Publications by authors named "Tamunoinemi Bob-Manuel"

41 Publications

Vertebral Artery Interventions: A comprehensive updated review.

Curr Cardiol Rev 2022 Mar 17. Epub 2022 Mar 17.

John Ochsner Heart and Vascular Center, New Orleans, LA, USA.

Patients with posterior circulation ischemia due to vertebral artery stenosis account for 20 to 25% of ischemic strokes and have an increased risk of recurrent stroke. In patients treated with medical therapy alone, the risk of recurrence is particularly increased in the first few weeks after symptoms occur with an annual stroke rate of 10 to 15%. Additionally, obstructive disease of the vertebrobasilar system carries a worse prognosis, with a 30% mortality at 2-years if managed medically without additional surgical or endovascular intervention. Percutaneous transluminal angioplasty and stenting of symptomatic vertebral artery stenosis is a promising option that is widely used in clinical practice with good technical results; however, improved clinical outcome has been examined in various clinical trials without sufficient sample size to conclusively determine whether stenting is better than medical therapy. Surgical revascularization is an alternative approach for the treatment of symptomatic vertebral artery stenosis that carries a 10-20% mortality rate. Despite the advances in medical therapy and endovascular and surgical options, symptomatic vertebral artery stenosis continues to impose a high risk of stroke recurrence with associated high morbidity and mortality. The aim of this review is to provide a focused update on percutaneous treatment of vertebral artery stenosis, its appropriate diagnostic approach and advances in medical therapies.
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http://dx.doi.org/10.2174/1573403X18666220317093131DOI Listing
March 2022

Peripheral Artery Disease: A Comprehensive Updated Review.

Curr Probl Cardiol 2021 Dec 11:101082. Epub 2021 Dec 11.

Department of Cardiology, Montefiore Medical Centre, NY. Electronic address:

Peripheral arterial disease is estimated to affect more than 200 million people worldwide. Although more than 50% of those affected are asymptomatic, it accounts for 3%-4% of amputations and a crude 5-year death rate of 82.4 deaths per 1000 patient-years when adjusted for duration of follow-up. Additionally, peripheral artery disease is often an indicator of obstructive atherosclerotic disease involvement of cerebral and coronary vessels, consequently increasing the risk of stroke, cardiovascular death, and myocardial infarction in these patient populations. The management of peripheral arterial disease includes conservative therapies, pharmacological treatments, interventional and surgical revascularization of blood vessels. Percutaneous transluminal angioplasty with balloons and stents has improved clinical outcomes compared to medical treatment alone. Despite these advances, the prevalence of peripheral arterial disease remains high. This review article aims to provide focused, up-to-date information on the clinical course, diagnosis, medical and interventional approach of the management of peripheral artery disease.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.101082DOI Listing
December 2021

Reply to "The SARS-COV Pandemic Does Not Absolve From Solid Medical Trade".

Ochsner J 2021 ;21(3):238-239

Department of Cardiology, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA.

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http://dx.doi.org/10.31486/toj.21.5021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8442214PMC
January 2021

Structural Heart Interventions During COVID-19.

Curr Probl Cardiol 2022 Feb 24;47(2):100934. Epub 2021 Jul 24.

Department of Cardiology, Ochsner Medical Center, New Orleans, LA; Department of Cardiology, Albert Einstein University, Montefiore Medical Center, Bronx, NY.

The spread of Coronavirus Disease 2019 (COVID-19) pandemic across the globe and the United States presented unprecedented challenges with dawn of new policies to reserve resources and protect the public. One of the major policies adopted by hospitals across the nations were postponement of non-emergent procedures such as transaortic valve replacement (TAVR), left atrial appendage closure device (LAAC), MitraClip and CardioMEMS. Guidelines were based mainly on the avoidable clinical outcomes occurring during COVID-19 era. As our understanding of the SARS-CoV-2 evolved, advanced cardiac procedures may safely continue through careful advanced coordination. We aim to highlight the new guidelines published by different major cardiovascular societies, and discuss solutions to safely perform procedures to improve outcomes in a patient population with high acuity of illness during the COVID-19 pandemic era.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.100934DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8302827PMC
February 2022

Spectrum of Suspected Cardiomyopathy Due to COVID-19: A Case Series.

Curr Probl Cardiol 2021 Oct 3;46(10):100926. Epub 2021 Jul 3.

