Publications by authors named "Rohan Goswami"

11 Publications

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The current state of artificial intelligence in cardiac transplantation.

Authors:
Rohan Goswami

Curr Opin Organ Transplant 2021 Jun;26(3):296-301

Division of Transplant, Mayo Clinic Florida, San Pablo, Jacksonville, Florida, USA.

Purpose Of Review: The field of heart transplantation is a complex practice that combines both science and art to optimize the quality and quantity of an organ transplant recipient's life span. In the current age of Transplant Medicine there are many limiting factors that prevent potentially usable organs to be transplanted in addition to the many unknown factors in assessing the risk of posttransplant complications in a proactive manner. This review focuses on the current state, and potential use, and implementation of artificial intelligence technologies in the field of heart transplantation. Furthermore, the utilization of predictive algorithms to assess donor quality, graft function, posttransplant complications and prediction of high-risk complications will be discussed. Artificial intelligence technologies in the pretransplant population is also explored.

Recent Findings: Artificial intelligence process use has been increasing over the past decade. Early adoption in radiology and laboratory medicine have shown promise for future applications. Implementation of nascent technologies within the field of transplant medicine remains in its infancy. Cardiac and renal medicine have been recent focuses of large-scale artificial intelligence projects because of the wealth of data, the main limiting factor for producing accurate models. Understanding the true role of artificial intelligence in medicine is key - and has been divided into three areas of focus: data quality, interpretation, and clinical application. These areas allow the clinician to translate problems facing patients into algorithms utilized by data scientists to create solutions, which may provide in-depth analysis and detection of relationships not immediately clear. Although some published data has led to commercial products for cardiac, diabetic, and dermatologic applications -- widespread adoption remains limited to specialized centers.

Summary: Artificial intelligence applications with clinically relevant models in transplant medicine have the potential to optimize organ utilization, prediction of complications, and potential pretransplant management, which may mitigate the need for transplant. Further translational projects are under development at major centers, with proof of concepts demonstrating validity and safety in the clinical setting. Limiting factors of infrastructure, expertise, and data availability continue to be addressed. Ongoing efforts for commercialization and large-scale trials will provide a foundation for the development of artificial intelligence applications in transplant medicine.
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http://dx.doi.org/10.1097/MOT.0000000000000875DOI Listing
June 2021

Case of Coronavirus Disease 2019 Myocarditis Managed With Biventricular Impella Support.

Cureus 2021 Feb 7;13(2):e13197. Epub 2021 Feb 7.

Cardiology, Mayo Clinic Hospital, Jacksonville, USA.

Severe acute respiratory syndrome coronavirus 2, responsible for coronavirus disease 2019 (COVID-19), is a pandemic that has taken the world by storm. We present the only contemporary reported case of COVID-19 myocarditis leading to recovery with utilization of biventricular Impella (Abiomed, Danvers, MA, USA) for temporary mechanical circulatory support. A 35-year-old female with systemic sclerosis who was found to have five days of generalized malaise associated with fevers and cough. She tested positive for COVID-19 via nasal polymerase chain reaction. Cardiac enzymes were found elevated on admission. Invasive hemodynamics assessment was significant for elevated right and left-sided filling pressures, along with calculated cardiac index of 1.3 L/min/m. Decision was made to place right and left-sided ventricular support with percutaneous Impella for mechanical circulatory support. She was started on intravenous immunoglobulin for suspected COVID-19 myocarditis along with remdesivir and solumedrol. After two weeks of continuous temporary mechanical circulatory support, the patient's hemodynamics improved and she was discharged. Repeat echocardiogram demonstrated normalization of left ventricular function.
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http://dx.doi.org/10.7759/cureus.13197DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7943053PMC
February 2021

Empagliflozin in Heart Failure.

N Engl J Med 2021 01;384(4):386

Mayo Clinic, Florida, Jacksonville, FL.

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http://dx.doi.org/10.1056/NEJMc2033669DOI Listing
January 2021

A 3-Decade Analysis of Pancreatic Adenocarcinoma After Solid Organ Transplant.

Pancreas 2021 Jan;50(1):54-63

From the Division of Gastroenterology and Hepatology.

