Publications by authors named "Vincent L Sorrell"

86 Publications

Cardiovascular Risk After Sepsis: Understanding the Role of Statin Indications and the Impact of Clinical Inertia on Prescribing Patterns.

J Cardiovasc Pharmacol Ther 2020 11 19;25(6):541-547. Epub 2020 Jun 19.

Gill Heart and Vascular Institute, 4530University of Kentucky, Lexington, KY, USA.

Introduction: Patients with sepsis have high rates of major adverse cardiovascular events (MACE) in the literature, but the stratification of those at risk has been limited. Statin indicated groups provides clear criteria for therapy, but the risk of MACE after sepsis based on these groups has never been assessed.

Materials And Methods: This was a retrospective cohort analysis conducted on adult patients admitted from January 1, 2013, to December 31, 2013, with suspected or confirmed sepsis and data available on statin use. Patients' past medical history; statin use prior, during, or at time of discharge; and occurrence of MACE were recorded from electronic health records.

Result: A total of 321 patients were screened and 265 were found to have data available on statin use. The mean age of the patients was 59 ± 15 years and 47% were female. Overall, 9% were observed to have a MACE at 1 year, with significantly higher rates in those in a statin indicated group (12.2%). On admission, 174 patients were not taking a statin out of whom 52% were in a statin indicated group. Among those in a statin indicated group who survived to hospital discharge, only 10% not on a statin on admission received a statin on discharge, whereas 89% on a statin on admission received a statin on discharge.

Conclusion: There is a high risk of MACE after sepsis especially among those in statin indicated groups with significant clinical inertia in prescribing practices.
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http://dx.doi.org/10.1177/1074248420933395DOI Listing
November 2020

What the EF Is Going on Here?

J Am Soc Echocardiogr 2020 07 6;33(7):812-814. Epub 2020 May 6.

University of Kentucky, Gill Heart and Vascular Institute, Lexington, KY.

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http://dx.doi.org/10.1016/j.echo.2020.03.023DOI Listing
July 2020

Incidental Coronary Artery Calcification and Stroke Risk in Patients With Atrial Fibrillation.

AJR Am J Roentgenol 2020 08 29;215(2):344-350. Epub 2020 Apr 29.

Gill Heart and Vascular Institute, University of Kentucky, 900 S. Limestone St, CTW 326, Lexington, KY 40536.

Atrial fibrillation (AF) is a major risk factor for stroke. The CHADSVASc score is used to risk stratify patients, and the score includes known coronary artery disease (CAD) as a variable. The aim of this study was to assess if the presence of incidental coronary artery calcification (CAC), without known CAD, is associated with stroke independent of CHADS-VASc variables. A retrospective review of health records was performed for patients who had AF, a chest CT scan performed within 1 year, and a subsequent visit for stroke. Patients with CAD and other vascular disease, a mechanical valve, or who were older than 74 years old were excluded. Included patients were one-to-one matched by age and CHADS-VASc risk factors to patients who had had similar follow-up but who did not have a stroke. Nongated CT images were reviewed for CAC. Univariate and Cox regression analyses were performed. A total of 203 patients met the study criteria, and 203 matched patients without stroke were identified. Median age was 61 years old with stroke and 62 years old without stroke ( = 0.99). In both groups, 82 (39.0%) were women and the median CHADS-VASc was 2 (interquartile range, 1-2). Anticoagulation medication was prescribed to 46 (22.7%) patients in the group who had had a stroke and 52 (25.6%) in the group without stroke ( = 0.49). On Cox regression analysis, CAC was associated with stroke (hazard ratio [HR], 1.47; 95% CI, 1.10-1.97; < 0.01) and mortality (adjusted HR, 1.41; 95% CI, 1.02-1.95; = 0.04). Patients with AF and incidental CAC depicted on chest CT have an increased risk of stroke and mortality beyond established risk factors.
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http://dx.doi.org/10.2214/AJR.19.22298DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7447556PMC
August 2020

Usefulness of Findings by Multimodality Imaging to Stratify Risk of Major Adverse Cardiac Events After Sepsis at 1 and 12 months.

Am J Cardiol 2020 06 5;125(11):1732-1737. Epub 2020 Mar 5.

