Publications by authors named "Serge Harb"

88 Publications

Simultaneous Pulmonary Artery Pressure and Left Ventricle Stroke Volume Assessment Predicts Adverse Events in Patients With Pulmonary Embolism.

J Am Heart Assoc 2021 Sep 6;10(18):e019849. Epub 2021 Sep 6.

Department of Cardiovascular Medicine Heart Vascular and Thoracic InstituteCleveland Clinic Foundation Cleveland OH.

Background Certain echocardiographic parameters may serve as early predictors of adverse events in patients with hemodynamically compromising pulmonary embolism (PE). Methods and Results An observational analysis was conducted for patients with acute pulmonary embolism evaluated by a Pulmonary Embolism Response Team (PERT) between 2014 and 2020. The performance of clinical prediction algorithms including the Pulmonary Embolism Severity Index and Carl Bova score were compared using a ratio of right ventricle and left ventricle hemodynamics by dividing the pulmonary artery systolic pressure by the left ventricle stroke volume. The primary outcome of in-hospital mortality, cardiac arrest, and the need for advanced therapies was evaluated by univariate and multivariable analyses. Of the 343 patients meeting the inclusion criteria, 215 had complete data. Pulmonary artery systolic pressure/left ventricle stroke volume was a clear predictor of the primary end point (odds ratio [OR], 2.31; =0.005), performing as well or better than the Pulmonary Embolism Severity Index (OR, 1.43; =0.06) or the Bova score (OR, 1.28; =0.01). Conclusions This study is the first study to demonstrate the utility of early pulmonary artery systolic pressure/left ventricle stroke volume in predicting adverse clinical events in patients with acute pulmonary embolism. Pulmonary artery systolic pressure/left ventricle stroke volume may be a surrogate marker of ventricular asynchrony in high-risk pulmonary embolism and should be prognostically evaluated.
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http://dx.doi.org/10.1161/JAHA.120.019849DOI Listing
September 2021

Stress testing and noninvasive coronary imaging: What's the best test for my patient?

Cleve Clin J Med 2021 Sep 1;88(9):502-515. Epub 2021 Sep 1.

Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic; Assistant Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH.

Coronary artery disease (CAD) causes significant morbidity and mortality. Accurate noninvasive evaluation is important to facilitate appropriate diagnosis and treatment. The ubiquitous nature of CAD requires all practitioners, regardless of their specialty, to be familiar with noninvasive diagnostic modalities. This article reviews currently available tests, including specific features, diagnostic and prognostic value, strengths, and limitations.
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http://dx.doi.org/10.3949/ccjm.88a.20068DOI Listing
September 2021

Associations between cardiorespiratory fitness, sex and long term mortality amongst adults undergoing exercise treadmill testing.

Int J Cardiol 2021 Nov 4;342:103-107. Epub 2021 Aug 4.

Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States. Electronic address:

Background: Cardiorespiratory fitness (CRF) varies with sex and is an independent predictor of mortality. We sought to investigate sex differences in the exercise protocol selected, CRF levels, and their relationships with long term all-cause mortality.

Methods: In a 25-year stress testing registry spanning from 1991 to 2014, consecutive all-comer patients who underwent exercise stress testing at Cleveland Clinic were categorized by sex, stress protocol and imaging modality. All tests were conducted by one or more of stress test technicians, sonographers and nuclear medicine technologists, and interpreted by cardiologists. The primary outcome all-cause mortality was analyzed in using multivariable Cox regression.

Results: In 120,705 patients, the mean age was 53.3 ± 12.5 years, and 41% were female. Females were more commonly referred for non-Bruce exercise protocols (modified Bruce, Cornell 0, 5 and 10, Naughton and modified Naughton) with odds ratio of 2.62; 95% confidence interval (95%CI) (2.54-2.70) after adjusting for age and comorbidities. When also adjusting for the protocol chosen, females achieved lower CRF with beta -1.40, 95% CI (-1.43, -1.37). There were 8426 (6.9%) deaths during a mean follow-up of 8.7 years. Both female sex and CRF were independently associated with lower all-cause mortality with hazards ratio (95%CI) of 0.44 (0.41-0.46) and 0.41 (0.39-0.42) respectively, after adjusting for age, co-morbidities and protocol chosen.

