Publications by authors named "Paul Mather"

60 Publications

Trends, Predictors and Outcomes of Ischemic Stroke Among Patients Hospitalized with Takotsubo Cardiomyopathy.

J Stroke Cerebrovasc Dis 2021 Jul 28;30(10):106005. Epub 2021 Jul 28.

Department of Medicine, Morehouse School of Medicine, 720 Westview Drive S.W., Atlanta, GA 30310, United States. Electronic address:

Objectives: This study assessed the temporal trends in the incidence of ischemic stroke among patients hospitalized with takotsubo cardiomyopathy (TCM) stratified by the subtypes of ischemic stroke (cardioembolic versus thrombotic).Predictors of each stroke subtype, the association with atrial fibrillation (AF), the occurrence of ventricular fibrillation/ventricular tachycardia (VF/VT),cardiogenic shock (CS), in-hospital mortality, length of stay (LOS), and total healthcare cost were also assessed.

Background: Ischemic stroke in TCM is thought to be primarily cardioembolic from left ventricular mural thromboembolism. limited data are available on the incidence of thrombotic ischemic stroke in TCM.

Materials And Methods: We identified 27,970 patients hospitalized with the primary diagnosis of TCM from the 2008 to 2017 National Inpatient Sample, of which 751 (3%) developed ischemic stroke. Of those with ischemic stroke, 571 (76%) had thrombotic stroke while 180 (24%) had cardioembolic stroke. Cochrane armitage test was used to assess the incidence of thrombotic and cardioembolic strokes and multivariate regression was used to identify risk factors associated with each stroke subtype. We compared the incidence of AF, VF/VT, CS, LOS, in-hospital mortality and total cost between hospitalized patients with TCM alone to those with cardioembolic and thrombotic strokes.

Results: From 2008 - 2017, the incidence of thrombotic stroke (4.7%-9.5% (p< 0.0001) increased while it was unchanged for cardioembolic stroke (0.5%-0.7% P=0.5). In the multivariate regression, peripheral artery disease, prior history of stroke, and hyperlipidemia were significantly associated with thrombotic stroke, while CS, AF, and Asian race (compared to White race) were associated with cardioembolic stroke. Both cardioembolic and thrombotic strokes were associated with higher odds of IHM, AF, CS, longer LOS and increased cost. Trends in in-hospital mortality and the utilization of thrombolysis, cerebral angiography, and mechanical thrombectomy among patients with TCM and ischemic stroke were unchanged from 2008 to 2017.

Conclusion: Among patients with TCM and ischemic stroke, thrombotic stroke was more common compared to cardioembolic stroke. Ischemic stroke was associated with poorer outcomes, including higher in-hospital mortality and increased healthcare resource utilization in TCM.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.106005DOI Listing
July 2021

Treatment of corticosteroid refractory immune checkpoint inhibitor myocarditis with Infliximab: a case series.

Cardiooncology 2021 Mar 30;7(1):13. Epub 2021 Mar 30.

Department of Medicine, University of Pennsylvania, PA, Philadelphia, USA.

Background: Glucocorticoid treatment remains the cornerstone of therapy for immune checkpoint inhibitor (ICI) myocarditis, but data supporting the use of additional immunotherapy for steroid refractory cases remains limited. We investigate the safety and efficacy of infliximab in patients with ICI myocarditis who are refractory to corticosteroids. Additionally, we highlight the importance of a multi-disciplinary approach in the care for these complex patients.

Methods: We retrospectively identified consecutive patients who developed ICI myocarditis at our institution between January 2017 and January 2020. Baseline characteristics, laboratory data and clinical outcomes were compared between patients who received infliximab and those who did not.

Results: Of a total of 11 patients who developed ICI myocarditis, 4 were treated with infliximab. Aside from age, there were no significant differences in baseline patient characteristics between the two groups including total number of ICI doses received and duration from initial ICI dose to onset of symptoms. The time to troponin normalization was 58 vs. 151.5 days (p = 0.25). The duration of prednisone taper was longer in the infliximab group (90 vs. 150 days p = 0.32). All patients survived initial hospital admission. Over a median follow-up period of 287 days, two of the 4 patients died from sepsis 2 and 3 months after initial treatment of their myocarditis; one of these patients was on a steroid taper and the other patient had just completed a steroid taper.

Conclusions: Infliximab, despite its black box warning in patients with heart failure, may be a safe and effective treatment for ICI myocarditis.
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http://dx.doi.org/10.1186/s40959-021-00095-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8008661PMC
March 2021

The dawn of the four-drug era? SGLT2 inhibition in heart failure with reduced ejection fraction.

Ther Adv Cardiovasc Dis 2021 Jan-Dec;15:17539447211002678

Perelman School of Medicine, University of Pennsylvania, 2 East Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA.