Gill Heart and Vascular Institute, Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA.

Cardiovascular complications are reported in up to 30% of sepsis survivors. Currently, there is limited evidence to guide cardiovascular risk stratification of septic patients. We propose the use of left ventricular ejection fraction (LVEF) and coronary artery calcification (CAC) on nongated computed tomography (CT) scans to identify septic patients at highest risk for major adverse cardiovascular events (MACE). We retrospectively reviewed 517 adult patients with sepsis, elevated troponin levels, nongated CT scans that visualized the coronaries, and an echocardiogram. Patients were stratified into 4 groups based on the LVEF and presence or absence of CAC. Using the CAC negative/LVEF ≥ 50% as a control, we compared MACE and all-cause mortality outcomes across the patient groups. At 30 days, 39 patients (7.5%) experienced MACE and 166 patients (32%) died. Patients with no CAC and LVEF ≥ 50% experienced no MACE at 30 days or 1 year. Among patients with EF < 50%, CAC positive or negative patients were statistically more likely to experience a MACE event at 30 days (p < 0.001 for both groups). After 30 days, a further 6 patients (1.2%) experienced MACE and 66 (12.7%) patients died within the first year. Patients with CAC positive/LVEF < 50% experienced the highest rates of MACE at 1 year (p < 0.001). In conclusion, the combination of LVEF on echocardiography and CAC on nongated CT scans provides a powerful risk stratification tool for predicting cardiovascular events in septic patients.
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http://dx.doi.org/10.1016/j.amjcard.2020.02.015DOI Listing
June 2020

Predictive Model for High-Risk Coronary Artery Disease.

Circ Cardiovasc Imaging 2019 02;12(2):e007940

Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.B., A.C., S.V., C.B.F., K.L.L., W.S.J., D.B.M., P.S.D., M.R.P.).

Background: Patients with high-risk coronary artery disease (CAD) may be difficult to identify.

Methods: Using the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) cohort randomized to coronary computed tomographic angiography (n=4589), 2 predictive models were developed for high-risk CAD, defined as left main stenosis (≥50% stenosis) or either (1) ≥50% stenosis [50] or (2) ≥70% stenosis [70] of 3 vessels or 2-vessel CAD involving the proximal left anterior descending artery. Pretest predictors were examined using stepwise logistic regression and assessed for discrimination and calibration.

Results: High-risk CAD was identified in 6.6% [50] and 2.4% [70] of patients. Models developed to predict high-risk CAD discriminated well: [50], bias-corrected C statistic=0.73 (95% CI, 0.71-0.76); [70], bias-corrected C statistic=0.73 (95% CI, 0.68-0.77). Variables predictive of CAD in both models included family history of premature CAD, age, male sex, lower glomerular filtration rate, diabetes mellitus, elevated systolic blood pressure, and angina. Additionally, smoking history was predictive of [50] CAD and sedentary lifestyle of [70] CAD. Both models characterized high-risk CAD better than the Pooled Cohort Equation (area under the curve=0.70 and 0.71 for [50] and [70], respectively) and Diamond-Forrester risk scores (area under the curve=0.68 and 0.71, respectively). Both [50] and [70] CAD was associated with more frequent invasive interventions and adverse events than non-high-risk CAD (all P<0.0001).

Conclusions: In contemporary practice, 2.4% to 6.6% of stable, symptomatic patients requiring noninvasive testing have high-risk CAD. A simple combination of pretest clinical variables improves prediction of high-risk CAD over traditional risk assessments.

Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01174550.
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http://dx.doi.org/10.1161/CIRCIMAGING.118.007940DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6368397PMC
February 2019

Closing the therapeutic loop.

Arch Biochem Biophys 2019 03 9;663:129-131. Epub 2019 Jan 9.

Department of Mechanical Engineering and Department of Surgery, University of Kentucky, United States.

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http://dx.doi.org/10.1016/j.abb.2019.01.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6377839PMC
March 2019

Identifying Coronary Artery Calcification on Non-gated Computed Tomography Scans.

J Vis Exp 2018 08 28(138). Epub 2018 Aug 28.

Gill Heart Institute, Division of Cardiovascular Medicine, University of Kentucky.