Conclusions: Women were more likely referred for less demanding exercise protocols, more imaging protocols and achieved lower CRF than men. Despite this, female sex was associated with significantly lower long term mortality for equivalent CRF level in adjusted analyses.
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http://dx.doi.org/10.1016/j.ijcard.2021.07.063DOI Listing
November 2021

Transcatheter Closure of Left Ventricular Outflow Tract-to-Left Atrium Fistula.

JACC Case Rep 2021 May 19;3(5):760-765. Epub 2021 May 19.

Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.

Surgical and rarely transcatheter aortic valve replacement can be complicated by intracardiac fistula. Transcatheter closure of those shunts has been previously reported with favorable results. We describe a case of percutaneous closure of left ventricular outflow tract-to-left atrium fistula after surgical aortic valve replacement using an Amplatzer Vascular Plug II. ().
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http://dx.doi.org/10.1016/j.jaccas.2021.02.040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8311196PMC
May 2021

Surgical Repair for Primary Tricuspid Valve Disease: Individualized Surgical Planning With 3-Dimensional Printing.

JACC Case Rep 2020 Nov 18;2(14):2217-2222. Epub 2020 Nov 18.

Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.

Primary tricuspid valve (TV) disease is rare and associated with high operative mortality. Optimal surgical planning requires a precise understanding of the pathological features; however, detailed imaging of the TV can be challenging. We present 4 cases of primary TV disease where 3-dimensional printing was pivotal to operative planning and success. ().
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http://dx.doi.org/10.1016/j.jaccas.2020.09.047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8299861PMC
November 2020

Roles of Cardiac Computed Tomography in Guiding Transcatheter Tricuspid Valve Interventions.

Curr Cardiol Rep 2021 07 16;23(9):114. Epub 2021 Jul 16.

Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.

Purpose Of Review: The field of transcatheter tricuspid valve interventions (TTVI) is rapidly evolving to meet a well-defined but unmet clinical need. Severe tricuspid regurgitation is common and is associated with significant morbidity and mortality. Surgical options are limited and of high risk. The success of TTVI depends on careful procedural planning, and cardiac computed tomography (CCT) plays an emerging key role.

Recent Findings: TTVI technologies have various targets, including the leaflets, annulus, and venae cavae, along with valve replacement. Based on the planned procedure, CCT allows for device sizing, careful assessment of the access route, and comprehensive analysis of relevant adjacent anatomic structures to enhance procedural safety. It can also evaluate right-sided heart function, and its data can be for fusion imaging and 3D printing. Procedural planning is key to TTVI's success and is highly dependent on high-quality CCT data. This review details the comprehensive roles of CCT, specifics of the dedicated TTVI protocol, and its limitations.
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http://dx.doi.org/10.1007/s11886-021-01547-7DOI Listing
July 2021

Transcatheter Aortic Valve Implantation in Patients With Inflammatory Bowel Disease.

Am J Cardiol 2021 09 6;154:133-135. Epub 2021 Jul 6.

Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

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http://dx.doi.org/10.1016/j.amjcard.2021.05.030DOI Listing
September 2021

Multi-modality imaging and 3D printing to facilitate the management of complex, recurrent infarct VSD.

J Cardiovasc Comput Tomogr 2021 Jun 8. Epub 2021 Jun 8.

Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Ohio, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jcct.2021.06.001DOI Listing
June 2021

Predicting Infective Endocarditis After Transcatheter Aortic Valve Implantation Via a Risk Model.

Am J Cardiol 2021 07 9;150:131-132. Epub 2021 May 9.

