Publications by authors named "Parasuram Krishnamoorthy"

78 Publications

Prognostic value of left ventricular global longitudinal strain in mitral regurgitation: a systematic review.

Heart Fail Rev 2022 Jul 28. Epub 2022 Jul 28.

Division of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave L. Levy Place, New York, NY, 10029, USA.

Conventional echocardiographic assessment may overestimate the left ventricular (LV) function in mitral regurgitation (MR). LV global longitudinal strain (GLS) is more sensitive marker to detect subclinical LV dysfunction. Multiple studies have investigated the prognostic value of LV-GLS in MR to examine its potential to determine the timing and indication of intervention. This systematic review aimed to assess the prognostic value of LV-GLS in patients with mitral regurgitation (MR) to define its clinical applicability. PUBMED and EMBASE were queried through July 2021 to identify studies investigating the prognostic value of LV-GLS in MR. A total of 24 observational studies with 5267 patients were identified. Sixteen studies investigated for primary MR, 7 studies for secondary MR, and 1 study for both. Most studies included patients who underwent intervention. There was significant heterogeneity in patient population, intervention status, follow-up period, LV-GLS cutoff value, outcomes, and statistical methods among the studies. Meta-analysis was not performed considering the significant variability. With exception to 1 study, all studies demonstrated significant association between impaired LV-GLS and worse clinical and echocardiographic outcomes in primary MR. Prognostic value of LV-GLS in secondary MR was less certain due to inconsistent findings and limited reporting. LV-GLS is a promising parameter of prognostication in primary MR and can be considered as alternative to determine the timing of intervention. However, the optimal cutoff value remains unclear. The prognostic value of LV-GLS in secondary MR is less clear. Further large-scale prospective study is warranted before its routine clinical application.
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http://dx.doi.org/10.1007/s10741-022-10265-3DOI Listing
July 2022

Contrast-associated acute kidney injury: Type may not matter.

Catheter Cardiovasc Interv 2022 07;100(1):94-95

Division of Cardiology, Department of Medicine, Mount Sinai Hospital, New York, New York, USA.

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http://dx.doi.org/10.1002/ccd.30314DOI Listing
July 2022

Deploying a novel custom mobile application for STEMI activation and transfer in a large healthcare system to improve cross-team workflow. STEMIcathAID implementation project.

Am Heart J 2022 Jun 30;253:30-38. Epub 2022 Jun 30.

The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address:

Background: ST-segment elevation myocardial infarction (STEMI) is a high-risk patient medical emergency. We developed a secure mobile application, STEMIcathAID, to optimize care for STEMI patients by providing a digital platform for communication between the STEMI care team members, EKG transmission, cardiac catherization laboratory (cath lab) activation and ambulance tracking. The aim of this report is to describe the implementation of the app into the current STEMI workflow in preparation for a pilot project employing the app for inter-hospital STEMI transfer.

Approach: App deployment involved key leadership stakeholders from all multidisciplinary teams taking care of STEMI patients. The team developed a transition plan addressing all aspects of the health system improvement process including the workflow analysis and redesign, app installation, personnel training including user account access to the app, and development of a quality assurance program for progress evaluation. The pilot will go live in the Emergency Department (ED) of one of the hospitals within the Mount Sinai Hospital System (MSHS) during the daytime weekday hours at the beginning and extending to 24/7 schedule over 4-6 weeks. For the duration of the pilot, ED personnel will combine the STEMIcathAID app activation with previous established STEMI activation processes through the MSHS Clinical Command Center (CCC) to ensure efficient and reliable response to a STEMI alert. More than 250 people were provisioned app accounts including ED Physicians and frontline nurses, and trained on their user-specific roles and responsibilities and scheduled in the app. The team will be provided with a feedback form that is discipline specific to complete after every STEMI case in order to collect information on user experience with the STEMIcathAID app functionality. The form will also provide quantitative metrics for the key time sensitive steps in STEMI care.

Conclusions: We developed a uniform approach for deployment of a mobile application for STEMI activation and transfer in a large urban healthcare system to optimize the clinical workflow in STEMI care. The results of the pilot will demonstrate whether the app has a significant impact on the quality of care for transfer of STEMI patients.
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http://dx.doi.org/10.1016/j.ahj.2022.06.008DOI Listing
June 2022

Outcomes and feasibility of redo-TAVR after Sapien 3 Ultra TAVR in extremely-undersized versus nominally-sized annuli.

Catheter Cardiovasc Interv 2022 05 21;99(6):1935-1944. Epub 2022 Mar 21.

Division of Cardiology, St. Paul's Hospital, Vancouver, British Columbia, Canada.

Objectives: To compare outcomes in Sapien 3 Ultra (S3U) transcatheter aortic valve replacement (TAVR) with extreme annular undersizing (EAU) versus nominal annular sizing (NAS).