Coronary artery calcification (CAC) provides an objective measure of coronary artery disease and can readily be identified on non-gated computed tomography (CT) scans with a high correlation with gated cardiac CT scans. This standardized protocol takes a step-wise approach to not only optimizing an image for the identification of calcification but also to distinguishing CAC from other common causes of calcification in the cardiac silhouette. Recognition of CAC on non-gated CT scans helps to identify a very powerful prognostic factor that can influence therapeutic interventions or downstream diagnostic testing without requiring a gated cardiac scan. These non-gated CT scans are often acquired as part of the routine care of the patient, and this data is readily available without another dose of ionizing radiation. This protocol allows for the precise and accurate extraction of this data for the purposes of retrospective data analysis in clinical research studies, but also in the clinical evaluation and management of patients.
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http://dx.doi.org/10.3791/57918DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6231920PMC
August 2018

Clinical Outcome of Takotsubo Cardiomyopathy Diagnosed With or Without Coronary Angiography.

Angiology 2019 Jan 18;70(1):56-61. Epub 2018 Jun 18.

1 Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA.

Takotsubo cardiomyopathy (TC) is definitively diagnosed following the exclusion of acute coronary syndrome. We aimed to examine the rate of coronary angiography in patients diagnosed with TC and also the outcome of patients with TC diagnosed with or without coronary angiography. We analyzed the National Inpatient Sample database from 2010 to 2014 and identified patients hospitalized with a primary diagnosis of TC. We compared in-hospital mortality between patients who underwent coronary angiography and those who did not. We also evaluated the association between coronary angiography and in-hospital mortality using a propensity score-adjusted multivariable analysis. Among 22 818 patients diagnosed with TC, 87.4% underwent coronary angiography and 12.6% did not. Patients who did not undergo coronary angiography had a higher in-hospital mortality than those who did (3.0% vs 0.9%; P < .001). Increased mortality in patients who did not undergo coronary angiogram was observed in both male (8.0% vs 2.8%; P = .03) and female patients (2.6% vs 0.7%; P < .001) and in patients 61 to 80 years old and ≥81 years old, but not in patients ≤60 years old. Multivariable analysis demonstrated that the lack of coronary angiography was independently associated with higher in-hospital mortality (adjusted odds ratio: 2.92; 95% confidence interval: 1.52-5.65; P = .001).
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http://dx.doi.org/10.1177/0003319718782049DOI Listing
January 2019

Communication and Documentation of Critical Results from the Echocardiography Laboratory: A Call to Action.

J Am Soc Echocardiogr 2018 06 14;31(6):743-745. Epub 2018 Mar 14.

Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky. Electronic address:

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http://dx.doi.org/10.1016/j.echo.2018.01.017DOI Listing
June 2018

Outcomes of Heart Block in Myocarditis: A Review of 31,760 Patients.

Heart Lung Circ 2019 Feb 24;28(2):272-276. Epub 2017 Dec 24.

Gill Heart Institute, University of Kentucky, Lexington, KY, USA.

Background: Various electrocardiographic abnormalities, including atrioventricular conduction block, have been reported in patients with myocarditis. We performed an observation study to describe the characteristics and outcomes of inpatients diagnosed with myocarditis complicated by heart block (HB) in a large national cohort.

Methods: We identified patients with primary ICD-9 codes for myocarditis HB from the Nationwide Inpatient Sample (NIS) Database from 1998 to 2013. We compared the baseline characteristics and compared clinical outcomes between patients with and without HB, and in patients with/without high degree atrioventricular block (HDAVB).

Results: From the NIS database, 31,760 patients had a principal diagnosis of myocarditis and HB was reported in 1.7% of these patients (n=540). Female gender and Asian race were independently associated with HB. Out of 540 patients, 363 patients had HDAVB (67.2%) and 177 patients had not advanced HB (32.8%). Not advanced HB was not associated with an increased mortality rate compared to patients without HB (0% vs. 2.7%, p=0.315). On the other hand, the incidence of cardiogenic shock, respiratory failure and renal failure were higher in patients with HDAVB (26.2% vs. 5.0%, 33.9% vs. 5.9% and 29.2% vs. 5.5%, p<0.001 respectively). Patients with HDAVB required more procedural support (incidence of intra-aortic balloon pump 17.8% vs. 3.3%). They also had significantly longer lengths of hospital stay (9.4±9.4 vs. 4.3±8.4, p<0.001) and higher mortality (15.5% vs. 2.7%, p<0.001). Compared to myocarditis patients without HB, the odds for mortality in myocarditis patients with HDAVB 1.58 (95% CI=1.03-2.49, p=0.039).