Dept. of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

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http://dx.doi.org/10.1016/j.amjcard.2021.04.007DOI Listing
July 2021

Strain evaluation for mitral annular disjunction by echocardiography and magnetic resonance imaging: A case-control study.

Int J Cardiol 2021 Jul 29;334:154-156. Epub 2021 Apr 29.

Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, OH, United States. Electronic address:

Background: Mitral annular disjunction (MAD) is an increasingly recognized entity associated with mitral valve prolapse (MVP), ventricular arrhythmias and death. Few studies have investigated the utility of myocardial deformation analysis in MAD. We compared chamber quantification including strain by transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (CMR) between MVP patients with and without MAD.

Methods: Forty-two patients with MVP (21 with MAD, 21 without MAD) and 21 controls were studied. Global, basal and basal inferolateral (BIL) segmental strains were measured and compared using velocity-vector imaging TTE and feature-tracking CMR.

Results: Mean age was 54 ± 17 years, 19 (46%) were female, and 19 (46%) underwent surgical mitral valve repair with no deaths during follow-up in the 2 groups with MVP. Patients with MAD and MVP had lower basal longitudinal strain by TTE than those with MVP without MAD. Those with MAD and MVP had lower magnitude in BIL and basal segments by circumferential and radial strain by CMR compared to those with MVP without MAD and controls. Amongst global strain parameters, CMR-derived global circumferential strain was independently associated with MAD diagnosis odds ratio 1.49 (per 1%), 95% confidence interval 1.09-2.05, P = 0.014, with optimal threshold of -18.0% having 76% sensitivity and specificity for MAD.

Conclusion: Abnormal circumferential and radial strain patterns in the basal segments by CMR may be useful for identifying regional LV dysfunction associated with MAD.
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http://dx.doi.org/10.1016/j.ijcard.2021.04.052DOI Listing
July 2021

Novel Approach to Risk Stratification in Left Ventricular Non-Compaction Using A Combined Cardiac Imaging and Plasma Biomarker Approach.

J Am Heart Assoc 2021 04 9;10(8):e019209. Epub 2021 Apr 9.

Heart Vascular and Thoracic Institute Cleveland Clinic Cleveland OH.

Background Left ventricular non-compaction remains a poorly described entity, which has led to challenges of overdiagnosis. We aimed to evaluate if the presence of a thin compacted myocardial layer portends poorer outcomes in individuals meeting cardiac magnetic resonance criteria for left ventricular non-compaction . Methods and Results This was an observational, retrospective cohort study involving individuals selected from the Cleveland Clinic Foundation cardiac magnetic resonance database (N=26 531). Between 2000 and 2018, 328 individuals ≥12 years, with left ventricular non-compaction or excessive trabeculations based on the cardiac magnetic resonance Petersen criteria were included. The cohort comprised 42% women, mean age 43 years. We assessed the predictive ability of myocardial thinning for the primary composite end point of major adverse cardiac events (composite of all-cause mortality, heart failure hospitalization, left ventricular assist device implantation/heart transplant, ventricular tachycardia, or ischemic stroke). At mean follow-up of 3.1 years, major adverse cardiac events occurred in 102 (31%) patients. After adjusting for comorbidities, the risk of major adverse cardiac events was nearly doubled in the presence of significant compacted myocardial thinning (hazard ratio [HR], 1.88 [95% CI, 1.18‒3.00]; =0.016), tripled in the presence of elevated plasma B-type natriuretic peptide (HR, 3.29 [95% CI, 1.52‒7.11]; =0.006), and increased by 5% for every 10-unit increase in left ventricular end-systolic volume (HR, 1.01 [95% CI, 1.00‒1.01]; =0.041). Conclusions The risk of adverse clinical events is increased in the presence of significant compacted myocardial thinning, an elevated B-type natriuretic peptide or increased left ventricular dimensions. The combination of these markers may enhance risk assessment to minimize left ventricular non-compaction overdiagnosis whilst facilitating appropriate diagnoses in those with true disease.
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http://dx.doi.org/10.1161/JAHA.120.019209DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174181PMC
April 2021

Severe Atrial Functional Mitral Regurgitation: Clinical and Echocardiographic Characteristics, Management and Outcomes.