Sodium-glucose cotransporter type 2 (SGLT2) inhibitors are a relatively new class of antihyperglycemic drug with salutary effects on glucose control, body weight, and blood pressure. Emerging evidence now indicates that these drugs may have a beneficial effect on outcomes in heart failure with reduced ejection fraction (HFrEF). Post-approval cardiovascular outcomes data for three of these agents (canagliflozin, empagliflozin, and dapagliflozin) showed an unexpected improvement in cardiovascular endpoints, including heart failure hospitalization and mortality, among patients with type 2 diabetes mellitus (T2DM) and established cardiovascular disease or risk factors. These studies were followed by a placebo controlled trial of dapagliflozin in patients with HFrEF both with and without T2DM, showing a reduction in all-cause mortality comparable to current guideline-directed HFrEF medical therapies such as angiotensin-converting enzyme inhibitors and beta-blockers. In this review, we discuss the current landscape of evidence, safety and adverse effects, and proposed mechanisms of action for use of these agents for patients with HFrEF. The United States (US) and European guidelines are reviewed, as are the current US federally approved indications for each SGLT2 inhibitor. Use of these agents in clinical practice may be limited by an uncertain insurance environment, especially in patients without T2DM. Finally, we discuss practical considerations for the cardiovascular clinician, including within-class differences of the SGLT2 inhibitors currently available on the US market (217/300).
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http://dx.doi.org/10.1177/17539447211002678DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8010852PMC
April 2021

Clinical outcomes in patients with native valve infective endocarditis and diabetes mellitus.

World J Cardiol 2021 Jan;13(1):11-20

Department of Cardiovascular Disease, University of Pennsylvania, Pennsylvania, PA 19104, United States.

Background: There is a lack of data on the clinical outcomes in patients with native valve infective endocarditis (NVIE) and diabetes mellitus (DM).

Aim: To investigate (1) trends in the prevalence of DM among patients with NVIE; and (2) the impact of DM on NVIE outcomes.

Methods: We identified 76385 with NVIE from the 2004 to 2014 National Inpatient Sample, of which 22284 (28%) had DM. We assessed trends in DM from 2004 to 2014 using the Cochrane Armitage test. We compared baseline comorbidities, microorganisms, and in-patients procedures between those with without DM. Propensity match analysis and multivariate logistic regression were used to investigate study outcomes in in-hospital mortality, stroke, acute heart failure, cardiogenic shock, septic shock, and atrioventricular block.

Results: Crude rates of DM increased from in 22% in 2004 to 30% in 2014. There were significant differences in demographics, comorbidities and NVIE risk factors between the two groups. Staphylococcus aureus was the most common organism identified with higher rates in patients with DM (33.1% 35.6%; < 0.0001). After propensity matching, in-hospital mortality (11.1% 11.9%; < 0.0001), stroke (2.3% 3.0%; < 0.0001), acute heart failure (4.6% 6.5%; = 0.001), cardiogenic shock (1.5% 1.9%; < 0.0001), septic shock (7.2% 9.6%; < 0.0001), and atrioventricular block (1.5% 2.4%; < 0.0001), were significantly higher in patients with DM. Independent predictors of mortality in NVIE patients with DM include hemodialysis, congestive heart failure, atrial fibrillation, staphylococcus aureus, and older age.

Conclusion: There is an increasing prevalence of DM in NVIE and it is associated with poorer outcomes. Further studies are crucial to identify the clinical, and sociodemographic contributors to this trend and develop strategies to mitigate its attendant risk.
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http://dx.doi.org/10.4330/wjc.v13.i1.11DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7821010PMC
January 2021

CHA2DS2-VASc Is Associated With In-Hospital Mortality in Patients With Infective Endocarditis: A Cross-Sectional Cohort Study.

Cureus 2020 Nov 22;12(11):e11620. Epub 2020 Nov 22.

Department of Cardiovascular Disease, Perelman School of Medicine, Philadelphia, USA.

Background and objective The CHADS-VASc score is a stroke risk stratification tool that is used in patients with atrial fibrillation (AF). Most of its clinical variables have been associated with poor outcomes in patients with infective endocarditis (IE). In this study, we aimed to determine its utility in predicting outcomes in IE patients. Methods We included 35,570 patients with IE from the National Inpatient Sample (NIS), 2009-2012. The CHADS-VASc score was calculated for each patient. Hierarchical logistic regression was used to estimate the adjusted odds ratio for in-hospital mortality for CHADS-VASc scores from 1 to 9, using a score of 0 as the reference score. All clinical characteristics were defined using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Results The mean age of the sample was 57.81 ±14 years. Higher CHADS-VASc scores were associated with increased mortality, and the scores among the sample ranged from 0 for 8.1% to 8 for 21.7%. In the hierarchical logistic regression, after adjusting for age, sex, and relevant comorbidities, as the score increased, so did the odds for overall mortality. Conclusion In patients with IE, the CHADS-VASc score may serve as a risk assessment tool with which to predict outcomes. Further studies are needed to replicate these findings.
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http://dx.doi.org/10.7759/cureus.11620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7752800PMC
November 2020

The effect of transfusion of blood products on ventricular assist device support outcomes.