Background: The Edwards S3U valve has reduced paravalvular leak (PVL) in TAVR but outcomes remain unknown in extremely undersized anatomy. Implanting a smaller S3U valve may facilitate future redo-TAVR but risk compromising hemodynamics.

Methods: From December 2019 to July 2021, 366 patients with native aortic stenosis underwent S3U TAVR. Patients with EAU (annular areas >430 mm for 23 mm or >546 mm for 26 mm) were compared to NAS (338-430 mm for 23 mm or 430-546 mm for 26 mm). In-hospital and 30-day outcomes, and redo-TAVR feasibility were determined.

Results: There were 79 (21.6%) EAU patients, with more bicuspid (p = 0.0014) and ≥moderate annular/left ventricular outflow tract calcification (p < 0.001). The EAU group had less annular oversizing than NAS group (23 mm: -8.2 ± 2.6% vs. 4.0 ± 7.0%, p < 0.001; 26 mm: -8.9 ± 2.2% vs. 6.7 ± 6.9%, p < 0.001), more balloon overfilling (71.3% vs. 11.6%, p < 0.001), and postdilatation (15.0% vs. 5.8%, p = 0.016). No differences were found in in-hospital or 30-day mortality and stroke (p > 0.05). Mild PVL (13.4% EAU vs. 11.5% NAS, p = 0.56) and mean gradients (23 mm: 13.0 ± 4.5 vs. 14.1 ± 5.4 mmHg, p = 0.40; 26 mm: 11.4 ± 4.1 vs. 11.5 ± 3.9 mmHg, p = 1.0) were similar at 30 days. Had the EAU group undergone NAS with the larger Sapien 3/S3U, by computed tomography analysis simulating 80:20 or 90:10 target implant depth, 33.3%-60.9% (vs. 4.3%-23.2%) would not be feasible for redo-TAVR due to high risk of coronary obstruction.

Conclusions: In this first report of EAU with S3U TAVR, similar excellent short-term outcomes can be achieved compared to NAS, and may preserve future redo-TAVR option.
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http://dx.doi.org/10.1002/ccd.30146DOI Listing
May 2022

The Effect of TAVR on Left Ventricular and Left Atrial Mechanics in Patients with Aortic Stenosis.

J Cardiovasc Dev Dis 2022 Jan 21;9(2). Epub 2022 Jan 21.

Division of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, 1 Gustave L. Levy Place, New York, NY 10029, USA.

Measures of adverse cardiac remodeling, left ventricular global longitudinal strain (LVGLS) and left atrial (LA) phasic function, are predictive of cardiac events in patients with severe aortic stenosis (AS). How these parameters of cardiac function change following TAVR requires further investigation. A number of 109 consecutive patients with symptomatic severe AS who were seen in the heart valve clinic between 2014 and 2019 for TAVR were included. All patients underwent echocardiographic assessment prior to and 30 days following TAVR, with LVGLS and LA phasic function evaluation using 2D speckle-tracking echocardiography. Heart failure hospitalization, and death were assessed at 12 months. The mean age of the study cohort was 81 ± 7.3 years. Following TAVR, there was a significant reduction in NYHA class III/IV symptoms [89 (82%) vs. 12 (11%), < 0.01], and median mean aortic valve gradient [44 mmHg (16) vs. 9 mmHg (7), < 0.01]. There was no significant change in the median LVEF [62% (13) vs. 62% (6.0), = 0.2]; however, the LVGLS significantly increased following TAVR [15 ± 3.5% vs. 18 ± 3.3%, < 0.01]. The median LA reservoir, conduit and contractile function significantly improved following TAVR [22.0% (14.0) vs. 18.0% (14.0) < 0.01, 8.9% (5.4) vs. 7.8% (4.8) < 0.01, 12% (11.0) vs. 9.6% (11.0) < 0.01, respectively]. The incidence of death or heart failure hospitalization at 12 months was low, and occurred in eight patients (7.3%). TAVR results in significant short-term reverse LV and LA remodeling, as shown by improvement in LV GLS and all three components of LA phasic function, despite no change in the LVEF. The findings indicate the possible utility of strain imaging for the assessment of global LV and LA function following TAVR.
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http://dx.doi.org/10.3390/jcdd9020035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8877352PMC
January 2022

Cusp Overlap Technique: Should It Become the Standard Implantation Technique for Self-expanding Valves?

Curr Cardiol Rep 2021 10 1;23(11):154. Epub 2021 Oct 1.

Department of Cardiovascular Surgery, The Mount Sinai Hospital, New York, NY, USA.