JACC Cardiovasc Imaging 2021 04;14(4):797-808

Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA. Electronic address:

Objectives: This study was designed to compare the clinical and echocardiographic characteristics, management, and outcomes of severe atrial functional mitral regurgitation (AFMR) to primary mitral regurgitation (PMR).

Background: AFMR remains poorly defined clinically.

Methods: Consecutive patients who underwent transesophageal echocardiography at our institution between 2011 and 2018 for severe mitral regurgitation with preserved left ventricular function were screened. We excluded patients with endocarditis, any form of cardiomyopathy, or prior mitral intervention. The absence of leaflet pathology defined AFMR. Outcomes included death and heart failure hospitalizations.

Results: A total of 283 patients were included (AFMR = 14%, PMR = 86%). Compared to PMR, patients with AFMR had more comorbidities, including hypertension (94.9% vs. 76.2%; p = 0.015), diabetes mellitus (46.2% vs. 18.4%; p < 0.001), long-standing atrial fibrillation (28.2% vs. 13.1%; p = 0.015), prior nonmitral cardiac surgery (25.6% vs. 9.8%; p = 0.004), and pacemaker placement (33.3% vs. 13.5%; p = 0.002). They also had higher average E/e' (median [interquartile range]:16.04 [13.1 to 22.46] vs. 14.1 [10.89 to 19]; p = 0.036) and worse longitudinal left atrial strain peak positive value (16.86 ± 12.15% vs. 23.67 ± 14.09%; p = 0.002) compared to PMR. During follow-up (median: 22 months), patients with AFMR had worse survival (log-rank p = 0.009) and more heart failure hospitalizations (log-rank p = 0.002). They were also less likely to undergo mitral valve intervention (59.0% vs. 83.6%; p = 0.001), although surgery was associated with improved survival (log-rank p = 0.021). On multivariable regression analysis, AFMR was independently associated with mortality [adjusted odds ratio: 2.61, 95% confidence interval: 1.17 to 5.83; p = 0.02].

Conclusions: AFMR constitutes an under-recognized high-risk group, with significant comorbidities, limited therapeutic options, and poor outcomes.
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http://dx.doi.org/10.1016/j.jcmg.2021.02.008DOI Listing
April 2021

Short Term Outcomes of Transcatheter Mitral Valve Repair in Renal Transplant Recipients.

Am J Cardiol 2021 07 26;150:124-126. Epub 2021 Mar 26.

Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

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http://dx.doi.org/10.1016/j.amjcard.2021.03.031DOI Listing
July 2021

Implementation of a Myocardial Perfusion Imaging Risk Algorithm to Inform Appropriate Downstream Invasive Testing and Treatment.

Circ Cardiovasc Imaging 2021 04 26;14(4):e011984. Epub 2021 Mar 26.

Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, OH.

Background: To risk stratify patients undergoing single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) in accordance with appropriate use criteria for referral to coronary angiography, we developed a risk classification algorithm incorporating appropriate use criteria-defined risk features. We evaluated the association between this algorithm with downstream angiography, revascularization, and all-cause mortality.

Methods: We studied consecutive patients who underwent SPECT-MPI from January 1, 2015, to December 31, 2017, and assigned a scan risk of low, intermediate, high, or indeterminate. With this stratification, we assessed referral for angiography and revascularization within 3 months of SPECT-MPI and intermediate-term mortality.