ESC Heart Fail 2020 12 14;7(6):3573-3581. Epub 2020 Oct 14.

Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Aims: Perioperative blood transfusions are common among patients undergoing left ventricular assist device (LVAD) implantation. The association between blood product transfusion at the time of LVAD implantation and mortality has not been described.

Methods And Results: This was a retrospective cohort study of all patients who underwent continuous flow LVAD implantation at a single, large, tertiary care, academic centre, from 2008 to 2014. We assessed used of packed red blood cells (pRBCs), platelets, and fresh frozen plasma (FFP). Outcomes of interest included all-cause mortality and acute right ventricular (RV) failure. Standard regression techniques were used to examine the association between blood product exposure and outcomes of interest. A total of 170 patients were included in this study (mean age: 56.5 ± 15.5 years, 79.4% men). Over a median follow-up period of 11.2 months, for every unit of pRBC transfused, the hazard for mortality increased by 4% [hazard ratio (HR) 1.04; 95% CI 1.02-1.07] and odds for acute RV failure increased by 10% (odds ratio 1.10; 95% CI 1.05-1.16). This association persisted for other blood products including platelets (HR for mortality per unit 1.20; 95% CI 1.08-1.32) and FFP (HR for mortality per unit 1.08; 95% CI 1.04-1.12). The most significant predictor of perioperative blood product exposure was a lower pre-implant haemoglobin.

Conclusions: Perioperative blood transfusions among patients undergoing LVAD implantation were associated with a higher risk for all-cause mortality and acute RV failure. Of all blood products, FFP use was associated with worst outcomes. Future studies are needed to evaluate whether pre-implant interventions, such as intravenous iron supplementation, will improve the outcomes of LVAD candidates by decreasing need for transfusions.
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http://dx.doi.org/10.1002/ehf2.12780DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754735PMC
December 2020

Reduction in heart failure hospitalization rate during coronavirus disease 19 pandemic outbreak.

ESC Heart Fail 2020 Oct 23. Epub 2020 Oct 23.

Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome, 00161, Italy.

Aims: The recent coronavirus disease 19 (COVID-19) pandemic outbreak forced the adoption of restraint measures, which modified the hospital admission patterns for several diseases. The aim of the study is to investigate the rate of hospital admissions for heart failure (HF) during the early days of the COVID-19 outbreak in Italy, compared with a corresponding period during the previous year and an earlier period during the same year.

Methods And Results: We performed a retrospective analysis on HF admissions number at eight hospitals in Italy throughout the study period (21 February to 31 March 2020), compared with an inter-year period (21 February to 31 March 2019) and an intra-year period (1 January to 20 February 2020). The primary outcome was the overall rate of hospital admissions for HF. A total of 505 HF patients were included in this survey: 112 during the case period, 201 during intra-year period, and 192 during inter-year period. The mean admission rate during the case period was 2.80 admissions per day, significantly lower compared with intra-year period (3.94 admissions per day; incidence rate ratio, 0.71; 95% confidence interval [CI], 0.56-0.89; P = 0.0037), or with inter-year (4.92 admissions per day; incidence rate ratio, 0.57; 95% confidence interval, 0.45-0.72; P < 0.001). Patients admitted during study period were less frequently admitted in New York Heart Association (NYHA) Class II compared with inter-year period (P = 0.019). At covariance analysis NYHA class was significantly lower in patients admitted during inter-year control period, compared with patients admitted during case period (P = 0.014).

Conclusions: Admissions for HF were significantly reduced during the lockdown due to the COVID-19 pandemic in Italy.
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http://dx.doi.org/10.1002/ehf2.13043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754919PMC
October 2020

Massive myocardial edema and inflow cannula obstruction due to epicardial surgical ventricular tachycardia cryoablation at time of left ventricular assist device implantation.

HeartRhythm Case Rep 2020 Aug 28;6(8):523-527. Epub 2020 May 28.

Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1016/j.hrcr.2020.05.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7424293PMC
August 2020

Ethical Challenges in Care of Patients on Mechanical Circulatory Support at End-of-Life.

Curr Heart Fail Rep 2020 08;17(4):153-160

Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.

Purpose Of Review: Although the utilization of mechanical circulatory support (MCS) devices is increasing, ethical dilemmas regarding device deactivation and dying process persist, potentially complicating delivery of optimal and compassionate care at end-of-life (EOL). This review aims to study EOL challenges, left ventricular assist devices (LVADs) as a nuanced life support treatment, legal history in the US impacting EOL care, and suggestions to improve EOL care for patients on MCS support.