Purpose Of Review: Accurate imaging of the aortic root during valve implantation is crucial for proper prosthesis positioning during TAVR. The purpose of this review was to determine if routine use of the cusp-overlap view should be adopted for self-expanding valves.

Recent Findings: The use of the cusp-overlap view with the Evolut, Portico, ACURATE neo/neo2, and JenaValve systems is associated with lower post-procedural new permanent pacemaker implantation rates when compared with the standard 3-cusp view, presumably due to more precise valve implantation relative to the conduction system by the non-coronary cusp. By elongating the left ventricular outflow tract and accentuating the right-non commissure in the center of the fluoroscopic view, the cusp-overlap technique allows operators to more precisely control the prosthesis implant depth during self-expanding valve deployment. While the early experience with this approach in Evolut TAVR has been promising, the results of larger studies with longer follow-up across multiple self-expanding systems are warranted.
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http://dx.doi.org/10.1007/s11886-021-01583-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8845572PMC
October 2021

Types of myocardial injury and mid-term outcomes in patients with COVID-19.

Eur Heart J Qual Care Clin Outcomes 2021 09;7(5):438-446

The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA.

Aims: To evaluate the acute and chronic patterns of myocardial injury among patients with coronavirus disease-2019 (COVID-19), and their mid-term outcomes.

Methods And Results: Patients with laboratory-confirmed COVID-19 who had a hospital encounter within the Mount Sinai Health System (New York City) between 27 February 2020 and 15 October 2020 were evaluated for inclusion. Troponin levels assessed between 72 h before and 48 h after the COVID-19 diagnosis were used to stratify the study population by the presence of acute and chronic myocardial injury, as defined by the Fourth Universal Definition of Myocardial Infarction. Among 4695 patients, those with chronic myocardial injury (n = 319, 6.8%) had more comorbidities, including chronic kidney disease and heart failure, while acute myocardial injury (n = 1168, 24.9%) was more associated with increased levels of inflammatory markers. Both types of myocardial injury were strongly associated with impaired survival at 6 months [chronic: hazard ratio (HR) 4.17, 95% confidence interval (CI) 3.44-5.06; acute: HR 4.72, 95% CI 4.14-5.36], even after excluding events occurring in the first 30 days (chronic: HR 3.97, 95% CI 2.15-7.33; acute: HR 4.13, 95% CI 2.75-6.21). The mortality risk was not significantly different in patients with acute as compared with chronic myocardial injury (HR 1.13, 95% CI 0.94-1.36), except for a worse prognostic impact of acute myocardial injury in patients <65 years of age (P-interaction = 0.043) and in those without coronary artery disease (P-interaction = 0.041).

Conclusion: Chronic and acute myocardial injury represent two distinctive patterns of cardiac involvement among COVID-19 patients. While both types of myocardial injury are associated with impaired survival at 6 months, mortality rates peak in the early phase of the infection but remain elevated even beyond 30 days during the convalescent phase.
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http://dx.doi.org/10.1093/ehjqcco/qcab053DOI Listing
September 2021

One Image Gives the Answer: Do Not Balloon Me!

JACC Cardiovasc Interv 2021 10 25;14(20):e285-e286. Epub 2021 Aug 25.

Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jcin.2021.07.020DOI Listing
October 2021

Late-Phase Delayed Coronary Obstruction Caused by Protruding Calcified Aortic Valve Leaflet After Balloon-Expandable Transcatheter Aortic Valve Replacement.

Circ Cardiovasc Imaging 2021 09 27;14(9):e012854. Epub 2021 Aug 27.

Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, NY (K.Y., S.G., P.K., S.M.L., S.K.S., A.S.K.).

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http://dx.doi.org/10.1161/CIRCIMAGING.121.012854DOI Listing
September 2021

A Novel Strategy to Enable TAVR for Severe Aortic Stenosis in the Setting of a Persistent LAA Filling Defect.

JACC Cardiovasc Interv 2021 06 12;14(11):e119-e121. Epub 2021 May 12.

Division of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jcin.2021.03.005DOI Listing
June 2021

A Novel 3D Echocardiographic Rendering Tool for Assessment of Mitral Annuloplasty Ring Dehiscence.

JACC Cardiovasc Interv 2021 06 12;14(11):1259-1261. Epub 2021 May 12.

Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jcin.2021.03.015DOI Listing
June 2021

Impact of Surgical and Transcatheter Aortic Valve Replacement in Low-Gradient Aortic Stenosis: A Meta-Analysis.

JACC Cardiovasc Interv 2021 07 3;14(13):1481-1492. Epub 2021 May 3.

Division of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York, USA. Electronic address:

Objectives: The aim of this study was to assess the impact of aortic valve replacement (AVR) on survival in patients with each subclass of low-gradient (LG) aortic stenosis (AS) and to compare outcomes following surgical AVR (SAVR) and transcatheter AVR (TAVR).