Department of Internal Medicine, Ochsner Health Foundation, New Orleans, LA; Department of Cardiovascular Health, Ochsner Health Foundation, New Orleans, LA. Electronic address:

The effects of COVID-19 on the cardiovascular system remains understudied given the early stage of the pandemic. Several case series and case reports have been published on COVID-19 related cardiomyopathies; however, there is often a lack of baseline echocardiographic data confirming a normal cardiac health prior to infection. Here we examine four patients with preserved left ventricular systolic function on prior echocardiogram who developed de novo cardiomyopathies which following COVID-19 infection. The study comprised of four individuals with an average age of 80.5 years, 75% of which were white males. 50% of cases were suspected to have Takotsubo CM vs. myocarditis while the remaining half were diagnosed as myocarditis. Left ventricular systolic function dropped from a normal range to an average of 30% during COVID-19 infection in these individuals. Moreover, half of the cases later died. In conclusion, the COVID-19 pandemic has demonstrated its ability to cause several serious cardiovascular complications with associated worsening of prognosis. Repeat TTE showed recovery of systolic function in 50% of the patients included. There does not appear to be any correlation between COVID-19 related treatments, age, or level of inflammatory markers in those who recovered systolic function versus those who remained depressed. Given the minimal literature on this topic, it is evident more information is needed to help advance treatment and understanding of COVID-19 induced cardiomyopathies; particularly if the vaccination fails to protect against novel strains of COVID-19 and the virus becomes endemic.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.100926DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8254392PMC
October 2021

Successful Revascularization of Infrapopliteal Chronic Total Occlusions Using the Plantar Arch as a Conduit and Retrograde Pedal Access.

Ochsner J 2021 ;21(2):209-213

Department of Cardiology, Ochsner Clinic Foundation, Kenner, LA.

With the rising prevalence of critical limb ischemia (CLI), the pedal-plantar loop technique and retrograde access may be needed to increase interventional success. A 63-year-old female with severe peripheral artery disease presented with a 2-month nonhealing wound on the dorsum of her left foot despite wound care. We inserted a 65-cm Destination Guiding Sheath and crossed the right superficial femoral artery (SFA) chronic total occlusion (CTO) that we initially treated with a 4.0-mm Ultraverse balloon. We attempted unsuccessfully to cross the distal anterior tibial artery into the dorsalis pedis artery. We obtained antegrade access of the posterior tibial artery at the level of the ankle with a 2.9-French Cook pedal access kit. We inserted a 90-cm CXI catheter with a 0.014 Fielder XT wire and used the lateral plantar artery as a conduit to cross the dorsalis pedis artery and distal anterior tibial artery CTO with retrograde wire manipulation via lateral plantar artery. Finally, we performed distal anterior tibial and dorsalis pedis CTO balloon angioplasty with a 2.5 × 220-mm Ultraverse balloon and performed SFA percutaneous transluminal angioplasty and stenting with a 7.0 × 120-mm Zilver PTX stent, postdilated with a 6.0-mm Ultraverse balloon. We successfully established in-line flow to the foot with 3-vessel runoff. The patient's wound healed in a month. Retrograde pedal access can improve the success rate of recanalization of below-the-knee disease in patients with CLI.
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http://dx.doi.org/10.31486/toj.20.0085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8238093PMC
January 2021

Suspected COVID-19-Induced Myopericarditis.

Ochsner J 2021 ;21(2):181-186

The University of Queensland Faculty of Medicine, Ochsner Clinical School, New Orleans, LA.

The incidence of myocarditis in patients with coronavirus disease 2019 (COVID-19) remains unknown; however, increasing evidence links COVID-19 to cardiovascular complications such as arrhythmias, heart failure, cardiogenic shock, fulminant myocarditis, and cardiac death. We present a case of suspected COVID-19-induced myopericarditis and discuss the diagnostic implications, pathophysiology, and management. A 72-year-old female was admitted to the hospital with acute on chronic respiratory failure in the setting of COVID-19. The next day, she developed pressure-like retrosternal chest pain. Laboratory findings revealed elevated cardiac enzymes and inflammatory markers consistent with myocardial injury. Electrocardiogram revealed diffuse ST segment elevations without reciprocal changes, concerning for myopericarditis. Transthoracic echocardiography showed new findings of severely reduced left ventricular (LV) systolic function, with an estimated ejection fraction (EF) of 20%. Her hospital course was further complicated by cardiogenic shock that required treatment in the intensive care unit with vasopressors and inotropes. During the next few days, she had almost full recovery of her LV function, with EF improving to 50%. However, her clinical status deteriorated, likely the result of a bowel obstruction. She was transitioned to comfort care at the request of her family, and she died shortly after. This case highlights diagnostic and therapeutic challenges that physicians may encounter when managing acute cardiac injury in the setting of COVID-19. The multiple mechanisms of COVID-19-related myocardial injury may influence the approach to diagnosis and treatment.
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http://dx.doi.org/10.31486/toj.20.0090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8238094PMC
January 2021

Editorial: Premature death from heart failure among Aboriginal peoples in the Hunter New England region of new South Wales.

Int J Cardiol 2021 08 14;337:88-89. Epub 2021 May 14.

John Ochsner Heart and Vascular Institute, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70118, USA. Electronic address:

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http://dx.doi.org/10.1016/j.ijcard.2021.05.026DOI Listing
August 2021

Transcatheter Aortic Valve Replacement in Rheumatic Aortic Stenosis: A Comprehensive Review.

Curr Probl Cardiol 2021 Dec 19;46(12):100843. Epub 2021 Mar 19.