Recent Findings: Recent studies have demonstrated challenging aspects of EOL care for patients on LVAD support: low use of advanced directives, high rates of surrogate decision-making due to lack of patient capacity, difficult decision-making involving LVAD deactivation even with cooperating patients, and high rates of death in the hospital and ICU settings. Recent studies also suggest lack of consensus even among clinicians in approaching LVAD deactivation as beliefs equating LVAD deactivation with physician-assisted suicide and/or euthanasia remain. Optimal care at EOL will likely require collaborative efforts among multiple specialties, caregivers, and patients. In light of the complex medical, logistical, and ethical challenges in EOL care for LVAD patients, there is room for improvement by multidisciplinary efforts to reach consensus about LVAD deactivation and best practices for EOL care, development and implementation of LVAD-specific advance planning, and protocols for LVAD deactivation. Programmatic involvement of hospice and palliative care in the continuum of care of LVAD patients has the potential to increase and improve advance care planning, support surrogate decision-making, improve EOL compassionate care, and to support caregivers.
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http://dx.doi.org/10.1007/s11897-020-00460-4DOI Listing
August 2020

Advanced Heart Failure and End-Stage Heart Failure: Does a Difference Exist.

Diagnostics (Basel) 2019 Nov 1;9(4). Epub 2019 Nov 1.

Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.

Advanced heart failure (AdHF) represents a challenging aspect of heart failure patients. Because of worsening clinical symptoms, high rates of re-hospitalization and mortality, AdHF represents an unstable condition where standard treatments are inadequate and additional interventions must be applied. A heart transplant is considered the optimal therapy for AdHF, but the great problem linked to the scarcity of organs and long waiting lists have led to the use of mechanical circulatory support with ventricular-assist device (VAD) as a destination therapy. VAD placement improves the prognosis, functional status, and quality of life of AdHF patients, with high rates of survival at 1 year, similar to transplant. However, the key element is to select the right patient at the right moment. The complete assessment must include a careful clinical evaluation, but also take into account psychosocial factors that are of crucial importance in the out-of-hospital management. It is important to distinguish between AdHF and end-stage HF, for which advanced therapy interventions would be unreasonable due to severe and irreversible organ damage and, instead, palliative care should be preferred to improve quality of life and relief of suffering. The correct selection of patients represents a great issue to solve, both ethically and economically.
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http://dx.doi.org/10.3390/diagnostics9040170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6963179PMC
November 2019

Delayed aneurysmal complication of bicuspid aortic valve disease after heart transplantation.

J Thorac Cardiovasc Surg 2019 12 15;158(6):e185-e186. Epub 2019 Mar 15.

Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2019.02.113DOI Listing
December 2019

Cardiovascular Disease and Alcohol Consumption.

Am J Med Sci 2018 May 6;355(5):409-410. Epub 2018 Feb 6.

Department of Medicine, Division of Cardiology University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1016/j.amjms.2018.01.016DOI Listing
May 2018

Elevated Body Mass Index Is Not a Risk Factor for Adverse Outcomes Following Ventricular Assist Device Implantation.

Prog Transplant 2018 06 20;28(2):157-162. Epub 2018 Mar 20.

2 Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Background: Despite ventricular assist devices (VADs) becoming more common in heart failure (HF) treatment, it is still uncertain which patients are more prone to complications. One potential risk factor is increased body mass index (BMI), which is known to increase both all-cause mortality and mortality from ischemic heart disease; however, the role of the BMI in predicting morbidity and mortality following device implantation is unclear.

Methods: The study population for this single-institution retrospective chart review consisted of 136 patients with HF, who underwent VAD implantation between 2004 and 2015. Patients were divided into 2 groups based on their BMI: a nonobese group (18.5 < BMI < 30.0; n = 82) or an obese group (BMI >30.0; n = 54). These groups were compared at baseline and after implantation for survival, hospital readmission, and adverse events.

Results: No significant difference was found in initial hospital length of stay, number or length of readmissions, or readmission diagnosis. At 1 year, rates of ongoing device support, orthotopic heart transplant (OHT), and death were not significantly different between groups ( P = .89, P = .90, and P = .70, respectively). Multivariate analysis did not identify obesity as an independent predictor of mortality ( P = .90); only biventricular assist device implantation was associated with decreased survival (hazard ratio [HR] = 5.90, P = .002).

Conclusion: Obesity in itself should not preclude the use of VAD support in patients with HF, as carefully selected obese patients were shown to have similar rates of hospital readmission, 1-year outcomes, and survival following device implantation compared to nonobese patients.
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http://dx.doi.org/10.1177/1526924818765817DOI Listing
June 2018

Editorial commentary: Heart failure with preserved ejection fraction-Clinical syndrome with incomplete understanding.