Conclusions: The incidence of HB and HDAVB among patients with acute myocarditis was 1.7% and 1.1% respectively. Female gender and Asian race were both independently associated with significant odds for the occurrence of HB and HDAVB. High degree atrioventricular block was independently associated with increased morbidity and mortality.
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http://dx.doi.org/10.1016/j.hlc.2017.12.005DOI Listing
February 2019

Coronary artery calcification predicts cardiovascular complications after sepsis.

J Crit Care 2018 04 2;44:261-266. Epub 2017 Dec 2.

Gill Heart Institute, Division of Cardiovascular Medicine, University of Kentucky, 1000 S. Limestone, Lexington, KY 40536, USA. Electronic address:

Purpose: Sepsis is a highly prevalent and fatal condition, with reported cardiovascular event rates as high as 25-30% at 1year. Risk stratification in septic patients has been extremely limited.

Material And Methods: 267 septic patients with detectable troponin levels, APACHE II scores, and CT scans of the chest or abdomen were assessed. Patients with a recent cardiac intervention were excluded. Coronary artery calcification (CAC) was identified as present or absent on body CT scans. Cardiovascular death, acute myocardial infarction (AMI), or PCI at 1year was assessed using multivariate logistic regression analysis.

Results: Patients with CAC were older, predominantly male with more risk factors for coronary disease, but similar peak troponin levels and APACHE II scores. In a multivariate analysis, CAC was predictive of the primary outcome (OR 6.827; 95% CI 1.336-54.686; p=0.037). Patients with no CAC, history of CHF or CKD were at low risk (<1%) for cardiovascular complications at 1year even at very high troponin levels (<8.0ng/dL).

Conclusion: CAC risk stratifies septic patients for cardiovascular complications better than traditional risk factors and can be identified on body CT scans. This novel, risk stratifying framework built on CAC can help guide individualized management of septic patients.
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http://dx.doi.org/10.1016/j.jcrc.2017.11.038DOI Listing
April 2018

Sometimes You Have to Tilt Your Head and Strain to Take a Picture of the Truth.

J Am Soc Echocardiogr 2017 12;30(12):1189-1192

Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky. Electronic address:

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http://dx.doi.org/10.1016/j.echo.2017.10.001DOI Listing
December 2017

Incidence, predictors, and outcomes associated with pneumothorax during cardiac electronic device implantation: A 16-year review in over 3.7 million patients.

Heart Rhythm 2017 12 21;14(12):1764-1770. Epub 2017 Jul 21.

Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky; The Veterans Administration Medical Center, Lexington, Kentucky. Electronic address:

Background: Pneumothorax (PTX) is a potential complication of vascular access during cardiac implantable electronic device (CIED) procedures and is being scrutinized as a health care-acquired condition.

Objective: The purpose of this study was to determine the trends in PTX incidence in the United Stated over a 16-year period and to determine whether PTX is associated with increased mortality after adjustment for other factors.

Methods: Using weighted sampling in the largest inpatient health database in the United States (National Inpatient Sample), we evaluated data from patients with a primary procedure of CIED implantation from 1998 to 2013 who had at least 1 new vascular access (new or upgrade of prior CIED). The unadjusted and adjusted associations of PTX with mortality and other parameters were examined.

Results: Among 3,764,703 CIED procedures, PTX occurred in 47,839 cases (1.3%). The apparent incidence of PTX peaked at 1.6% in 2012 and 2013, although this result may have been affected by a concomitant decrease of inpatient (vs outpatient) CIED. PTX was significantly associated with pulmonary complications, chest tube insertion, length of stay, and costs. Mortality was statistically higher in patients with PTX (1.2% vs 0.7%; P <.001), a relationship that remained significant in a multivariate logistic regression analysis (odds ratio 1.50, 95% confidence interval 1.36-1.65; P <.001). Age >80 years, female gender, Caucasian race, chronic obstructive pulmonary disease, and dual-chamber (vs single-chamber) device were all associated with higher odds for PTX occurrence. Placement of a chest tube was a major determinant of worse outcomes and higher costs.