Division of Cardiovascular Diseases, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN.

Rheumatic heart disease (RHD) mainly affects people in developing, low-income countries. However, due to globalization and migration, developed countries are now seeing more cases of RHD. In RHD patients who develop severe symptomatic aortic stenosis, surgical aortic valve replacement remains the treatment of choice. In the past decade, there has been an extension of transcatheter aortic valve replacement (TAVR) to intermediate-risk and lower-risk patients with aortic stenosis. This review suggests the possible utility of TAVR for the treatment of rheumatic aortic stenosis. Rheumatic aortic stenosis has been excluded from major TAVR studies due to the predominantly noncalcific pathology of the rheumatic aortic valve. However, there have been case reports and case series showing successful implantation of the valve even in patients with and without significant leaflet calcification. In this review article, we summarize the latest evidence of severe rheumatic aortic stenosis treated with TAVR and discuss the procedure's impact on patient care, safety, and efficacy.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.100843DOI Listing
December 2021

Renal interventions in the management of hypertension.

Curr Opin Cardiol 2021 07;36(4):444-452

John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana.

Purpose Of Review: In the present comprehensive review, we describe the pathophysiology, indications, and evidence for both renal artery stenting and renal artery denervation. We also discuss the procedural techniques, risks, benefits, and future directions of renal intervention in the management of hypertension (HTN).

Recent Findings: Hemodynamic confirmation of lesion severity in severe renal artery stenosis is a resting or hyperemic translesional systolic gradient >20, resting or hyperemic mean translesional gradient >10 and/or renal fractional flow reserve <0.8 are considered severe. Knowing that correct stent size was used is the best predictor of restenosis, intravascular ultrasound is effective and well tolerated for stent sizing. The main categories of renal denervation: radiofrequency ablation, ultrasound, chemical ablation, and brachytherapy have shown impressive outcomes in treating resistant HTN.

Summary: Over the past decade, several studies have shown the safety and benefit of catheter-based renal interventions in managing HTN. Renal artery stenting and renal artery denervation are the leading alternative invasive treatment employed in managing HTN.
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http://dx.doi.org/10.1097/HCO.0000000000000859DOI Listing
July 2021

Leadless and Wireless Cardiac Devices: The Next Frontier in Remote Patient Monitoring.

Curr Probl Cardiol 2021 May 24;46(5):100800. Epub 2021 Jan 24.

John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, LA; Section of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA. Electronic address:

In the last decade, advances in wireless and sensor technologies, and the implementation of telemedicine, have led to innovative digital health care for cardiac patients. Continuous monitoring of patients' biomedical signals, and acute changes in these signals, may result in timely, accurate diagnoses and implementation of early interventions. In this review, we discuss commonly used wireless and leadless cardiac devices including pulmonary artery pressure sensors, implantable loop recorders, leadless pacemakers and subcutaneous implantable cardioverter-defibrillators. We discuss the concept and function of each device, indications, methods of delivery, potential complications, consideration for implantation, and cost-effectiveness.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.100800DOI Listing
May 2021

Outcomes following endovascular therapy for acute stroke by interventional cardiologists.

Catheter Cardiovasc Interv 2020 11 10;96(6):1296-1303. Epub 2020 Aug 10.

Department of Cardiology, Ochsner Clinical School, University of Queensland, St Lucia, Australia.

Objectives: To summarize the outcomes of acute ischemic stroke (AIS) intervention by interventional cardiologists (IC) working on a stroke team.

Background: There is a geographic maldistribution of dedicated neuro-interventionalists (NI) to treat large vessel occlusion (LVO) AIS.

Methods: Results of 166 consecutive patients who received endovascular therapy (EVT) for AIS due to LVO by IC at three centers between 2009 and 2019 are reported. A modified Rankin score (mRs) of ≤ 2 at 90 days after EVT was used as the primary measurement of a good neurological outcome. Univariate logistic regression was used to evaluate predictors of the mRS > 2 and mortality. Those variables with significance of p < .2 from the univariate analysis were included in a multivariate analysis.

Results: All-cause mortality at 30 days was 22%. A favorable clinical outcome, mRS ≤ 2 at 90 days, was 49%. After multivariate analysis and controlling for confounders, a higher baseline NIHSS was predictive of 30-day mortality (OR 1.20 [95% CI 1.09-1.32] p < .001) and unfavorable clinical outcome (mRS > 2) at 90 days (OR 1.16 [95% CI 1.07-1.25] p < .001).

Conclusion: Outcomes for carotid stent capable IC performing EVT for AIS are comparable to those achieved by NI physicians in major randomized clinical trials. Our data supports conducting a clinical trial of carotid stent capable IC working on multidisciplinary stroke teams to perform EVT for AIS due to LVO in communities and hospitals without timely access (<60 min by ground transport) to dedicated NI.
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http://dx.doi.org/10.1002/ccd.29180DOI Listing
November 2020

Transaxillary TAVR Leads to Shorter Ventilator Duration and Hospital Length of Stay Compared to Transapical TAVR.