Results: Among 12 799 patients, the mean age was 66 years, and a majority were men (56.8%). Most patients were low risk (83.6%) followed by intermediate (9.9%) and high risk (5.2%). Compared with low-risk patients, intermediate- and high-risk patients were more frequently referred for angiography (14.8% and 13.6% versus 2.0%; <0.001) and revascularization (7.7% and 6.8% versus 0.7%; <0.001). In 1008 propensity-matched patients, scan risk was independently associated with angiography after adjustment for ischemia, scar, or stress ejection fraction. At a mean follow-up of 2.3 years, mortality was higher with increased scan risk (high, 10.4%; intermediate, 7.1%; low, 4.1%; <0.001). Compared with low scan risk, intermediate (hazard ratio, 1.37 [95% CI, 1.09-1.72]; =0.008) and high scan risk (hazard ratio, 1.98 [95% CI, 1.53-2.56]; <0.001) were associated with mortality in multivariable analysis. Similar findings were observed for those undergoing pharmacological and exercise SPECT-MPI with comparatively worse prognosis among pharmacological patients.

Conclusions: This appropriate use criteria-derived risk classification algorithm for SPECT-MPI guided referral for coronary angiography and revascularization and was significantly associated with mortality. This algorithm may serve as an important tool to reaffirm appropriate use criteria and direct management of patients with stable ischemic heart disease undergoing stress testing.
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http://dx.doi.org/10.1161/CIRCIMAGING.120.011984DOI Listing
April 2021

Tricuspid annular dimensions in patients with severe mitral regurgitation without severe tricuspid regurgitation.

Cardiovasc Diagn Ther 2021 Feb;11(1):68-80

Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.

Background: Concomitant TV repair during mitral valve (MV) surgery based on tricuspid valve annulus (TVA) dilation, rather than the degree of tricuspid regurgitation (TR), is beneficial and supported by the valve guidelines. We sought to determine TVA geometry and dimensions in controls and assess the changes that occur in patients with severe primary (PMR) and secondary (SMR) mitral regurgitation without TR.

Methods: We analyzed cardiac computed tomographic angiography (CCTA) of 125 consecutive subjects: 50 controls with normal coronary CCTA and no valvular dysfunction, 50 PMR patients referred for robotic repair, and 25 SMR patients referred for transcatheter therapy. Patients with >2+ TR on echocardiography were excluded. Annular measurements were performed using dedicated software and compared. Correlations and determinants of TVA dimensions were analyzed.

Results: Patients with SMR were older and had significantly more comorbidities. In controls, the TVA was larger and more planar and eccentric compared to the MV annulus (all P<0.01). Dimensions of both annuli correlated significantly (r≥0.5; P<0.001 for all dimensions) in controls and patients with severe MR. In both PMR and SMR, the TVA enlarged in all dimensions (P<0.01) with a trend towards becoming more circular. On multivariable regression, the MV annular area was the primary determinant of the TVA area (adjusted β=0.430, P<0.001).

Conclusions: Substantial changes in TVA dimensions are encountered in patients with severe MR even in the absence of severe TR such that TVA and MVA dimensions remain correlated. Close attention to the TVA in patients with severe MR is warranted.
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http://dx.doi.org/10.21037/cdt-20-903DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944191PMC
February 2021

Incidence, Predictors, and Implications of Permanent Pacemaker Requirement After Transcatheter Aortic Valve Replacement.

JACC Cardiovasc Interv 2021 01;14(2):115-134

Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA. Electronic address:

