rates expected from induction of a systemic lytic state. To mitigate bleeding, "low-dose" systemic TT (Alteplase 50 mg) has been advocated, based on recent studies which demonstrated clinical efficacy with elimination of any significant bleeding complications.

Methods: Over a 24-month period, our institutional PE Response Team treated 45 acute submassive PE patients with "Low Dose" IV Alteplase 50 mg. Clinical outcomes and bleeding complications were assessed.

Results: Overall clinical outcome was excellent, with 97.8% of patients surviving to discharge and a 30-day, all-cause mortality of 4.4%. Despite no patients having a HAS-BLED score > 2 (average score = 0.8 +/-), ISTH major and GUSTO moderate bleeding was observed in 11% (n = 5) of cases.

Conclusions: The present observations document that low-dose systemic TT is associated with excellent clinical outcome for intermediate-high risk submassive PE, but with attendant risk for bleeding. These findings are consistent with the concept that induction of a therapeutic lytic state carries inextricable bleeding risk.
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http://dx.doi.org/10.1002/ccd.28042DOI Listing
February 2019

Submassive pulmonary embolus: The challenge of thrombolytic decision-making in a heterogenous cohort.

Catheter Cardiovasc Interv 2018 08;92(2):372-373

Department of Cardiovascular Medicine, Diseases, Beaumont Health, Royal Oak, Michigan.

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http://dx.doi.org/10.1002/ccd.27778DOI Listing
August 2018

Coronary CT Angiography: Identification of Patients and Plaques "At Risk".

J Am Coll Cardiol 2018 06;71(22):2523-2526

Department of Cardiovascular Medicine, Beaumont Health System, Royal Oak, Michigan. Electronic address:

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http://dx.doi.org/10.1016/j.jacc.2018.02.080DOI Listing
June 2018

Occupational health hazards in the interventional laboratory: Time for a safer environment.

Catheter Cardiovasc Interv 2018 Jan 4. Epub 2018 Jan 4.

Rush Medical College, 675 West North Avenue, Suite 202, Melrose Park, IL 60160.

Over the past 30 years, the advent of fluoroscopically guided interventional procedures has resulted in dramatic increments in both X-ray exposure and physical demands that predispose interventionists to distinct occupational health hazards. The hazards of accumulated radiation exposure have been known for years, but until recently the other potential risks have been ill-defined and under-appreciated. The physical stresses inherent in this career choice appear to be associated with a predilection to orthopedic injuries, attributable in great part to the cumulative adverse effects of bearing the weight and design of personal protective apparel worn to reduce radiation risk and to the poor ergonomic design of interventional suites. These occupational health concerns pertain to cardiologists, radiologists and surgeons working with fluoroscopy, pain management specialists performing nonvascular fluoroscopic procedures, and the many support personnel working in these environments. This position paper is the work of representatives of the major societies of physicians who work in the interventional laboratory environment, and has been formally endorsed by all. In this paper, the available data delineating the prevalence of these occupational health risks is reviewed and ongoing epidemiological studies designed to further elucidate these risks are summarized. The main purpose is to publicly state speaking with a single voice that the interventional laboratory poses workplace hazards that must be acknowledged, better understood and mitigated to the greatest extent possible, and to advocate vigorously on behalf of efforts to reduce these hazards. Interventional physicians and their professional societies, working together with industry, should strive toward the ultimate zero radiation exposure work environment that would eliminate the need for personal protective apparel and prevent its orthopedic and ergonomic consequences. © 2008 Wiley-Liss, Inc.
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http://dx.doi.org/10.1002/ccd.21772DOI Listing
January 2018

Peri-procedural myocardial infarction: Plaques and patients "at-risk".

Catheter Cardiovasc Interv 2017 Nov;90(6):915-916

Department of Cardiovascular Medicine, Beaumont Health System, Royal Oak, Michigan.