Conclusion: PTX remains an important complication of CIED procedures and is associated with increased morbidity, mortality, and costs.
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http://dx.doi.org/10.1016/j.hrthm.2017.07.024DOI Listing
December 2017

Role of Echocardiography in the Diagnostic Assessment and Etiology of Heart Failure in Older Adults: Opacify, Quantify, and Rectify.

Heart Fail Clin 2017 Jul;13(3):445-466

Cardiovascular Imaging, Division of Cardiovascular Medicine, Department of Medicine, University of Kentucky, 900 South Limestone, 320 C.T. Wethington Building, Lexington, KY 40536, USA. Electronic address:

Echocardiography allows the assessment of systolic and diastolic function and identifies many of the common causes of heart failure (HF). Patients with minimally symptomatic or unsuspected left ventricular systolic dysfunction may be identified and receive the benefits of angiotensin-converting enzyme inhibitor therapy. Echocardiography is also for assessing prognosis and can be used serially to evaluate treatment. Ventricular filling pressures, pulmonary artery pressures, and cardiac output can be sequentially determined. The authors believe that all patients with HF should receive careful assessment echocardiography. The authors believe using echocardiography is especially valuable in the elderly.
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http://dx.doi.org/10.1016/j.hfc.2017.02.003DOI Listing
July 2017

Atrioventricular dyssynchrony from empiric device settings is common in cardiac resynchronization therapy and adversely impacts left ventricular morphology and function.

Echocardiography 2017 Apr 1;34(4):496-503. Epub 2017 Mar 1.

Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky Medical Center, University of Kentucky, Lexington, KY, USA.

Background: Echocardiographic atrioventricular (AV) optimization after cardiac resynchronization therapy (CRT) is uncommon due to time constraints and the use of vendor-specific device algorithms. It remains unclear whether optimization of mitral inflow velocities can still be useful. We aimed to investigate post implantation left ventricular (LV) inflow patterns to determine the incidence of AV dyssynchrony from empirically set devices.

Methods: This was a retrospective study of patients undergoing CRT using empiric device settings. Forty-eight patients with clinical, echocardiographic, and pacemaker follow-up were grouped by their post implantation LV filling pattern. Baseline characteristics and echocardiographic measurements were compared with post implantation findings at median 6.3 months (interquartile range [IQR], 3.9-17.0).

Results: Twenty-four patients demonstrated AV dyssynchrony (Group 1) after CRT, and 24 patients did not (Group 2). Group 1 patients had less LV reverse remodeling compared to Group 2 patients (ΔLV end-diastolic volume: -3.6 mL vs -49.5 mL, P<.05; ΔLV end-systolic volume: -16.9 mL vs -53.5 mL, P<.05) and did not experience significant improvements in LV outflow tract velocity time integral, stroke volume, or LV ejection fraction. There were no differences in new-onset atrial fibrillation, heart failure readmissions, or mortality between groups.

Conclusion: Our study suggests that up to 50% of patients with empiric device settings have AV dyssynchrony at 6 months despite atrioventricular delay optimization (AVO) algorithms. As AV dyssynchrony is common and has proven to be modifiable, a strategic approach to Doppler echocardiography-guided AVO after CRT is warranted, particularly in nonresponders where the LV filling pattern is fused or truncated.
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http://dx.doi.org/10.1111/echo.13486DOI Listing
April 2017

Coronary artery calcification in CKD-5D 
patients is tied to adverse cardiac function 
and increased mortality
.

Clin Nephrol 2016 Dec;86 (2016)(12):291-302

Background: Coronary artery calcification (CAC) is common in patients with chronic kidney disease on hemodialysis (CKD-5D) and is an important predictor of mortality. However, cardiac functional links between CAC and mortality have not been well established. This study tested the hypothesis that CAC increases mortality by adversely affecting cardiac function.