Objective: Solid organ transplant (SOT) recipients have moderately increased risk of pancreatic adenocarcinoma (PAC). We evaluated the incidence and survival of PAC in 2 cohorts and aimed to identify potential risk factors.

Methods: This study performed a retrospective cohort analysis. Cohort A was extracted from the United Network of Organ Sharing data set and cohort B from SOT recipients evaluated at 3 Mayo Clinic transplant centers. The primary outcome was age-adjusted annual incidence of PAC. Descriptive statistics, hazard ratios, and survival rates were compared.

Results: Cohort A and cohort B included 617,042 and 29,472 SOT recipients, respectively. In cohort A, the annual incidence rate was 12.78 per 100,000 in kidney-pancreas, 13.34 in liver, and 21.87 in heart-lung transplant recipients. Receiving heart-lung transplant, 50 years or older, and history of cancer (in either recipient or donor) were independent factors associated with PAC. Fifty-two patients developed PAC in cohort B. Despite earlier diagnosis (21.15% with stage I-II), survival rates were similar to those reported for sporadic (non-SOT) patients.

Conclusions: We report demographic and clinical risk factors for PAC after SOT, many of which were present before transplant and are common to sporadic pancreatic cancer. Despite the diagnosis at earlier stages, PAC in SOT portends a very poor survival.
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http://dx.doi.org/10.1097/MPA.0000000000001722DOI Listing
January 2021

Left Ventricular Assist Device Therapy and Acute Pancreatitis: Higher Incidence and Worse Clinical Outcomes.

Pancreas 2020 09;49(8):1069-1074

From the Divisions of Gastroenterology and Hepatology.

Objective: The aim of the study was to compare incidence and outcomes of acute pancreatitis among advanced heart failure therapies.

Methods: Two retrospective cohorts are as follows: A, patients with heart failure presenting to our hospitals and B, the US National Inpatient Sample. Three groups were compared: left ventricular assist device (LVAD) recipients, transplant recipients, and controls who did not qualify for advanced therapies. Primary outcomes were pancreatitis incidence and mortality. Secondary outcomes included kidney failure, multiorgan failure, shock, and health care utilization.

Results: Cohort A included 1344 heart failure patients, and cohort B included 677,905 patients with acute pancreatitis. In cohort A, annual pancreatitis incidence was 6.7 cases per 1000 LVAD recipients, 4.1 per 1000 LVAD bridge-to-transplant, 2.3 per 1000 transplant recipients, and 3.2 per 1000 heart failure controls (P = 0.03). Combined, the incidence was 5.6 per 1000 LVAD users and 2.7 in 1000 non-LVAD users (relative risk, 2.1; P = 0.009). In cohort B, increased mortality was seen in LVAD users, but not in transplant recipients. Left ventricular assist device patients had higher odds of kidney failure, multiorgan failure, shock, and intensive care.

Conclusions: Patients with LVAD have double risk of pancreatitis, worse clinical outcomes, and increased healthcare utilization. Studies elucidating the mechanisms behind pancreatic injury in advanced heart failure are suggested.
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http://dx.doi.org/10.1097/MPA.0000000000001624DOI Listing
September 2020

Kidney transplantation on extracorporeal life support for primary cardiac allograft dysfunction.

J Card Surg 2020 Mar 4;35(3):725-728. Epub 2020 Feb 4.

Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida.

Patients undergoing heart-kidney transplants who have primary graft dysfunction (PGD) of the heart are at risk of losing both organs, which may cause reluctance on the part of the transplant team to proceed with transplanting the kidney while the transplanted heart is being supported by mechanical device. We describe a case series in which 2 patients received kidney transplants while on veno-arterial ECMO support for PGD after heart transplant. Both patients are alive more than 1 year following transplant, with good cardiac and renal function and no signs of cardiac rejection. Kidney transplant surgery is safe for patients on veno-arterial ECMO support for cardiac PGD. It allows the heart recipient to receive a kidney from the same donor with both immunologic and survival advantages.
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http://dx.doi.org/10.1111/jocs.14451DOI Listing
March 2020

Paradoxical emboli following a pulmonary embolus in the presence of a patent foramen ovale.

Ann Transl Med 2018 Jan;6(1):21

University of Tennessee Health Science Center, Methodist University Hospital, Memphis, TN, USA.