Patients with acute coronary syndrome are at risk for peri-procedural myocardial infarction (PMI) Lipid-laden plaques with thinned disrupted fibrous caps are most prone to PMI PMI is associated with worse outcome over time, though whether such damaging events are causal or instead reflect patients prone to future instability from non-culprit vulnerable plaques requires further delineation.
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http://dx.doi.org/10.1002/ccd.27393DOI Listing
November 2017

Hemodynamic guidance of mitral paravalvular leak closure: The V is the key.

Catheter Cardiovasc Interv 2017 11;90(5):859-860

Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, Michigan.

Severe mitral paravalvular leak (PVL) induces elevated mean left atrial (LA) pressure (LAP) and prominent V waves, leading to pulmonary hypertension and right heart failure PVL closure promptly reduces V wave and mean LAP, correlates with improved echo regurgitation grade, and exerts immediate benefit to the lungs and right heart Hemodynamic response patterns facilitate PVL closure.
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http://dx.doi.org/10.1002/ccd.27355DOI Listing
November 2017

Maintenance of valvular integrity with Impella left heart support: Results from the multicenter PROTECT II randomized study.

Catheter Cardiovasc Interv 2018 10 8;92(4):813-817. Epub 2017 Oct 8.

Henry Ford Hospital, Detroit, Michigan.

Background: The Impella 2.5 axial flow pump, which is positioned across the aortic valve, is widely employed for hemodynamic support. The present study compared structural and functional integrity of the left heart valves in patients undergoing Impella vs intra-aortic balloon pump in the randomized PROTECT II trial.

Methods And Results: Transthoracic echocardiograms were performed at baseline, 1 and 3 months in 445 patients in the PROTECT II trial. Serial studies were analyzed by an independent echocardiography core laboratory for aortic and mitral valve structure and function, and left ventricular ejection fraction (LVEF). During Impella support there was no appreciable change in the degree of baseline valvular regurgitation. There were no cases of structural derangement of the mitral or aortic valve after use of the Impella device. At 90-day follow-up, there was an average 22% relative increase in LVEF from baseline (27% ± 9 vs. 33% ± 11, P < 0.001).

Conclusions: The present echocardiographic analysis of the PROTECT II study confirms prior observations regarding the safety of the Impella 2.5 device with respect to mitral and aortic valve function.
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http://dx.doi.org/10.1002/ccd.27242DOI Listing
October 2018

Pacemaker-induced tricuspid regurgitation is uncommon immediately post-implantation.

J Interv Card Electrophysiol 2017 Sep 6;49(3):281-287. Epub 2017 Jul 6.

Department of Cardiovascular Medicine, Beaumont Health, 3601 West 13 Mile Road, Royal Oak, MI, 48073, USA.

Background: Prior studies report permanent pacemaker (PPM)-induced tricuspid regurgitation (TR) in up to one third of cases late post-implantation. We sought to assess the extent of immediate PPM-induced TR.

Methods: Forty patients undergoing PPM implant were prospectively enrolled. Patients with pre-existing moderate or severe TR or an RVSP >50 mmHg were excluded. Pre- and immediate post-implantation transthoracic echocardiography (TTE) analyzed TR grade according to established methods. 3D TTE was utilized to determine lead position in relation to tricuspid leaflets as well as lead mobility across the TV.

Results: Of 40 patients, four were excluded due to baseline moderate TR (n = 3) or RVSP >50 mmHg (n = 1). In the remaining cohort (n = 36), immediate post-implantation TTE showed no increase in TR grade in 30 patients (83%), whereas a one-grade increase from no/trace to mild occurred in six (17%) others. In no patient did immediate moderate or severe TR develop. Exclusive RV pacing was present in 47% of the patients; however, only two of the six patients with increased TR were paced. 3D TTE identified lead position in 92% of the cases-more than 50% of the cases showed RV lead distribution in the middle or post eroseptal commissure of the TV. Lead immobility was seen in only three of the six patients with increased TR.