Curr Probl Cardiol 2021 Mar 22;46(3):100624. Epub 2020 May 22.

John Ochsner Heart and Vascular Center, New Orleans, LA.

There is an increasing need for alternative access in patients with prohibitive surgical risk who have unsuitable anatomy for transfemoral transcatheter aortic valve replacement (TAVR). Data on differences in periprocedural outcomes via alternative access sites are scarce. We performed a retrospective analysis of patients who underwent Transaxillary (TAX) or Transapical (TAP) TAVR at our center from 2012 to 2019. All data was summarized and displayed as mean ± SD for continuous variables and number of patients in each group. A propensity score was created for each patient in the dataset to determine the probability of axillary vs apical access. We adjusted for propensity score using multivariate logistic regression. A total of 102 patients underwent TAVR via alternative access: 28 patients (27%) via TAX and 74 patients (73%) via transapical (TAP) access. The average time to extubation in the TAX group was 5.3 ± 3.5 hours vs 9.1 ± 8.8 hours in the TAP patients (P = 0.03). None of the TAX patients required reintubation compared to 23% of TAP TAVR (P = 0.003). The average hospital length of stay for TAX was 2.4 ± 2.0 days compared to 6.9 ± 3.3 days (P < 0.0001) for TAP. TAX TAVR patients had significantly lower re-intubation rates, shorter time to extubation and in-hospital length of stay, but higher pacemaker implantation rates. TAX TAVR had improved periprocedural outcomes compared to TAP TAVR and remains the preferred TAVR alternative access.
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http://dx.doi.org/10.1016/j.cpcardiol.2020.100624DOI Listing
March 2021

Low risk TAVR: Long- term considerations and appropriate patient selection.

Prog Cardiovasc Dis 2020 May - Jun;63(3):377-382. Epub 2020 Apr 8.

John Ochsner Heart and Vascular Center, New Orleans, LA, USA.

Recent trials have shown impressive results in low-risk patients undergoing Transcatheter Aortic Valve Replacement (TAVR) with low procedural complication rates, short hospital length of stay, zero mortality, and zero disabling stroke at 30 days and have led to a Food and Drug Administration indication for TAVR in these patients. The long-term data on subclinical leaflet thrombosis, valve durability, effects of pacemaker implantation, right ventricular pacing, and progressive paravalvular leak is unclear. We describe clinical and procedural considerations for patient selection and introduce future potential procedural challenges. Finally, we discuss the importance of considering life expectancy and durability prior to TAVR in this low risk relatively young cohort and emphasize the importance of a heart team approach.
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http://dx.doi.org/10.1016/j.pcad.2020.04.002DOI Listing
August 2020

Renal and Mesenteric Artery Intervention.

Interv Cardiol Clin 2020 04 31;9(2):169-185. Epub 2020 Jan 31.

Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Center, Ochsner Medical Center, The Ochsner Clinical School, University of Queensland, 1514 Jefferson Highway, New Orleans, LA 70121, USA; Department of Cardiology, Ochsner Medical Center, 3rd Floor, 1514 Jefferson Highway, New Orleans, LA 70121, USA. Electronic address:

Atherosclerotic renal artery stenosis is the most common cause of secondary hypertension and may cause progressive renal disease and cardiac destabilization syndromes. Guideline-directed medical therapy is advised in all patients. Patients with refractory symptoms and hemodynamically significant stenoses are more likely to benefit from renal artery stent placement. Chronic mesenteric ischemia (CMI) is an infrequent and difficult to diagnose illness. Due to robust collateralization, clinical symptoms from mesenteric artery stenosis or occlusion is uncommon. Atherosclerosis is the most common etiology of CMI. Current evidence suggests that, compared with open surgical repair, endovascular therapy is the most cost-effective choice for CMI.
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http://dx.doi.org/10.1016/j.iccl.2019.11.002DOI Listing
April 2020

Renal denervation: Alternative treatment options for hypertension?

Prog Cardiovasc Dis 2020 Jan - Feb;63(1):51-57. Epub 2019 Dec 27.

Department of Cardiology at Ochsner Clinic Foundation, Ochsner Clinical School-the University of Queensland School of Medicine, New Orleans, LA, United States of America.

Hypertension affects millions of Americans and has adverse long-term consequences increasing morbidity and mortality. Resistant hypertension (RH) continues to be difficult to treat with medications alone which may be associated with significant side effects. Alternate therapies have been evaluated for treating RH and renal denervation has been investigated extensively. We review the data from renal denervation trials and other novel technologies which are not FDA approved to date.
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http://dx.doi.org/10.1016/j.pcad.2019.12.007DOI Listing
May 2020

Efficacy and Safety of Transcarotid Transcatheter Aortic Valve Replacement: A Systematic Review.

Cardiovasc Revasc Med 2020 07 10;21(7):917-926. Epub 2019 Dec 10.