Trends Cardiovasc Med 2018 08 2;28(6):401-402. Epub 2018 Feb 2.

Department of Medicine, Cardiovascular Division, University of Pennsylvania, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. Electronic address:

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http://dx.doi.org/10.1016/j.tcm.2018.01.005DOI Listing
August 2018

Obesity and heart failure with preserved ejection fraction: A growing problem.

Trends Cardiovasc Med 2018 07 14;28(5):322-327. Epub 2017 Dec 14.

Department of Medicine, Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Heart Failure with Preserved Ejection Fraction (HFpEF) is increasing in prevalence due to the aging of the United States population as well as the current obesity epidemic. While obesity is very common in patients with HFpEF, obesity may represent a specific phenotype of HFpEF characterized by unique hemodynamics and structural abnormalities. Obesity induces a systemic inflammatory response that may contribute to myocardial fibrosis and endothelial dysfunction. The most obese patients continue to be excluded from HFpEF clinical trials, and thus ongoing research is needed to determine the role of pharmacologic and interventional approaches in this growing population.
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http://dx.doi.org/10.1016/j.tcm.2017.12.003DOI Listing
July 2018

Circulating T-Cell Subsets, Monocytes, and Natural Killer Cells in Peripartum Cardiomyopathy: Results From the Multicenter IPAC Study.

J Card Fail 2018 01 24;24(1):33-42. Epub 2017 Oct 24.

Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania.

Objective: The aim of this work was to evaluate the hypothesis that the distribution of circulating immune cell subsets, or their activation state, is significantly different between peripartum cardiomyopathy (PPCM) and healthy postpartum (HP) women.

Background: PPCM is a major cause of maternal morbidity and mortality, and an immune-mediated etiology has been hypothesized. Cellular immunity, altered in pregnancy and the peripartum period, has been proposed to play a role in PPCM pathogenesis.

Methods: The Investigation of Pregnancy-Associated Cardiomyopathy (IPAC) study enrolled 100 women presenting with a left ventricular ejection fraction of <0.45 within 2 months of delivery. Peripheral T-cell subsets, natural killer (NK) cells, and cellular activation markers were assessed by flow cytometry in PPCM women early (<6 wk), 2 months, and 6 months postpartum and compared with those of HP women and women with non-pregnancy-associated recent-onset cardiomyopathy (ROCM).

Results: Entry NK cell levels (CD3-CD56+CD16+; reported as % of CD3- cells) were significantly (P < .0003) reduced in PPCM (6.6 ± 4.9% of CD3- cells) compared to HP (11.9 ± 5%). Of T-cell subtypes, CD3+CD4-CD8-CD38+ cells differed significantly (P < .004) between PPCM (24.5 ± 12.5% of CD3+CD4-CD8- cells) and HP (12.5 ± 6.4%). PPCM patients demonstrated a rapid recovery of NK and CD3+CD4-CD8-CD38+ cell levels. However, black women had a delayed recovery of NK cells. A similar reduction of NK cells was observed in women with ROCM.

Conclusions: Compared with HP control women, early postpartum PPCM women show significantly reduced NK cells, and higher CD3+CD4-CD8-CD38+ cells, which both normalize over time postpartum. The mechanistic role of NK cells and "double negative" (CD4-CD8-) T regulatory cells in PPCM requires further investigation.
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http://dx.doi.org/10.1016/j.cardfail.2017.10.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6467571PMC
January 2018

Sleep Overnight Monitoring for Apnea in Patients Hospitalized with Heart Failure (SOMA-HF Study).

J Clin Sleep Med 2017 Oct 15;13(10):1185-1190. Epub 2017 Oct 15.

Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.

Introduction: Sleep-disordered breathing (SDB) is highly prevalent in hospitalized patients with congestive heart failure (CHF) and the condition is diagnosed and treated in only a minority of these patients. Portable monitoring (PM) is a screening option, but due to costs and the expertise required, many hospitals may find it impractical to implement. We sought to test the utility of an alternative approach for screening hospitalized CHF patients for SDB, high-resolution pulse oximetry (HRPO).

Methods: We conducted a prospective controlled trial of 125 consecutive patients admitted to the hospital with CHF. Simultaneous PM and HRPO for a single night was performed. All but one patient were monitored on breathing room air. The HRPO-derived ODI (oxygen desaturation index) was compared with PM-derived respiratory event index (REI) using both receiver operator characteristic (ROC) curve analysis and a Bland-Altman plot.

Results: Of 105 consecutive CHF patients with analyzable data, 61 (58%) were males with mean age of 64.9 ± 15.1 years and mean body mass index of 30.3 ± 8.3 kg/m. Of the 105 patients, 10 (9.5%) had predominantly central sleep apnea (central events > 50% of the total events), although central events were noted in 42 (40%) of the patients. The ROC analysis showed an area under the curve of 0.89 for REI > 5 events/h. The Bland-Altman plot showed acceptable agreement with 95% limits of agreement between -28.5 to 33.7 events/h and little bias.