Conclusions: These findings show that significant PPM-induced TR is uncommon immediately post-implantation and, when it occurs, causes no greater than mild TR. RV pacing and lead mobility do not correlate with worsening of TR. 3D TTE is highly reliable at identifying lead position.
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http://dx.doi.org/10.1007/s10840-017-0266-2DOI Listing
September 2017

Prioritizing and Combining Therapies for Heart Failure in the Era of Mechanical Support Devices.

Interv Cardiol Clin 2017 07 10;6(3):465-480. Epub 2017 May 10.

Cardiovascular Research and Education, Department of Cardiovascular Medicine, William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48073, USA. Electronic address:

Technological advances have promoted challenges to prioritizing and combining therapies for heart failure. The concept of prioritization implies distinct but inextricably linked considerations. They may be viewed from pathophysiologic, clinical, and procedural perspectives, encompassing analysis of hemodynamic status, anatomic considerations, and technical challenges. It is essential to consider factors, including conduction disease, renal and pulmonary function, hematological derangements, and so forth. These considerations allow determination of clinical goals, which determine prioritization and interventional strategies. These considerations then facilitate goal setting for medical and interventional therapies as definitive/destination, preservation/salvage, stepwise, bridge, or palliation.
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http://dx.doi.org/10.1016/j.iccl.2017.03.015DOI Listing
July 2017

Radiation attenuating hand cream: Better than bare.

Catheter Cardiovasc Interv 2017 03;89(4):716-717

Beaumont Health System, Royal Oak, Michigan.

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http://dx.doi.org/10.1002/ccd.27017DOI Listing
March 2017

Invasive characterization of atherosclerotic plaque in patients with peripheral arterial disease using near-infrared spectroscopy intravascular ultrasound.

Catheter Cardiovasc Interv 2017 Sep 17;90(3):461-470. Epub 2017 Mar 17.

Department of Cardiovascular Medicine, Center for Innovation and Research in Cardiovascular Diseases, Beaumont Health, Royal Oak, Michigan.

Objectives: We describe the characteristics of atherosclerotic plaque in patients with peripheral arterial disease (PAD) using near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS) BACKGROUND: Imaging and autopsy studies have described atherosclerotic plaque in different vascular beds, including varying degrees of lipid, fibrosis, and calcification. Recently, NIRS has been validated as an accurate method for detecting lipid-core plaque (LCP) in the coronary circulation. Invasive evaluation of plaque composition using NIRS-IVUS has not been reported in different peripheral arterial circulations.

Methods: We performed invasive angiography and NIRS-IVUS in consecutive PAD patients prior to percutaneous revascularization. Imaging evaluation included parameters from angiography, IVUS, and NIRS. NIRS-IVUS findings were compared among different vascular beds with regard to the presence and extent of calcification and LCP.

Results: One hundred and forty-nine lesions in 126 PAD patients were enrolled, including the internal carotid (n = 10), subclavian/axillary (n = 9), renal (n = 14), iliac (n = 35), femoropopliteal (n = 69), and infrapopliteal (n = 12) arteries. Plaque morphology was calcified in 132 lesions (89%) and fibrous in 17 lesions (11%). Calcification varied from 100% of renal artery stenoses to 55% of subclavian/axillary artery stenoses. LCP was present in 48 lesions (32%) and prevalence varied from 60% in carotid artery stenoses to 0% in renal artery stenoses (P < 0.005). LCP was only observed in fibrocalcific plaque, and was longitudinally and circumferentially surrounded by a more extensive degree of calcium.

Conclusions: NIRS-IVUS in stable PAD patients demonstrates a high frequency of calcific plaque and statistically significant differences in the frequency of LCP in different arterial beds. LCP, when present in the peripheral circulation, is always associated with calcified plaque. The strong co-localization of calcified plaque and LCP in severe PAD lesions may provide plaque-stabilizing effects; further studies are needed. © 2017 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ccd.27023DOI Listing
September 2017

Stenting precision: "Image small, miss small".