A paradoxical embolism is defined as a systemic arterial embolus due to passage of a venous thrombus through a right to left shunt. We describe a case of acute cerebral vascular accident (CVA), right subclavian arterial embolus, and pulmonary emboli in the setting of a large patent foramen ovale (PFO). A 74-year-old woman with multiple comorbidities presented to the emergency department with acute onset of shortness of breath, weakness, and right arm pain. She was found to have bilateral pulmonary emboli, left CVA, and a right subclavian arterial embolus on computed tomography (CT). She emergently underwent embolectomy of her right upper extremity along with a fasciotomy. On chest CT, a PFO was visualized. Transesophageal echocardiogram (TEE) revealed a large PFO with at least a 3-mm primum/secundum separation and evidence of right to left shunting. Multidisciplinary consensus was that she would benefit from closure of her PFO in order to reduce her risk of further emboli. The patient was agreeable and taken to the catheterization lab where a sizing balloon over a stiff wire was advanced to measure the size of the defect. A 25-mm Cardioform device was successfully delivered across the defect. The patient was started on oral anticoagulation and antiplatelets. In summary, increase in right-sided pressures from pulmonary emboli can cause right to left shunting and lead to a paradoxical embolus. Assessment of patients who present with acute CVA or arterial embolus in the setting of pulmonary emboli with elevated right atrial pressures should include an evaluation for a PFO. Closure of PFO in these patients is of potential additive benefit.
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http://dx.doi.org/10.21037/atm.2018.01.04DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5787730PMC
January 2018

Acute right ventricular failure after orthotopic liver transplantation.

Ann Transl Med 2018 Jan;6(1):19

Department of Cardiovascular Medicine, University of Tennessee Health Science Center, Memphis, TN 38136, USA.

The interdependence between the heart and liver in maintaining hemodynamic stability during the perioperative period of either orthotopic heart (OHT) or liver (OLT) transplantation is important. The pre-transplant hemodynamic changes that occur in patients with end-stage liver disease (ESLD) can include decreased systemic vascular resistance, poor ventricular response to stress and increased cardiac output (CO). Concomitant pulmonary disorders are often present in ESLD. Portopulmonary hypertension (PoPHTN) is an important marker for increased mortality in liver transplant patients. The pathophysiologic mechanisms specific to PoPHTN have been compared with other known forms of pulmonary hypertension, including primary pulmonary hypertension, and has been found to fall within a spectrum of disorders related to factors both due to intrinsic liver failure [with resultant portal hypertension and hepatopulmonary syndrome (HPS)] as well as pulmonary vascular remodeling. We present a 47-year-old Caucasian female with ESLD secondary to non-alcoholic steatohepatitis and HPS. Our current case demonstrates the difficulty in managing patients with acute pulmonary hypertension after OLT. Review of the contemporary literature demonstrated a total of eight case reports of post-transplant severe pulmonary hypertension thought to be due to a combination of either HPS or PoPHTN. This case highlights the complexities of patient management in the acute setting after OLT. Furthermore, it demonstrates the intricate role of careful preoperative evaluation and screening in patients undergoing workup for solid organ transplantation.
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http://dx.doi.org/10.21037/atm.2017.11.39DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5787716PMC
January 2018

Perioperative predictors of permanent pacing and long-term dependence following tricuspid valve surgery: a multicentre analysis.

Europace 2017 Dec;19(12):1988-1993

Division of Cardiology and Department of Internal Medicine, University of Louisville, 550 South Jackson Street 3rd Floor, Louisville, Kentucky, 40202 USA.

Aims: Permanent pacemaker placement (PPM) is often required after valvular surgery and is especially common following tricuspid valve surgery [tricuspid valve repair or replacement (TVR)]. Literature suggests that surgical intervention for isolated tricuspid valve disease is becoming more prevalent. Predictors of PPM dependency following TVR are currently unknown and would be clinically useful from a prognostication standpoint.