Conclusions: We conclude that high-resolution pulse oximetry is a simple and cost-effective screening tool for SDB in CHF patients admitted to the hospital. Such screening approaches may be valuable for large-scale implementation and for the optimal design of interventional trials.
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http://dx.doi.org/10.5664/jcsm.6768DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5612634PMC
October 2017

Recognition and Treatment of Sleep-Disordered Breathing in Obese Hospitalized Patients May Improve Survival. The HoSMed Database.

Am J Med 2017 10 3;130(10):1184-1191. Epub 2017 May 3.

Division of Sleep Medicine, Harvard Medical School, Boston, Mass; Arizona Respiratory Center, University of Arizona College of Medicine, Tucson.

Purpose: Sleep-disordered breathing is a common sleep disorder. Recent studies have shown that hospitalized obese patients have a high likelihood of unrecognized sleep-disordered breathing. However, no systematic large study has so far evaluated the outcomes of a screening program. This study provides demographic, clinical, and outcome data from a screening program at a tertiary care academic center.

Methods: Subjects were 5062 patients screened from March 2013 to July 2016. Of these, 1410 underwent in-hospital overnight high-resolution pulse oximetry and 680 underwent polysomnography post discharge. Patients placed on positive airway therapy were followed in an ambulatory setting.

Results: The mean age was 60.7 years (SD 15.2), and mean body mass index was 34.8 kg/m (SD 8.3), with 2477 (49.0%) males. Of the 1410 high-risk patients who underwent high-resolution plethysmography (HRPO), 1092 were sleep-disordered breathing positive (oxygen desaturation index [ODI] ≥5) and 680 high-risk patients underwent polysomnography. In this latter group, 585 (87%) were found to have sleep-disordered breathing (apnea-hypopnea index [AHI] >5). A receiver operating characteristic curve for ODI derived from HRPO plotted against AHI from polysomnography showed an area under the curve of 0.83 for an ODI of >5. Patients who were adherent to positive airway pressure therapy in the first 3 months had improved survival over a mean follow-up of 609 days compared with those who were nonadherent (P = .01).

Conclusion: This large database of hospitalized patients confirms a high prevalence of undetected sleep-disordered breathing. Long-term follow-up of those compliant with treatment reveals a survival benefit.
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http://dx.doi.org/10.1016/j.amjmed.2017.03.055DOI Listing
October 2017

Cardiomyopathy in becker muscular dystrophy: Overview.

World J Cardiol 2016 Jun;8(6):356-61

Rady Ho, My-Le Nguyen, Paul Mather, Department of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, PA 19107, United States.

Becker muscular dystrophy (BMD) is an X-linked recessive disorder involving mutations of the dystrophin gene. Cardiac involvement in BMD has been described and cardiomyopathy represents the number one cause of death in these patients. In this paper, the pathophysiology, clinical evaluations and management of cardiomyopathy in patients with BMD will be discussed.
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http://dx.doi.org/10.4330/wjc.v8.i6.356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4919702PMC
June 2016

Right Ventricular Function in Peripartum Cardiomyopathy at Presentation Is Associated With Subsequent Left Ventricular Recovery and Clinical Outcomes.

Circ Heart Fail 2016 05;9(5)

From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (L.A.B.); University of Pittsburgh, PA (A.D.-M., K.R., J.J.M., J.P., D.M.M., J.G.); Intermountain Medical Center, Murray, UT (R.A.); Thomas Jefferson University, Philadelphia, PA (P.J.M.); Louisiana State University Health Science Center, Shreveport, LA (K.M.); McGill University, Montreal, Canada (R.S.); and Aurora Healthcare, Milwaukee, Wisconsin (V.T.).

Background: Peripartum cardiomyopathy has variable disease progression and left ventricular (LV) recovery. We hypothesized that baseline right ventricular (RV) size and function are associated with LV recovery and outcome.

Methods And Results: Investigations of Pregnancy-Associated Cardiomyopathy was a prospective 30-center study of 100 peripartum cardiomyopathy women with LV ejection fraction (LVEF) <45% within 13 weeks after delivery. Baseline RV function was assessed by echocardiographic end-diastolic area, end-systolic area, fractional area change, tricuspid annular plane excursion, and RV speckle-tracking longitudinal strain. LV recovery was defined as LVEF of ≥50% at 1 year, persistent severe LV dysfunction as LVEF of ≤35%, and major events as death, transplant, or LV assist device implantation. RV measurements were feasible for 90 of the 96 patients (94%) with echocardiograms available. Mean baseline LVEF was 36±9%. RV fractional area change was <35% in 38% of patients. Of 84 patients with 1-year follow-up data, 63 (75%) had LV recovery and 11 (13%) had LVEF of ≤35% or a major event (4 LV assist devices and 2 deaths). Tricuspid annular plane excursion and RV strain did not predict outcome. Baseline RV fractional area change by multivariable analysis was independently associated with subsequent LV recovery and clinical outcome.