Transcatheter aortic valve replacement (TAVR) is a safe and feasible alternative to surgery in patients with symptomatic severe aortic stenosis regardless of the surgical risk. Conduction abnormalities requiring permanent pacemaker (PPM) implantation remain a common finding after TAVR due to the close proximity of the atrioventricular conduction system to the aortic root. High-grade atrioventricular block and new onset left bundle branch block (LBBB) are the most commonly reported conduction abnormalities after TAVR. The overall rate of PPM implantation after TAVR varies and is related to pre-procedural and intraprocedural factors. The available literature regarding the impact of conduction abnormalities and PPM requirement on morbidity and mortality is still conflicting. Pre-procedural conduction abnormalities such as right bundle branch block and LBBB have been linked with increased PPM implantation and mortality after TAVR. When screening patients for TAVR, heart teams should be aware of various anatomical and pathophysiological conditions that make patients more susceptible to increased risk of conduction abnormalities and PPM requirement after the procedure. This is particularly important as TAVR has been recently approved for patients with low surgical risk. The purpose of this review is to discuss the incidence, predictors, impact, and management of the various conduction abnormalities requiring PPM implantation in patients undergoing TAVR.
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http://dx.doi.org/10.1016/j.jcin.2020.09.063DOI Listing
January 2021

Prevalence and Outcomes of Tricuspid Valve Disease in Patients Undergoing Mitral Valve Surgery (from the Nationwide Inpatient Sample Database).

Am J Cardiol 2021 04 19;144:151-152. Epub 2021 Jan 19.

Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

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http://dx.doi.org/10.1016/j.amjcard.2021.01.007DOI Listing
April 2021

Attenuated heart rate recovery is associated with higher arrhythmia recurrence and mortality following atrial fibrillation ablation.

Europace 2021 07;23(7):1063-1071

Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA.

Aims: Heart rate recovery (HRR), the decrease in heart rate occurring immediately after exercise, is caused by the increase in vagal activity and sympathetic withdrawal occurring after exercise and is a powerful predictor of cardiovascular events and mortality. The extent to which it impacts outcomes of atrial fibrillation (AF) ablation has not previously been studied. The aim of this study is to investigate the association between attenuated HRR and outcomes following AF ablation.

Methods And Results: We studied 475 patients who underwent EST within 12 months of AF ablation. Patients were categorized into normal (>12 b.p.m.) and attenuated (≤12 b.p.m.) HRR groups. Our main outcomes of interest included arrhythmia recurrence and all-cause mortality. During a mean follow-up of 33 months, 43% of our study population experienced arrhythmia recurrence, 74% of those with an attenuated HRR, and 30% of those with a normal HRR (P < 0.0001). Death occurred in 9% of patients in the attenuated HRR group compared to 4% in the normal HRR cohort (P = 0.001). On multivariable models adjusting for cardiorespiratory fitness (CRF), medication use, left atrial size, ejection fraction, and renal function, attenuated HRR was predictive of increased arrhythmia recurrence (hazard ratio 2.54, 95% confidence interval 1.86-3.47, P < 0.0001).

Conclusion: Heart rate recovery provides additional valuable prognostic information beyond CRF. An impaired HRR is associated with significantly higher rates of arrhythmia recurrence and death following AF ablation.
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http://dx.doi.org/10.1093/europace/euaa419DOI Listing
July 2021

Apical defect following Tendyne valve placement.

J Nucl Cardiol 2020 Nov 19. Epub 2020 Nov 19.

Cleveland Clinic Heart, Vascular and Thoracic Institute, Cleveland, OH, USA.

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http://dx.doi.org/10.1007/s12350-020-02440-6DOI Listing
November 2020

Incidental Thoracic Aortic Dilation on Chest Computed Tomography in Patients With Atrial Fibrillation.

Am J Cardiol 2021 02 2;140:78-82. Epub 2020 Nov 2.

Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Ohio; Section of Cardiovascular Imaging, Imaging Institute, Cleveland Clinic, Ohio.