Division of Cardiology, University of Tennessee Health Science Center, Memphis, TN, USA. Electronic address:

Background: In patients who are not suitable for traditional access routes for transcatheter aortic valve replacement (TAVR) due to severe peripheral vascular disease (PVD) or prohibitive surgical risk, carotid artery (CA) access is an emerging route for TAVR. This study represents the most up to date on outcomes of carotid access TAVR.

Methods: A systematic review was conducted as per the Preferred Reporting Instructions for Systematic Reviews and Meta-analysis (PRISMA). We performed a thorough electronic search through Pubmed, SCOPUS and Embase databases. Statistical analyses were performed using SPSS version 24 (IBM Corporation, Armonk, New York, USA).

Results: A total of 15 non-randomized studies were included in this systematic review comprising of patients that received TAVR via 4 vascular access sites, transcarotid (TC) (N = 1035), transfemoral (TF) (N = 1116), transapical (TAP) (N = 307), transaortic (TAO) (N = 176) and transaxillary (TAX) (N = 90). In the Transcarotid cases, device success was achieved in 95.6% of patients (n = 748). The 30-day and 1-yr mortality was 4.2% and 10.5% respectively. 15.3% of patients required new pacemaker implantation. In-hospital stroke or TIA occurred in 4% of cases. 30-day stroke or TIA occurred in 5% of cases. There were no hemorrhagic strokes. 30-day Mortality was significantly higher in the Transaortic group (12.1%) compared to the Transcarotid group (2.6%) [RR = 2.93 95% CI = 1.15-7.58; p = 0.027]. There were no differences in outcomes between the Transcarotid group and the Transapical or Transaxillary groups.

Conclusion: The most contemporary data on Carotid access TAVR shows impressive device success, low rates of stroke and pacemaker implantation and an acceptable 30-day and 1-year mortality. 30-day mortality was significantly lower in TC compared to TAO patients.
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http://dx.doi.org/10.1016/j.carrev.2019.12.012DOI Listing
July 2020

Renal revascularization in resistant hypertension.

Prog Cardiovasc Dis 2020 Jan - Feb;63(1):58-63. Epub 2019 Dec 7.

Department of Cardiology, Ochsner Clinic Foundation. Electronic address:

Renal artery stenosis (RAS) is a common cause of secondary hypertension (HTN) and may lead to resistant (refractory) HTN despite guideline directed medical therapy. Although randomized controlled trials comparing medical therapy to medical therapy and renal artery stenting have shown no benefit with renal artery stenting, according to comparative effectiveness reviews by the Agency for Healthcare Research and Quality, the trials did not enroll patients with the most severe RAS who would be more likely to benefit from renal stenting. Because of limitations of conventional angiography, it is important to assess the hemodynamic severity of moderate (50%-70%) RAS lesions with a hemodynamic measurement. We review techniques to optimize patient selection, to minimize procedural complications, and to facilitate durable patency of renal stenting. We also review the current ACC/AHA Guidelines and SCAI Appropriate Use Criteria as they relate to renal stenting.
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http://dx.doi.org/10.1016/j.pcad.2019.12.001DOI Listing
May 2020

What is causing this patient's cyclical fever?

JAAPA 2019 11;32(11):53-55

Pooja S. Jagadish practices in the Department of Internal Medicine, University of Tennessee Health Science Center in Memphis, Tenn. Tamunoinemi Bob-Manuel practices in the Heart & Vascular Institute at Ochsner Clinic Foundation in New Orleans, La. Taylor Simmons is a student in the PA program at Mississippi College in Clinton, Miss. Hemnishil K. Marella and Jayna Kelly practice at the University of Tennessee Health Science Center. Uzoma N. Ibebuogu practices in the Division of Cardiology at the University of Tennessee Health Science Center. The authors have disclosed no potential conflicts of interest, financial or otherwise.

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http://dx.doi.org/10.1097/01.JAA.0000586352.50114.09DOI Listing
November 2019

Non-arrhythmic causes of sudden death: A comprehensive review.

Prog Cardiovasc Dis 2019 May - Jun;62(3):265-271. Epub 2019 May 8.

John Ochsner Heart and Vascular Center, New Orleans, LA, United States of America; University of Queensland Ochsner Clinical School, New Orleans, LA, United States of America. Electronic address:

Sudden cardiac death (SCD) is a major public health issue in the United States and worldwide. It is estimated to affect between 1 and 1.5 million patients worldwide annually, with the global burden expected to rise due to the concomitant rise in coronary artery disease in the developing world. Although arrhythmic causes of SCD such as ventricular tachycardia and ventricular fibrillation are common and well-studied, non-arrhythmic causes are also important, with diverse etiologies from ischemia-related structural heart disease to non-ischemic heart diseases, non-atherosclerotic coronary pathologies, and inflammatory states. Recent research has also found that risk factors and/or demographics predispose certain individuals to a higher risk of non-arrhythmia-related SCD. This review discusses the epidemiology, mechanisms, etiologies, and management of non-arrhythmic SCD.
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http://dx.doi.org/10.1016/j.pcad.2019.05.004DOI Listing
October 2019

Outcomes of transcatheter aortic valve replacement in bicuspid aortic valve stenosis.