Conclusions: Peripartum cardiomyopathy patients had a high incidence of LV recovery, but a significant minority had persistent LV dysfunction or a major clinical event by 1 year. RV function per echocardiographic fractional area change at presentation was associated with subsequent LV recovery and clinical outcomes and thus is prognostically important.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.115.002756DOI Listing
May 2016

Dichotomous Relationship Between Age and 30-Day Death or Rehospitalization in Heart Failure Patients Admitted With Acute Decompensated Heart Failure: Results From the ASCEND-HF Trial.

J Card Fail 2016 Jun 4;22(6):409-16. Epub 2016 Mar 4.

Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA.

Background: Younger age as an independent predictor of death or all-cause rehospitalization at 30 days post-randomization for hospitalized heart failure (HF) patients has not been well described.

Methods And Results: ASCEND-HF enrolled 7141 hospitalized acute HF patients (categorized by age: <45, 45 to <55, 55 to <65, 65 to <75, and ≥75 years) and followed them for 30 days to assess clinical outcomes, which included death or rehospitalization. Patients 45 to <55 years had the lowest percentages of death (1.4%) and total rehospitalizations (10.7%); percentages increased for younger (3.0% and 12.2%, respectively, for age <45 y) and older (5.8% and 12.5%, respectively, for age ≥75 y) patients. For those rehospitalized, the total HF-induced readmissions were highest in the youngest (68%) and declined with increasing age (P = .03). Although patients ≥55 years of age were more likely to die or be rehospitalized within 30 days of randomization for each additional 10 years of life, those <55 years of age had a significant reduction in death or HF rehospitalization for each 10-year increase in age (similar findings for death and HF rehospitalization).

Conclusions: There is a dichotomous relationship between age and risk of death or rehospitalization, and death or HF rehospitalization-risk decreases as age increases up to age 55 years, then increases after age 55 years.
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http://dx.doi.org/10.1016/j.cardfail.2016.02.011DOI Listing
June 2016

Effect of Early Intervention With Positive Airway Pressure Therapy for Sleep Disordered Breathing on Six-Month Readmission Rates in Hospitalized Patients With Heart Failure.

Am J Cardiol 2016 Mar 31;117(6):940-5. Epub 2015 Dec 31.

Division of Cardiology, Department of Internal Medicine, Advanced Heart Failure and Cardiac Transplant Center, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania.

Rehospitalization for congestive heart failure (CHF) is high within 6 months of discharge. Sleep disordered breathing (SDB) is common and underdiagnosed condition in patients with CHF. We hypothesized that early recognition and treatment of SDB in hospitalized patients with CHF will reduce hospital readmissions and emergency room visits. Patients admitted for CHF underwent overnight polysomnography within 4 weeks of discharge. Patients diagnosed with SDB were provided therapy with positive airway pressure therapy. Patients were identified as having good compliance if the device use was for a minimum of 4 hours 70% of the time for a minimum of 4 weeks during the first 3 months of therapy. Hospital admissions for 6 months before therapy were compared with readmission within 6 months after therapy in patients with good and poor compliance. A total of 70 patients were diagnosed with SDB after discharge. Of the 70 patients, 37 (53%) were compliant with positive airway pressure therapy. Compliant patients were more likely to be older (64 ± 12 vs 58 ± 11 years) and women (54% vs 33%) and less likely to be patient with diabetes (40% vs 67%) versus noncompliant patients. Although both groups experienced a decrease in total readmissions, compliant patients had a significant reduction (mean ± SE: -1.5 ± 0.2 clinical events vs -0.2 ± 0.3; p <0.0001). In this single-center analysis, identification and treatment of SDB in admitted patients with CHF with SDB is associated with reduced readmissions over 6 months after discharge. Adherence to the treatment was associated with a greater reduction in clinical events.
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http://dx.doi.org/10.1016/j.amjcard.2015.12.032DOI Listing
March 2016

Massive Thrombosis of the Transplanted Heart in the Early Postoperative Period.

J Card Surg 2016 Feb 4;31(2):117-9. Epub 2015 Dec 4.

Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania.

We experienced a case with the left atrium almost completely filled with a thrombus after orthotopic heart transplantation while the patient was supported on extracorporeal membrane oxygenation for primary graft failure. The patient had recurrent thrombosis even after successful surgical thrombectomy and appropriate anticoagulation. The cardiac thrombosis resolved only after starting plasmapheresis.
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http://dx.doi.org/10.1111/jocs.12674DOI Listing
February 2016

Diastolic function improvement is associated with favourable outcomes in patients with acute non-ischaemic cardiomyopathy: insights from the multicentre IMAC-2 trial.