Patients with atrial fibrillation (AF) have risk factors that predispose to thoracic aneurysmal disease (TAD) and atherosclerosis. In this study in patients with AF, we assessed the occurrence of incidental TAD and assessed if a validated predictive score used to predict AF, the CHARGE-AF score, was associated with greater aortic dimensions. We also assessed the prevalence of coronary calcification. We conducted a cross-sectional study of 1,000 consecutive patients with AF undergoing chest multidetector CT during evaluation for pulmonary vein isolation. A dilated aortic root or ascending aorta (AA, dimension/ body surface area >2.05 cm/m) were found in 195 (20%). A total of 12 (1%) had significant aortic aneurysmal enlargement of > 5.0 cm. Advancing age, a bicuspid aortic valve, hypertension, and male gender were associated with increased aortic dimensions. Aortic root dimensions increased linearly (p < 0.001) and ascending aortic dimensions increased nonlinearly across CHARGE-AF deciles (p < 0.001). Nearly two-thirds (63%) had coronary calcification, 38% of whom were not on lipid-lowering therapy. In conclusion, in patients with AF undergoing gated chest CT, 1 in 5 had previously undetected TAD, with a small proportion having significantly aneurysmal dimensions approaching surgical thresholds. Risk factors previously established to increase the propensity to develop AF are also associated with increased TAD. These findings raise the need to consider a surveillance strategy for TAD in patients with AF, particularly in those with other risk factors for aortic disease. A high prevalence of coronary calcium was also detected, representing an opportunity to optimize statin therapy in patients with AF.
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http://dx.doi.org/10.1016/j.amjcard.2020.10.059DOI Listing
February 2021

MitraClip Insertion to Hasten Recovery from Severe COVID-19.

CASE (Phila) 2021 Feb 16;5(1):51-52. Epub 2020 Oct 16.

Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio.

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http://dx.doi.org/10.1016/j.case.2020.10.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7566784PMC
February 2021

Atrial Fibrillation and Transcatheter Repair of Functional Mitral Regurgitation: Evidence From a Meta-Regression.

JACC Cardiovasc Interv 2020 10;13(20):2374-2384

Department of Interventional Cardiology, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Objectives: The aim of this study was to assess the impact of atrial fibrillation (AF) on mortality and efficacy in patients with functional mitral regurgitation (FMR) undergoing MitraClip implantation.

Background: AF is a common arrhythmia in patients with severe FMR undergoing transcatheter mitral valve repair with the MitraClip device. Although AF has been consistently shown to be associated with poor outcomes after mitral valve surgery, the impact of AF on outcomes of MitraClip placement in patients with FMR has not been well studied.

Methods: Prospective, retrospective registries, observational studies, and randomized controlled trials on MitraClip reporting AF and FMR as one of the variables from inception until January 2019 were included.

Results: Of the initial 1,694 studies, 15 studies met the inclusion criteria. From a total of 5,184 patients, 2,105 patients were identified to have FMR and AF. All-cause 30-day mortality in patients with FMR was 3.7% (95% confidence interval: 2.87 to 4.66) and 1-year mortality was 17.9% (95% confidence interval: 16.01 to 19.71). The meta-regression analysis studying the impact of AF among patients with FMR treated with the MitraClip demonstrated no difference in mortality at 30 days but demonstrated significantly increased mortality at 1 year (95% confidence interval: 0.0006 to 0.0027) (p = 0.004). AF did not influence procedural success.

Conclusions: This meta-regression identifies AF as an independent negative predictor of long-term mortality after MitraClip implantation in patients with FMR. The mechanism of worse outcomes in patients with AF requires further study.
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http://dx.doi.org/10.1016/j.jcin.2020.06.050DOI Listing
October 2020

Impact of Hospital Procedural Volume on Outcomes Following Balloon Aortic Valvuloplasty.

Am J Cardiol 2021 01 9;138:120-122. Epub 2020 Oct 9.

Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

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http://dx.doi.org/10.1016/j.amjcard.2020.10.002DOI Listing
January 2021

Structural Interventions and Procedural Imaging: Hand in Hand for Better Outcomes.

JACC Cardiovasc Interv 2020 09;13(18):2121-2123

Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1016/j.jcin.2020.06.063DOI Listing
September 2020

Higher baseline cardiorespiratory fitness is associated with lower arrhythmia recurrence and death after atrial fibrillation ablation.