Background: LG severe AS encompasses a wide variety of pathophysiology, including classical low-flow, LG (LF-LG), paradoxical LF-LG, and normal-flow, LG (NF-LG) AS, and uncertainty exists regarding the impact of AVR on each subclass of LG AS.

Methods: PubMed and Embase were queried through October 2020 to identify studies comparing survival with different management strategies (SAVR, TAVR, and conservative) in patients with LG AS. Pairwise meta-analysis comparing AVR versus conservative management and network meta-analysis comparing SAVR versus TAVR versus conservative management were performed.

Results: Thirty-two studies with a total of 6,515 patients and a median follow-up time of 24.2 months (interquartile range: 36.5 months) were included. AVR was associated with a significant decrease in all-cause mortality in classical LF-LG (hazard ratio [HR]: 0.42; 95% confidence interval [CI]: 0.36 to 0.48), paradoxical LF-LG (HR: 0.41; 95% CI: 0.29 to 0.57), and NF-LG (HR: 0.41; 95% CI: 0.27 to 0.62) AS compared with conservative management. SAVR and TAVR were each associated with a decrease in all-cause mortality in classical LF-LG (HR: 0.46 [95% CI: 0.38 to 0.55] and 0.49 [95% CI: 0.37 to 0.64], respectively), paradoxical LF-LG (HR: 0.42 [95% CI: 0.28 to 0.65] and 0.42 [95% CI: 0.25 to 0.72], respectively), and NF-LG (HR: 0.40 [95% CI: 0.21 to 0.77] and 0.46 [95% CI: 0.26 to 0.84], respectively) AS compared with conservative management. No significant difference was observed between SAVR and TAVR.

Conclusions: In all subclasses of LG AS, AVR was associated with a significant decrease in all-cause mortality regardless of surgical or transcatheter approach.
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http://dx.doi.org/10.1016/j.jcin.2021.04.038DOI Listing
July 2021

Comparison of the effect of Morphine and Fentanyl in patients with acute coronary syndrome receiving Ticagrelor - The COMET (Comparison Morphine, Fentayl and Ticagrelor) randomized controlled trial.

Int J Cardiol 2021 05 15;330:1-6. Epub 2021 Feb 15.

Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.

Introduction: Dual antiplatelet therapy (DAPT) remains the cornerstone of acute coronary syndrome (ACS) management, and ticagrelor is one of the commonly used second antiplatelet agents. There is some evidence to suggest that morphine may reduce the antiplatelet effect of ticagrelor.

Methods And Results: In a single-center, randomized controlled trial, we compared the effect of morphine and fentanyl on platelet aggregation (PA) among patients with ACS treated with ticagrelor. Platelet aggregation was studied by automated light transmittance aggregometry (LTA) at baseline, and at 2 h after ticagrelor loading. The primary outcome was the difference in the maximal inhibition of platelet aggregation [IPA(%)] between the groups at 2 h. Pain relief, and drug-related adverse events were secondary outcomes. Of 136 patients randomized, 70 received fentanyl and 66 received morphine. At baseline, the median (IQR) platelet aggregation [61.35% (54.6 to 70) Vs. 58.8% (52.7 to 72.9)] were comparable between the groups. There was no statistically significant difference between the fentanyl and the morphine groups in IPA at 2-h [85.88%(64.65-98.16) and 81.93%(44.2-98.03), p = 0.09]. However, morphine use was independently associated with a PA of >30% at 2 h (p < 0.009). There was no difference in adverse events.

Conclusion: In patients with ACS, there was no significant difference between the use of fentanyl or morphine on the effect of ticagrelor on PA. (CTRI/2018/04/013423).
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http://dx.doi.org/10.1016/j.ijcard.2021.02.037DOI Listing
May 2021

A Novel Hybrid Imaging Approach for Guidance of Percutaneous Transcatheter Tricuspid Valve Edge-to-Edge Repair.

J Am Soc Echocardiogr 2021 05 7;34(5):567-568. Epub 2021 Jan 7.

Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.

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http://dx.doi.org/10.1016/j.echo.2020.12.026DOI Listing
May 2021

Pulmonary Arterial Hypertension in Hospitalized Patients With Polycythemia Vera (from the National Inpatient Database).

Am J Cardiol 2021 03 19;143:154-157. Epub 2020 Dec 19.

Department of Internal Medicine, Einstein Medical Center, Philadelphia, Pennsylvania; Department of Internal Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1016/j.amjcard.2020.12.023DOI Listing
March 2021

Rotational Atherectomy: Coming in Clutch at Desperate Times?

Cardiovasc Revasc Med 2021 01 9;22:42-43. Epub 2020 Nov 9.