Catheter Cardiovasc Interv 2016 09;88(3):348-9

Beaumont Health System, Royal Oak, Michigan.

Stenting by angiography alone predisposes to geographic miss STEMI culprit lesions are most susceptible to Geographic Miss Direct coronary imaging assures procedural precision and perfection.
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http://dx.doi.org/10.1002/ccd.26712DOI Listing
September 2016

"Cardio-Oncology": Implications for interventionists.

Catheter Cardiovasc Interv 2016 Apr;87(5):900-1

Department of Cardiovascular Medicine, Beaumont Health System.

CV complications in cancer patients predominantly result from collateral damage from chemotherapy and radiation Complex interplay of manifold pathophysiologic processes poses evaluation challenges and management conundrums. Pre-cath planning essential, employing advanced non-invasive imaging of myocardium, PC, and great vessels.
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http://dx.doi.org/10.1002/ccd.26535DOI Listing
April 2016

Severe mitral regurgitation and biventricular heart failure successfully treated with biventricular percutaneous axial flow pumps as a bridge to mitral valve surgery.

Catheter Cardiovasc Interv 2017 Jan 25;89(1):159-162. Epub 2016 Mar 25.

Department of Cardiovascular Medicine, Beaumont Health System, Royal Oak, Michigan.

Prompt recognition of acute right ventricular failure is essential in order to provide timely hemodynamic support. We report a case of a patient with severe mitral regurgitation complicated by cardiogenic shock that failed to improve with left ventricular support alone. The recognition of concomitant right ventricular failure led to the addition of a right ventricular support device, resulting in dramatic hemodynamic improvement. © 2016 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ccd.26496DOI Listing
January 2017

Left ventricular systolic dysfunction is associated with adverse outcomes in acute right ventricular infarction.

Coron Artery Dis 2016 Jun;27(4):277-86

aDepartment of Cardiovascular Medicine, Beaumont Health System, Royal Oak bHurley Medical System, Flint, Michigan, USA.

Background: In patients with acute right ventricular infarction (RVI), global right ventricular (RV) performance is dependent on compensatory left ventricular (LV)-septal contractile contributions. This study was designed to assess the influence of depressed left ventricular ejection fraction (LVEF) on hemodynamics and clinical outcomes in patients with RVI.

Methods And Results: We retrospectively identified 338 patients with acute inferior ST elevation myocardial infarction (STEMI) undergoing a primary percutaneous coronary intervention. RVI was determined echocardiographically by right ventricular free wall motion abnormalities and depressed global RV performance (fractional area change); LV function was similarly calculated. RVI was documented in 185 (55%) cases. Compared with those with inferior myocardial infarction alone, patients with RVI suffered more hemodynamic compromise (need for inotropes or vasopressors 39 vs. 15%, P<0.0001, and intra-aortic balloon pump 32 vs. 13%, P<0.0001) and higher in-hospital mortality (14 vs. 3%, P=0.0006). In cases without RVI, the status of LV function did not influence in-hospital mortality (ejection fraction≤40%=7.3% vs. ejection fraction>40%=1.8, P=0.12). In contrast, in patients with RVI, LVEF was an important determinant of outcome: those with LVEF ≤ 40% suffered more hemodynamic compromise (need for inotropes or vasopressors 63 vs. 30%, P<0.0001, and intra-aortic balloon pump 59 vs. 22%, P<0.0001) and had markedly higher in-hospital mortality (33 vs. 7%, P<0.0001).

Conclusion: In patients with acute inferior myocardial infarction complicated by RVI, depressed LVEF is associated with greater hemodynamic compromise and higher in-hospital mortality. These findings may have clinical implications for supportive efforts in such cases.
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http://dx.doi.org/10.1097/MCA.0000000000000358DOI Listing
June 2016
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