Heart Rhythm 2020 10 3;17(10):1687-1693. Epub 2020 Aug 3.

Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: Cardiorespiratory fitness (CRF) has been shown to correlate with incident atrial fibrillation (AF) and AF burden. In recent years there has been increasing recognition of the pivotal role of modifying risk factors before AF ablation.

Objective: The purpose of this study was to investigate whether higher baseline CRF measured using exercise stress testing (EST) was associated with improved outcomes after AF ablation.

Methods: We studied 591 patients who underwent EST within 12 months before AF ablation. Patients were categorized into low (<85% predicted), adequate (85%-100% predicted), and high (>100% predicted) CRF groups. Outcomes of interest included arrhythmia recurrence, cessation of antiarrhythmic therapy, repeat hospitalization for arrhythmia, repeat rhythm control procedures, and all-cause mortality.

Results: During mean follow-up of 32 months after ablation, arrhythmia recurrence was observed in 79% of patients in the low CRF group compared to 54% in the adequate CRF group and 27.5% in the high CRF group (P <.0001). Similarly, rates of repeat arrhythmia-related hospitalization, repeat rhythm control procedures, and need for ongoing antiarrhythmic therapy were significantly lower in the high CRF group (P <.0001). Death occurred in 2.5% of patients in the high CRF group compared to 4% in the adequate CRF group and 11% in the low CRF group (P <.0001). In Cox proportional hazards analyses, high CRF was significantly associated with lower arrhythmia recurrence.

Conclusion: Higher CRF is associated with reduced arrhythmia recurrence rates and death among patients undergoing AF ablation. Efforts should be made to enhance CRF before AF ablation.
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http://dx.doi.org/10.1016/j.hrthm.2020.05.013DOI Listing
October 2020

Association of baseline kidney disease with outcomes of transcatheter mitral valve repair by MitraClip.

Catheter Cardiovasc Interv 2021 May 23;97(6):E857-E867. Epub 2020 Jul 23.

Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio.

Objectives: This study sought to determine the impact of baseline chronic kidney disease (CKD) on in-hospital outcomes of transcatheter mitral valve repair with MitraClip (MC).

Background: MC is now an established treatment in high surgical risk patients. However, limited data are available on outcomes of MC in patients with baseline renal dysfunction.

Methods: The authors used data from January 2014 to December 2017 National Readmission Database to identify all patients ≥18 years of age who underwent MC. International classification of diseases (ICD)-9 and ICD-10 codes were used to identify patients with no-CKD, CKD (without chronic dialysis), or end-stage renal disease (ESRD) on dialysis. Multivariable logistic regression models were constructed using generalized estimating equations to examine in-hospital outcomes.

Results: Of 13,563 patients undergoing MC, 8,935 (65.8%) had no-CKD, 4,152 (30.6%) had CKD, and 476 (3.5%) had ESRD. ESRD patients compared to CKD and no-CKD had significantly higher mortality (7.2% vs. 2.5% vs. 2.0%; p < .001), higher incidence of bleeding, blood transfusions, and 30 day all cause readmission. CKD patients compared to no-CKD had significantly higher mortality (odds ratio-1.29; CI 1.01-1.65; p = .04), acute kidney injury (odds ratio-3.0; CI 2.69-3.34; p < .001), new in-hospital hemodialysis (odds ratio- 2.70; CI 1.57-4.62; p < .001), blood transfusions, 30 day all cause and congestive heart failure (CHF) readmissions. In-hospital stroke and cardiac tamponade did not differ between the three groups. Patients with baseline kidney disease undergoing MC had higher mortality at high volume centers compared to low volume centers. CHF was the most common cause of readmission postMC in patients with or without preprocedural kidney disease.

Conclusion: Patients with baseline kidney disease have worse outcomes after MC with higher readmission rates requiring careful patient selection and follow up in this population.
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http://dx.doi.org/10.1002/ccd.29129DOI Listing
May 2021
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