The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA. Electronic address:

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http://dx.doi.org/10.1016/j.carrev.2020.10.009DOI Listing
January 2021

Abnormal left ventricular global longitudinal strain by speckle tracking echocardiography in COVID-19 patients.

Future Cardiol 2021 07 9;17(4):655-661. Epub 2020 Oct 9.

The Zena & Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY 10029, USA.

COVID-19 infection can affect the cardiovascular system. We sought to determine if left ventricular global longitudinal strain (LVGLS) is affected by COVID-19 and if this has prognostic implications. Retrospective study, with LVGLS was measured in 58 COVID-19 patients. Patients discharged were compared with those who died. The mean LV ejection fraction (LVEF) and LVGLS for the cohort was 52.1 and -12.9 ± 4.0%, respectively. Among 30 patients with preserved LVEF (>50%), LVGLS was -15.7 ± 2.8%, which is lower than the reference mean LVGLS for a normal, healthy population. There was no significant difference in LVGLS or LVEF when comparing patients who survived to discharge or died. LVGLS was reduced in COVID-19 patients, although not significantly lower in those who died compared with survivors.
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http://dx.doi.org/10.2217/fca-2020-0121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7673304PMC
July 2021

Characteristics and Outcomes of Patients Deferred for Transcatheter Aortic Valve Replacement Because of COVID-19.

JAMA Netw Open 2020 09 1;3(9):e2019801. Epub 2020 Sep 1.

Division of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York.

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http://dx.doi.org/10.1001/jamanetworkopen.2020.19801DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527872PMC
September 2020

Stable Significant Coronary Artery Disease: An Innocent Bystander in Sudden Cardiac Death?

Circ Cardiovasc Interv 2020 09 8;13(9):e009888. Epub 2020 Sep 8.

Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY.

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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.120.009888DOI Listing
September 2020

Biventricular strain by speckle tracking echocardiography in COVID-19: findings and possible prognostic implications.

Future Cardiol 2021 07 4;17(4):663-667. Epub 2020 Aug 4.

The Zena & Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY, USA.

The COVID-19 infection adversely affects the cardiovascular system. Transthoracic echocardiography has demonstrated diagnostic, prognostic and therapeutic utility. We report biventricular myocardial strain in COVID-19. Biventricular strain measurements were performed for 12 patients. Patients who were discharged were compared with those who needed intubation and/or died. Seven patients were discharged and five died or needed intubation. Right ventricular strain parameters were decreased in patients with poor outcomes compared with those discharged. Left ventricular strain was decreased in both groups but was not statistically significant. Right ventricular strain was decreased in patients with poor outcomes and left ventricular strain was decreased regardless of outcome. Right ventricular strain measurements may be important for risk stratification and prognosis. Further studies are needed to confirm these findings.
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http://dx.doi.org/10.2217/fca-2020-0100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405100PMC
July 2021

Use of Rotational Atherectomy in Patients With LV Systolic Dysfunction "Works Better Where it Matters the Most".

Cardiovasc Revasc Med 2020 10 23;21(10):1228-1229. Epub 2020 Jul 23.

Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, NY, New York, USA. Electronic address:

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http://dx.doi.org/10.1016/j.carrev.2020.07.019DOI Listing
October 2020

Gender Difference Is Associated With Severity of Coronavirus Disease 2019 Infection: An Insight From a Meta-Analysis.

Crit Care Explor 2020 Jun 19;2(6):e0148. Epub 2020 Jun 19.

Division of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY.

Objectives: Coronavirus disease 2019 is a novel infection now causing pandemic around the world. The gender difference in regards to the severity of coronavirus disease 2019 infection has not been well described thus far. Our aim was to investigate how gender difference can affect the disease severity of coronavirus disease 2019 infection.

Data Sources: A comprehensive literature search of PubMed and Embase databases was conducted from December 1, 2019, to March 26, 2020. An additional manual search of secondary sources was conducted to minimize missing relevant studies. There were no language restrictions.

Study Selection: Studies were included in our meta-analysis if it was published in peer-reviewed journals and recorded patient characteristics of severe versus nonsevere or survivor versus nonsurvivor in coronavirus disease 2019 infection.

Data Extraction: Two investigators independently screened the search, extracted the data, and assessed the quality of the study.

Data Synthesis: Our search identified 15 observational studies with a total of 3,494 patients (1,935 males and 1,559 females) to be included in our meta-analysis. Males were more likely to develop severe coronavirus disease 2019 infection compared with females (odds ratio, 1.31; 95% CI, 1.07-1.60). There was no significant heterogeneity ( = 12%) among the studies.