Eur Heart J Cardiovasc Imaging 2016 Sep 30;17(9):1027-35. Epub 2015 Nov 30.

Heart & Vascular Institute-UPMC, UPMC/University of Pittsburgh, 200 Lothrop Street, Scaife Hall, S-558, Pittsburgh, PA, USA.

Aims: Patients with recent onset non-ischaemic cardiomyopathy have a variable clinical course with respect to recovery of left ventricular ejection fraction (LVEF). The aim of this study was to understand whether temporal changes in diastolic function (DF) are associated with clinical outcomes independent of LVEF recovery.

Methods And Results: The Intervention in Myocarditis and Acute Cardiomyopathy (IMAC)-2 study was a prospective, multicentre trial investigating myocardial recovery in subjects with symptoms onset of <6 months and LVEF ≤40% of non-ischaemic dilated cardiomyopathy related to idiopathic cardiomyopathy or myocarditis. LVEF and DF were measured at presentation and at 6-month follow-up. Of 147 patients (mean age 46 ± 14 years, 40% female), baseline LVEF was 23 ± 8%. At 6 months, LVEF improved to 41 ± 12%, with 71% increasing by at least 10% ejection fraction units. DF improved in 58%, was unchanged in 28%, and worsened in 14%. Over a mean follow-up of 1.8 ± 1.2 years, there were 18 events: 11 heart failure (HF) hospitalizations, 3 deaths, and 4 heart transplants. LVEF (HR = 0.94, 95% CI 0.91-0.98, P = 0.002) and DF improvements at 6 months (HR = 0.32, 95% CI 0.11-0.92, P = 0.03) were independently associated with lower likelihood for the combined end point of death, transplantation, and HF hospitalization. Diastolic functional improvement at 6-month follow-up was as prognostically important as LVEF recovery for these patients, and provided incremental prognostic value to the risk stratification (X(2) increased from 12.6 to 18, P = 0.02).

Conclusion: In patients with recent onset non-ischaemic cardiomyopathy, DF recovery was associated with favourable outcomes independent of LVEF improvement, adding incremental prognostic value to these patients.
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http://dx.doi.org/10.1093/ehjci/jev311DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5066337PMC
September 2016

Photoplethysmographic Signal to Screen Sleep-Disordered Breathing in Hospitalized Heart Failure Patients: Feasibility of a Prospective Clinical Pathway.

JACC Heart Fail 2015 Sep;3(9):725-31

Thomas Jefferson University and Hospitals, Philadelphia, Pennsylvania.

Objectives: The purpose of this study was to evaluate the plethysmographic signal-derived oxygen desaturation index (ODI) as an inpatient screening strategy to identify sleep-disordered breathing (SDB) in patients with congestive heart failure (CHF).

Background: SDB is highly prevalent among patients hospitalized with CHF but is widely underdiagnosed. We evaluated overnight photoplethysmography as a possible screening strategy for hospitalized patients with CHF.

Methods: Consecutively admitted heart failure patients with high clinical suspicion of SDB and ODI ≥5 were offered outpatient polysomnography (PSG), which was completed within 4 weeks of discharge. PSG was considered positive if the apnea hypoxia index (AHI) was ≥5. A Bland-Altman plot was used to assess agreement between ODI and AHI. Receiver-operator characteristics were determined for ODI ≥5 and AHI ≥5.

Results: A screening questionnaire identified 246 of 282 consecutive patients with positive symptoms for SDB. Of these patients, 105 patients were offered further evaluation and 86 had ODI ≥5 (mean ODI 17 ± 17). Among these 86 patients, 68 underwent outpatient PSG within 4 weeks of discharge. PSG showed that 64 (94%) had SDB, with a mean AHI of 28. Inpatient ODI correlated well with PSG-derived AHI. The area under the curve was 0.82 for AHI ≥5. The Bland-Altman plot revealed no major bias. Matthew's correlation coefficient revealed that the optimal cut-off for ODI is 5.

Conclusions: Screening hospitalized patients with heart failure using targeted inpatient ODI identifies a cohort of patients with a high prevalence of SDB. Our screening strategy provides a potentially cost-effective method for early detection and treatment of SDB.
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http://dx.doi.org/10.1016/j.jchf.2015.04.015DOI Listing
September 2015

Late Recurrence of Rheumatic Fever.

Am J Med Sci 2015 Oct;350(4):342-3

Jefferson Heart Institute, Thomas Jefferson University Hospital, Philadelphia, PA.

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http://dx.doi.org/10.1097/MAJ.0000000000000547DOI Listing
October 2015
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