Ann Transl Med 2019 Mar;7(5):102

Division of Cardiovascular Diseases, Ochsner Clinic Foundation, New Orleans, USA.

Background: Due to abnormal valve geometry, patients with bicuspid aortic valve (BAV) have been excluded in many transcatheter aortic valve replacement (TAVR) trials resulting in very limited data with regards to its safety and efficacy.

Methods: We searched electronic databases including Cochrane Database of Systematic Reviews, MEDLINE and EMBASE for all studies including case series, and original reports published before December 2018 that assessed outcomes following TAVR in BAV stenosis. We also included studies that had patients with TAV for comparison. Pooled effect size was calculated with a random-effect model and weighted for the inverse of variance, to compare outcomes post-TAVR between BAV and TAV. The heterogeneity of effect estimates across the studies was assessed using I2. Publication bias was assessed with funnel plots. Statistical analysis was performed using SPSS version 24 (IBM Corp., SPSS Statistics for Windows, Version 24.0. Armonk, NY.).

Results: A total of 19 studies describing 1,332 patients with BAV and 3,610 with TAV. There was no significant difference in the30-day mortality between patients with BAV and TAV [odds ratio (OR): 1.18, 95% confidence interval (CI): 0.7-1.7, P=0.41, I=0]. One-year mortality rate in the BAV population was 13.1% compared to 15.4% in the TAV patients (P=0.75). Patients with BAV had significantly more moderate to severe paravalvular leak (PVL) post TAVR (PVL ≥3) 8.8% 4.2% in TAV patients (OR: 1.478, 95% CI: 1.000-2.184, P=0.050, I=0. Device success was significantly higher in TAV patients compared to BAV patients 93.5% 87% (OR: 0.63, 95% CI: 0.49-0.86, P=0.003).

Conclusions: TAVR in patients with BAV is associated with a high incidence of paravalvular regurgitation with a comparable 30-day mortality rate to TAV patients. The use of newer generation valve prosthesis improved outcomes.
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http://dx.doi.org/10.21037/atm.2019.02.04DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6462665PMC
March 2019

Correlation Between Aortic Angulation and Outcomes of Transcatheter Aortic Valve Replacement With New-Generation Valves.

Curr Probl Cardiol 2021 Feb 14;46(2):100415. Epub 2019 Mar 14.

The aim of this study was to assess the correlation of aortic angulation (AA) on immediate postprocedural and long-term outcomes following transcatheter aortic valve replacement (TAVR) with new-generation valves. There is limited and conflicting data on the impact of AA on short- and long-term outcomes in patients undergoing TAVR. Available studies to date were done with first-generation valves. We assessed 179 patients who underwent TAVR with either a balloon-expandable or self-expandable valve at our institute from May 2014 to June 2017 and had multislice computed tomography scans available for AA evaluation. All included patients received a second- or third-generation valve. TAVR endpoints, device success, and adverse events were defined according to the Valve Academic Research Consortium-2 criteria. The mean AA of the study population was 49.05 ± 10.07. Patients were divided into 2 groups: AA <49 and AA ≥49, and then further subdivided by valve type. There were no difference in mean age, The Society for Thoracic Surgery (STS) score, or race distribution between the AA <49 and AA ≥49 groups. The preimplantation balloon valvuloplasty rate was higher in patients with AA ≥ 49 compared to patients with AA <49, (70% vs 55.1%, P = 0.04). There was no difference in re-hospitalization, pacemaker implantation, postprocedural aortic regurgitation or mortality between patients with AA <49 and AA ≥49 irrespective of valve type (P < 0.05). AA does not significantly affect short- or long-term outcomes in patients who undergo TAVR with new-generation balloon-expandable or self-expandable valves.
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http://dx.doi.org/10.1016/j.cpcardiol.2019.03.004DOI Listing
February 2021

Cocaine Positivity in ST-Elevation Myocardial Infarction: A True or False Association.

Perm J 2019 ;23

University of Tennessee Health Science Center College of Medicine, Memphis, TN.

Introduction: Every year, more than 500,000 US Emergency Department visits are associated with cocaine use. People who use cocaine tend to have a lower incidence of true ST-elevation myocardial infarction (STEMI).

Objective: To identify the factors associated with true STEMI in patients with cocaine-positive (CPos) findings.

Methods: We retrospectively analyzed 1144 consecutive patients with STEMI between 2008 and 2013. True STEMI was defined as having a culprit lesion on coronary angiogram. Multivariate and univariate analyses were used to identify risk factors and create a predictive model.