Conclusions: This meta-analysis suggests that the male gender may be a predictor of more severe coronavirus disease 2019 infection. Further accumulation of evidence from around the world is warranted to confirm our findings.
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http://dx.doi.org/10.1097/CCE.0000000000000148DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314340PMC
June 2020

Clinical Characteristics and In-Hospital Mortality for COVID-19 Across The Globe.

Cardiol Ther 2020 Dec 18;9(2):553-559. Epub 2020 Jul 18.

Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.

Introduction: Numerous case series have reported on the baseline characteristics and in-hospital mortality of patients with COVID-19, however, these studies included patients localized in a specific geographic region. The purpose of our study was to identify differences in the clinical characteristics and the in-hospital mortality of patients with a laboratory-confirmed diagnosis of COVID-19 internationally.

Methods: A comprehensive search of all published literature on adult patients with laboratory-confirmed diagnosis of COVID-19 that reported on the clinical characteristics and in-hospital mortality was performed. Groups were compared using a Chi-square test with Yates correction of continuity. A two-tailed p value of less than 0.05 was considered as statistically significant.

Results: After screening 516 studies across the globe, 43 studies from 12 countries were included in our final analysis. Patients with COVID-19 in America and Europe were older compared to their Asian counterparts. Europe had the highest percentage of male patients. American and European patients had a higher incidence of co-morbid conditions (p < 0.05 for all variables). In-hospital mortality was significantly higher in America (22.23%) and Europe (22.9%) compared to Asia (12.65%) (p < 0.0001), but no difference was seen when compared with each other (p = 0.49).

Conclusions: There is a significant variation in the clinical characteristics in patients diagnosed with COVID-19 across the globe. In-hospital mortality is similar between America and Europe, but considerably higher than Asia.
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http://dx.doi.org/10.1007/s40119-020-00189-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368614PMC
December 2020

Coronary angiography and percutaneous coronary intervention after transcatheter aortic valve replacement with medtronic self-expanding prosthesis: Insights from correlations with computer tomography.

Int J Cardiol 2020 Oct 1;317:18-24. Epub 2020 Jun 1.

Division of Cardiology, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, NY, New York, United States of America. Electronic address:

Objectives: We aim to describe the feasibility, challenges, success rates and techniques utilized in coronary angiography (CA) and percutaneous coronary intervention (PCI) in patients post transcatheter aortic valve replacement (TAVR).

Background: CA and PCI after TAVR are becoming increasingly encountered in clinical practice. There have been technical difficulties reported in re-accessing the coronary arteries through the self-expanding CoreValve prosthesis.

Methods: From January 2012 to November 2017, 672 patients who underwent TAVR with a self-expanding prosthesis were retrospectively reviewed and those who had a CA and/or PCI post TAVR were analysed. Clinical characteristics, angiographic and procedural details were obtained. A subgroup of patients had computed tomographic angiography (CTA) post TAVR to evaluate positions of the coronary ostia relative to the self-expanding prosthesis. Study endpoint was successful selective engagement of coronary ostia for CA and PCI.

Results: Thirty-two patients (4.8%) had attempted 46 CA and 26 PCI after TAVR with a self-expanding valve. Mean age was 85.2 years and 41% were females. Selective left and right coronary angiography using standard catheters could be achieved in 50% and 28% of cases respectively. Successful PCI was performed in 25 cases (96%); however, significant technique modification was required in 64% of cases. CTA in 9 patients confirmed the difficulty in coronary re-access was due to a combination of the sealing skirt relationship to coronary ostia and sinotubular junction as well as commissural post orientation and significant native leaflet calcification.

Conclusions: CA and PCI post TAVR with self-expanding CoreValve is technically challenging but feasible with modification of standard techniques.
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http://dx.doi.org/10.1016/j.ijcard.2020.05.065DOI Listing
October 2020

Murphy's Law or Domino Effect: Severe Aortic Annular Calcification in Transcatheter Aortic Valve Replacement.

Circ Cardiovasc Imaging 2020 04 25;13(4):e010162. Epub 2020 Mar 25.

Division of Cardiology, Mount Sinai Hospital (R.R., S.K., P.K., S.K.S., A.K., S.L.), Icahn School of Medicine at Mount Sinai, New York, NY.

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http://dx.doi.org/10.1161/CIRCIMAGING.119.010162DOI Listing
April 2020

Prevalence and Clinical Correlates of Extended Mechanical Support in Patients Undergoing High-Risk Percutaneous Coronary Intervention in Current Clinical Practice: Insights from the cVAD Registry.

Cardiovasc Revasc Med 2020 03 11;21(3):342-347. Epub 2019 May 11.

Einstein Medical Center, Philadelphia, PA, United States of America.