Methods And Results: We conducted a multicentre, retrospective study to assess perioperative factors of TVR that predispose to PPM placement and long-term PPM dependency from 2008 to 2014. Regression analysis was used to determine independent predictors of PPM implantation. A total of 237 patients (age 66 ± 15 years, 29% male) were studied, and the incidence of PPM placement following TVR was 27% (65/237). No significant differences were observed between those who received PPM and those who did not in age (P = 0.092), gender (P = 0.359), and co-morbidities. Regression analysis identified cross-clamp time >60 min (OR 4.1, 95% CI 1.3-12.9, P = 0.015) and concomitant mitral valve surgery (OR 3.8, 95% CI 1.2-12.2, P = 0.026) as independent risk factors for PPM following TVR. Long-term PPM dependency data were only available in 28 patients who received PPM with 14 of these patients developing long-term dependence. The only statistically significant difference noted was an increased frequency of coronary artery disease in the long-term dependent group vs. the non-dependent group (64% vs. 14%, P = 0.018).

Conclusion: Cross-clamp time >60 min and concomitant mitral valve surgery were independent predictors of PPM implantation following TVR. Long-term PPM dependency is more prevalent after TVR than other types of valvular surgery.
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http://dx.doi.org/10.1093/europace/euw391DOI Listing
December 2017

Radial Artery Occlusion After Cardiac Catheterization: Significance, Risk Factors, and Management.

Curr Probl Cardiol 2016 Jun 28;41(6):214-227. Epub 2016 Sep 28.

Multiple modifiable risk factors have been proposed to decrease the likelihood of developing radial artery occlusion (RAO) in patients who undergo transradial (TR) catheterization. RAO, the most significant complication for these patients, however, remains poorly identified and under diagnosed owing to its clinical quiescence and lack of clinical guidelines for systematic evaluation of radial artery patency. Currently, only best practices are available. As TR catheterization is becoming more widely adopted across the United States it has become more important to develop concrete strategies for identifying modifiable risk factors, high-risk patients, and better understanding the mechanisms to adequately approach treatment of RAO. We reviewed the contemporary literature regarding RAO and TR catheterization to provide a simplified method for discerning identifiable risk factors, high-risk groups, and management of RAO after TR catheterization.
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http://dx.doi.org/10.1016/j.cpcardiol.2016.09.002DOI Listing
June 2016

Meta-Analysis Comparing Complete Revascularization Versus Infarct-Related Only Strategies for Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Artery Disease.

Am J Cardiol 2016 Nov 23;118(10):1466-1472. Epub 2016 Aug 23.

The Duke Clinical Research Institute, Durham, North Carolina.

Several recent randomized controlled trials (RCTs) demonstrated better outcomes with multivessel complete revascularization (CR) than with infarct-related artery-only revascularization (IRA-OR) in patients with ST-segment elevation myocardial infarction. It is unclear whether CR should be performed during the index procedure (IP) at the time of primary percutaneous coronary intervention (PCI) or as a staged procedure (SP). Therefore, we performed a pairwise meta-analysis using a random-effects model and network meta-analysis using mixed-treatment comparison models to compare the efficacies of 3 revascularization strategies (IRA-OR, CR-IP, and CR-SP). Scientific databases and websites were searched to find RCTs. Data from 9 RCTs involving 2,176 patients were included. In mixed-comparison models, CR-IP decreased the risk of major adverse cardiac events (MACEs; odds ratio [OR] 0.36, 95% CI 0.25 to 0.54), recurrent myocardial infarction (MI; OR 0.50, 95% CI 0.24 to 0.91), revascularization (OR 0.24, 95% CI 0.15 to 0.38), and cardiovascular (CV) mortality (OR 0.44, 95% CI 0.20 to 0.87). However, only the rates of MACEs, MI, and CV mortality were lower with CR-SP than with IRA-OR. Similarly, in direct-comparison meta-analysis, the risk of MI was 66% lower with CR-IP than with IRA-OR, but this advantage was not seen with CR-SP. There were no differences in all-cause mortality between the 3 revascularization strategies. In conclusion, this meta-analysis shows that in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease, CR either during primary PCI or as an SP results in lower occurrences of MACE, revascularization, and CV mortality than IRA-OR. CR performed during primary PCI also results in lower rates of recurrent MI and seems the most efficacious revascularization strategy of the 3.
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http://dx.doi.org/10.1016/j.amjcard.2016.08.009DOI Listing
November 2016