Results: A total of 64 patients with suspected STEMI were CPos (mean age 53.1 ± 11.2 years; male = 80%). True STEMI was diagnosed in 34 patients. Patients with CPos true STEMI were more likely to be uninsured than those with false STEMI (61.8% vs 34.5%, p = 0.03) and have higher peak troponin levels (21.1 ng/mL vs 2.12 ng/mL, p = < 0.01) with no difference in mean age between the 2 groups (p = 0.24). In multivariate analyses, independent predictors of true STEMI in patients with CPos findings included age older than 65 years (odds ratio [OR] = 19.3, 95% confidence iterval [CI] = 1.2-318.3), lack of health insurance (OR = 4.9, 95% CI = 1.2-19.6), and troponin level higher than 0.05 (OR = 24.0, 95% CI = 2.6-216.8) (all p < 0.05). A multivariate risk score created with a C-statistic of 82% (95% CI = 71-93) significantly improved the identification of patients with true STEMI.

Conclusion: Among those with suspected STEMI, patients with CPos findings had a higher incidence of false STEMI. Older age, lack of health insurance, and troponin levels outside of defined limits were associated with true STEMI in this group.
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http://dx.doi.org/10.7812/TPP/18-048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6443362PMC
September 2019

Protein-Energy Malnutrition and Outcomes of Hospitalizations for Heart Failure in the USA.

Am J Cardiol 2019 03 19;123(6):929-935. Epub 2018 Dec 19.

Associate Professor of Medicine, WJB Dorn VAMC Heart and Vascular Institute/USC School of Medicine, Columbia, South Carolina.

Chronically elevated cytokines from un-abating low-grade inflammation in heart failure (HF) results in Protein-Energy Malnutrition (PEM). However, the impact of PEM on clinical outcomes of admissions for HF exacerbations has not been evaluated in a national data. From the 2012 to 2014 Nationwide Inpatient Sample (NIS) patient's discharge records for primary HF admissions, we identified patients with concomitant PEM, and their demographic and comorbid factors. We propensity-matched PEM cohorts (32,771) to no-PEM controls (1:1) using a greedy algorithm-based methodology and estimated the effect of different clinical outcomes (SAS 9.4). There were 32,771 (∼163,885) cases of PEM among the 541,679 (∼2,708,395) primary admissions for HF between 2012 and 2014 in the US. PEM cases were older (PEM:76 vs no-PEM:72 years), Whites (70.75% vs 67.30%), and had higher comorbid burden, with Deyo-comorbidity index >3 (31.61% vs 26.30%). However, PEM cases had lower rates of obesity, hyperlipidemia and diabetes. After propensity-matching, PEM was associated with higher mortality (AOR:2.48 [2.31 to 2.66]), cardiogenic shock (3.11[2.79 to 3.46]), cardiac arrest (2.30[1.96 to 2.70]), acute kidney failure (1.49[1.44 to 1.54]), acute respiratory failure (1.57[1.51 to 1.64]), mechanical ventilation (2.72[2.50 to 2.97]). PEM also resulted in higher non-routine discharges (2.24[2.17 to 2.31]), hospital cost ($80,534[78,496 to 82,625] vs $43,226[42,376 to 44,093]) and longer duration of admission (8.6[8.5 to 8.7] vs 5.3[5.2 to 5.3] days). In conclusion, PEM is a prevailing comorbidity among hospitalized HF subjects, and results in devastating health outcomes. Early identification and prevention of PEM in HF subjects during clinic visits and prompt treatment of PEM both in the clinic and during hospitalization are essential to decrease the excess burden of PEM.
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http://dx.doi.org/10.1016/j.amjcard.2018.12.014DOI Listing
March 2019

Spontaneous Rupture of Sinus of Valsalva Aneurysm Presenting as Perivalvular Hematoma.

J Cardiovasc Echogr 2018 Jul-Sep;28(3):201-203

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

Acute rupture of sinus of Valsalva often presents as an acute emergency with significant hemodynamic compromise whereas contained rupture of sinus of Valsalva with a perivalvular hematoma formation is rarely seen. We describe the case of a 63-year-old male who presented with acute shortness of breath and was found to have rupture of sinus of Valsalva aneurysm (SVA) with a perivalvular hematoma and severe aortic regurgitation. We also review the presentation, diagnosis, and management of SVAs.
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http://dx.doi.org/10.4103/jcecho.jcecho_6_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6172882PMC
October 2018

Ventricular Tachycardia (VT) Substrate Characteristics: Insights from Multimodality Structural and Functional Imaging of the VT Substrate Using Cardiac MRI Scar, I-Metaiodobenzylguanidine SPECT Innervation, and Bipolar Voltage.

J Nucl Med 2019 01 29;60(1):79-85. Epub 2018 Jun 29.

Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.