Background: High-risk percutaneous coronary interventions (HR-PCI) are prone to hemodynamic instability, resulting in poor outcomes. Acute mechanical circulatory support (AMCS) devices are used during HR-PCI to improve outcomes. However, the clinical criteria for extended AMCS have not been well characterized. The aim of this study was to describe the prevalence and clinical correlates of extended AMCS in patients undergoing elective or urgent HR-PCI.

Methods: We retrospectively analyzed 507 patients enrolled in the catheter-based ventricular assist device (cVAD) registry who underwent elective or urgent HR-PCI with prophylactic use of Impella. The study population was divided into two groups: Impella support removed immediately after PCI (Group A, n = 464) and extended support after PCI (Group B, n = 43). Multivariable regression analysis was used to identify independent predictors of extended AMCS.

Results: Baseline characteristics were similar between the groups. Non-ST-elevation myocardial infarction in 26.3% in Group A vs 41.8% in Group B (p = 0.03). PCI of left main was common in Group A (p = 0.02), whereas the right coronary artery was common in Group B (p < 0.001). The mean duration of Impella support 1.1 ± 0.6 h in Group A vs 11.4 ± 16.8 h in Group B (p < 0.001). Death and vascular complications were higher with extended Impella support. Revascularization of chronic total occlusion (CTO) was an independent predictor of extended Impella support (OR 3.2, 95% CI 1.20-8.53).

Conclusions: About 9% of patients enrolled in the cVAD registry undergoing elective or urgent HR-PCI received extended Impella support. In-hospital mortality was about 12% in patients requiring extended Impella support. CTO was associated with a higher likelihood of extended AMCS. The hemodynamic benefits of extended AMCS support must be weighed in terms of risk of complications.
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http://dx.doi.org/10.1016/j.carrev.2019.05.001DOI Listing
March 2020

Echocardiographic and Hemodynamic Parameters Associated with Diminishing Renal Filtration among Patients with Heart Failure with Preserved Ejection Fraction.

Cardiorenal Med 2019 13;9(2):83-91. Epub 2018 Dec 13.

Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania, USA.

Background: Renal dysfunction is an important predictor of poor outcomes in patients with heart failure with preserved ejection fraction (HFpEF). Right ventricular (RV) dysfunction is implicated as one of the explanations for worsening renal function in cardiorenal syndrome. Novel right heart catheterization (RHC) parameters such as pulmonary artery pulsatility index (PAPi) and right atrial to pulmonary capillary wedge pressure ratio (RA:PCWP) have been found as predictors of RV dysfunction. However, most studies investigating these parameters have been done in the setting of myocardial infarction or left ventricular assist device implantation, with limited data on these metrics in patients with HFpEF.

Objective: The purpose of this study was to determine whether novel RHC parameters such as RA:PCWP and PAPi correlate with long-term renal outcomes among patients with HFpEF.

Methods: A retrospective single-center study of adult patients with a documented diagnosis of heart failure who had RHC was performed between January 2006 and December 2010 at Einstein Med ical Center Philadelphia. Selected patients also had a serum B-type natriuretic peptide level ≥100 pg/mL and a PCWP ≥15 mm Hg. Patients with an ejection fraction < 50%, including those with recovered ejection fraction, and end-stage renal disease were excluded.

Results: A total of 81 patients with a clinical diagnosis of HFpEF were identified who met the inclusion criteria. On multivariate analysis, after adjusting for age, sex, race, diabetes, hypertension, and cardiac index, PAPi was associated with long-term estimated glomerular filtration rate (eGFR) (β = 3.43, 95% CI = 0.635-6.23, p = 0.017), and RA:PCWP showed a trend towards significance (β = 14.81, 95% CI = -0.096-29.73, p = 0.051). The results were unchanged after further adjustment for eGFR at the time of RHC.

Conclusion: Novel hemodynamic indices obtained by RHC may have predictive value for long-term renal dysfunction in patients with HFpEF.
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http://dx.doi.org/10.1159/000494089DOI Listing
June 2019

Usefulness of the Echocardiographic Calcium Score to Refine Risk of Major Adverse Cardiovascular Events Beyond the Traditional Framingham Risk Score.

Am J Cardiol 2019 02 19;123(3):392-395. Epub 2018 Oct 19.

Albert Einstein Medical Center, Division of Cardiology, Philadelphia, Pennsylvania.

Echocardiographic calcifications are associated with major adverse cardiovascular events (MACE). A recently described semiquantitative Global Cardiac Calcium Score (GCCS) has been associated with mortality and stroke, with increasing scores associated with increasing risk. This score assigns points for calcium in the aortic root and valve, mitral valve and annulus, and submitral apparatus, with additional points for restricted leaflet mobility. We tested the hypothesis that the GCCS could improve prediction of MACE beyond traditional risk scores. This was a retrospective study of 216 subjects from a general echocardiography database (mean age 59 ± 15; 51% male). Follow-up was 3.8 ± 1.7 years. The Framingham Risk Score (FRS) and Pooled Cohort Equations (PCE) were applied to each patient. Mean GCCS was 3.2 ± 2. In the total cohort, GCCS predicted MACE (myocardial infarction, stroke, all-cause mortality), even after adjusting for FRS (odd ratio 1.19, p = 0.03). There were 106 subjects (49%) in the low-risk FRS group, 71 (33%) in the intermediate-risk group, and 39 (18%) in the high-risk group. GCCS ≥3 was associated with increased MACE (vs <3) in the low-risk group (p = 0.03), while GCCS <3 was associated with decreased MACE (vs ≥3) in the high-risk group (p = 0.04). When applied to the PCE risk estimate (dichotomized at <7.5% vs ≥7.5%) the GCCS similarly refined risk prediction. In conclusion, the semiquantitative GCCS appears to be a marker of additional unaccounted risk factors; it is easily applied and can further stratify risk of MACE beyond traditional FRS or PCE estimates.
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http://dx.doi.org/10.1016/j.amjcard.2018.10.009DOI Listing
February 2019

Anaemia and mortality in patients with transcatheter aortic valve replacement: a systematic review and meta-analysis.

Acta Cardiol 2019 Oct 17;74(5):386-392. Epub 2018 Oct 17.

Division of Cardiology, Department of Medicine, Einstein Medical Center , Philadelphia , PA , USA.

This study was done to determine the relationship between pre-procedural anaemia and mortality post transcatheter aortic valve replacement (TAVR). TAVR is now a treatment option for patients with severe aortic stenosis (AS) with high surgical risk. Anaemia is a common comorbidity in the TAVR population. Small studies have suggested that anaemia is associated with worse short-term and long-term mortality in patients who underwent TAVR. However, there are no meta-analyses to further assess this association. Studies were systematically searched from electronic databases (EMBASE and MEDLINE). Inclusion criteria were adult population with aortic stenosis who underwent TAVR, and number of patients with pre-procedural anaemia reported. Outcomes were short-term mortality or long-term mortality. Pooled effect size was calculated with a random-effect model, weighted for the inverse of variance. Heterogeneity was assessed with . Six studies were included in the final analysis. Of these, pooled analysis of four studies examining association between anaemia and 30-day mortality did not show a statistically significant relationship. A pooled analysis of four studies examining the association of anaemia and long-term mortality after TAVR showed pooled adjusted risk ratio (RR) of 1.43, 95% CI 1.22-1.67 with low heterogeneity ( = 33%). Subgroup analysis after exclusion of one smaller study showed that the association remained significant (RR 1.41, 95% CI 1.27-1.56) with decreased heterogeneity ( = 0%). This systematic review and meta-analysis found an association between pre-procedural anaemia and increased long-term but not short-term mortality after TAVR. Further study of the pathophysiology underlying this association is needed.
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http://dx.doi.org/10.1080/00015385.2018.1510802DOI Listing
October 2019

New-onset atrial fibrillation is associated with increased mortality in critically ill patients: a systematic review and meta-analysis.

Acta Cardiol 2019 Apr 5;74(2):162-169. Epub 2018 Jul 5.

c Department of Medicine, Division of Cardiology , Einstein Medical Center , Philadelphia , PA, USA.

Introduction: Atrial fibrillation (AF) is one of the most comorbid conditions in critically ill patients requiring intensive care unit (ICU). Multiple studies have suggested that there may be an association between new-onset AF and adverse outcome in critically ill patients. However, there are no meta-analyses to assess this association.

Methods: Studies were systematically searched from electronic databases. Studies that examined the relationship between new-onset AF and adverse outcomes including mortality and length of stay in ICU patients were included. Studies that included patients with prior AF were excluded. The pooled effect size was calculated with a random-effect model, weighted for the inverse of variance, to determine an association between new-onset AF and in-hospital mortality. Heterogeneity was assessed with I.

Results: Twelve studies were included. Pooled analysis showed statistically significant difference rate of the hospital mortality between patients with and without new-onset AF (OR 2.70; 95% CI 2.43-3.00). Subgroup analysis of only patients with sepsis or septic shock showed a significant association between new-onset AF and in-hospital mortality (OR 2.32; 95% CI 1.88-2.87). No significant heterogeneity was observed (I = 0%) in both analyses. Pooled analysis of four studies also showed a significant association between new-onset AF and short-term mortality (OR 2.22; 95% CI 1.28-3.83) with moderate heterogeneity (I = 67%).

Conclusions: New-onset AF is associated with worse outcome in critically ill patients. Further studies should be done to evaluate for causality and adjust for confounders.
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http://dx.doi.org/10.1080/00015385.2018.1477035DOI Listing
April 2019
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