Postischemic adaptation results in characteristic myocardial structural and functional changes in the ventricular tachycardia (VT) substrate. The aim of this study was to compare myocardial structural and functional adaptations (late gadolinium enhancement/abnormal innervation) with detailed VT mapping data to identify regional heterogeneities in postischemic changes. Fifteen patients with ischemic cardiomyopathy and drug-refractory VT underwent late gadolinium enhancement cardiac MRI (CMR), I-metaiodobenzylguanidine SPECT, and high-resolution bipolar voltage mapping to assess fibrosis (>3 SDs), abnormal innervation (<50% tracer uptake), and low-voltage area (<1.5 mV), respectively. Three-dimensional reconstructed CMR/I-metaiodobenzylguanidine models were coregistered for further comparison. Postischemic structural and functional adaptations in all 3 categories were similar in size (reported as median [quartile 1-quartile 3]: CMR scar, 46.1 cm [33.1-86.9 cm]; abnormal innervation, 47.8 cm [40.5-68.1 cm]; and low-voltage area, 29.5 cm [24.5-102.6 cm]; > 0.05). However, any single modality underestimated the total VT substrate area defined as abnormal in at least 1 of the 3 modalities (76.0 cm [57.9-143.2 cm]; < 0.001). Within the total VT substrate area, regions abnormal in all 3 modalities were most common (25.2%). However, significant parts of the VT substrate had undergone heterogeneous adaptation (abnormal in <3 modalities); the most common categories were "abnormal innervation only" (18.2%), "CMR scar plus abnormal innervation only" (14.9%), and "CMR scar only" (14.6%). All 14 VT channel/exit sites (0.88 ± 0.74 mV) were localized to myocardium demonstrating CMR scar and abnormal innervation. This specific tissue category accounted for 68.3% of the CMR scar and 31.2% of the total abnormal postischemic VT substrate area. Structural and functional imaging demonstrated regional heterogeneities in the postischemic VT substrate not appreciated by any single modality alone. The coexistence of abnormal innervation and CMR scar may identify a particularly "proarrhythmic" adaptation and may represent a potential novel target for VT ablation.
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http://dx.doi.org/10.2967/jnumed.118.211698DOI Listing
January 2019

Access site complications in transcutaneous aortic valve replacement: frequency, outcomes, prevention, and treatment.

Ann Transl Med 2018 Jan;6(1):14

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

Aortic stenosis (AS) is a common cause of valvular heart disease with heavy disease burden in elderly patients. It is present in almost 7% of patients older than 65. The mortality rate increases significantly once it becomes symptomatic with average life expectancy of around 1-year. Symptoms include angina, syncope, or heart failure. This requires either surgical or transcutaneous replacement. Transcutaneous aortic valve replacement (TAVR) use has increased in recent years from high risk patients to now even including intermediate risk patients. With the increased number of procedures performed, one of the consequences is access site complications. These complications can lead to increased hospitalization, cost, infections, and eventually worse outcomes. In this manuscript, we provide a comprehensive review discussing the consequences, outcomes, frequency, predictors and some possible solutions to these complications set forth in these studies.
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http://dx.doi.org/10.21037/atm.2017.10.32DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5787720PMC
January 2018

Incidence and predictors of acute coronary syndrome within a year following a negative stress test-a false sense of security: is routine screening any useful?

Ann Transl Med 2018 Jan;6(1):13

Department of Internal Medicine, Division of Cardiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.

One of the major issues in management of the acute coronary syndrome (ACS) is classification of patients with atypical presentation who have low risk of having a coronary episode at presentation. There have been multiple studies on the stratification of high risk patients and medical management of such cases, however, there is a sub-class of patients who do not fit any category. In this paper, we have looked at the current literature on stratification of patients based on the study tools available and the risk of having a coronary episode during the following year. In our overview, we have found that the current methods in place namely, cardiac stress test and stress echocardiogram have a good prognostic factor in terms of mortality in the next one year and can safely stratify the patients at low risk when correlated with clinical presentation and laboratory studies. However, such data are limited for computerized tomography or magnetic resonant imaging and their application might be limited due to accessibility and cost of studies. Current guidelines for classification of high risk patient do an excellent job and we believe that proper application of stress tests together with other imaging modalities together with laboratory, clinical judgment, and proper use of medical management can help with safe discharge of patients from the emergency department (ED) and reduction of burden from healthcare.
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http://dx.doi.org/10.21037/atm.2017.11.12DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5787711PMC
January 2018

Asian-Indians: a review of coronary artery disease in this understudied cohort in the United States.

Ann Transl Med 2018 Jan;6(1):12

Department of Internal Medicine, Division of Cardiology, University of Tennessee Health Science Center, Memphis, TN, USA.

Coronary artery disease (CAD) is a major cause of cardiovascular death worldwide. Prevalence of CAD is highly variable among different races. Asian Indians have been noted to have the highest CAD rates and the conventional risk factors fail to explain this difference completely. Asian Indians constitute a fifth of the global population, and the higher rates of CAD in this population constitute a major health challenge. There have been studies in the early 2000s that investigate the risk factors in this population; however, very few studies have been done since then that explore the higher CAD rates in Asian Indians. This is a comprehensive and current review of the known risk factors for CAD in Asian Indians and strategies physicians should consider relieving this burden.
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http://dx.doi.org/10.21037/atm.2017.10.18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5787729PMC
January 2018
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