Methods: Patients were recruited from 37 regional dialysis centers. 2-D and Doppler echocardiographic analyses were performed, and CAC was measured using 64-slice computed tomography. Relationships between CAC and echocardiographic measures of left ventricular (LV) function were analyzed. Survival was assessed with median follow-up of 37 months.

Results: There were 157 patients: 59% male, 46% Caucasian, 48% diabetic. Median age was 55 years, and median duration of CKD-5D was 45 months. Agatston CAC scores 100 were found in 69% of patients, with 51% having a score  400. CAC was associated with measures of LV systolic and diastolic function (global longitudinal strain (GLS; rho = 0.270, p = 0.004)), peak LV systolic velocity (rho = -0.259, p = 0.004), and estimate of LV filling pressure (E:E'; rho = 0.286, p = 0.001). Multivariate regression confirmed these relationships after adjustment for age, gender, LV ejection fraction, and coronary artery disease. Valvular calcification varied linearly with CAC (p < 0.05). Both LV diastolic and systolic functional measures were significant predictors of mortality, the strongest of which was LV diastolic dysfunction.

Conclusions: These findings show a link between CAC, cardiac function, and mortality in CKD-5D. LV diastolic function (E:E'), peak LV systolic velocity, and GLS are independent predictors of mortality. Valvular calcification may be an important marker of CAC in CKD-5D. These effects on cardiac function likely explain the high mortality with CKD-5D and describe a potentially-valuable role for echocardiography in the routine management of these patients.
.
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http://dx.doi.org/10.5414/CN108940DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5467156PMC
December 2016

Rad-deletion Phenocopies Tonic Sympathetic Stimulation of the Heart.

J Cardiovasc Transl Res 2016 12 31;9(5-6):432-444. Epub 2016 Oct 31.

Department of Physiology, University of Kentucky College of Medicine, 800 Rose St, Lexington, KY, 40536-0298, USA.

Sympathetic stimulation modulates L-type calcium channel (LTCC) gating to contribute to increased systolic heart function. Rad is a monomeric G-protein that interacts with LTCC. Genetic deletion of Rad (Rad) renders LTCC in a sympathomimetic state. The study goal was to use a clinically inspired pharmacological stress echocardiography test, including analysis of global strain, to determine whether Rad confers tonic positive inotropic heart function. Sarcomere dynamics and strain showed partial parallel isoproterenol (ISO) responsiveness for wild-type (WT) and for Rad. Rad basal inotropy was elevated compared to WT but was less responsiveness to ISO. Rad protein levels were lower in human patients with end-stage non-ischemic heart failure. These results show that Rad reduction provides a stable inotropic response rooted in sarcomere level function. Thus, reduced Rad levels in heart failure patients may be a compensatory response to need for increased output in the setting of HF. Rad deletion suggests a future therapeutic direction for inotropic support.
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http://dx.doi.org/10.1007/s12265-016-9716-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5143207PMC
December 2016

An interactive videogame designed to improve respiratory navigator efficiency in children undergoing cardiovascular magnetic resonance.

J Cardiovasc Magn Reson 2016 09 6;18(1):54. Epub 2016 Sep 6.

Department of Pediatrics, University of Kentucky, Lexington, KY, USA.

Background: Advanced cardiovascular magnetic resonance (CMR) acquisitions often require long scan durations that necessitate respiratory navigator gating. The tradeoff of navigator gating is reduced scan efficiency, particularly when the patient's breathing patterns are inconsistent, as is commonly seen in children. We hypothesized that engaging pediatric participants with a navigator-controlled videogame to help control breathing patterns would improve navigator efficiency and maintain image quality.

Methods: We developed custom software that processed the Siemens respiratory navigator image in real-time during CMR and represented diaphragm position using a cartoon avatar, which was projected to the participant in the scanner as visual feedback. The game incentivized children to breathe such that the avatar was positioned within the navigator acceptance window (±3 mm) throughout image acquisition. Using a 3T Siemens Tim Trio, 50 children (Age: 14 ± 3 years, 48 % female) with no significant past medical history underwent a respiratory navigator-gated 2D spiral cine displacement encoding with stimulated echoes (DENSE) CMR acquisition first with no feedback (NF) and then with the feedback game (FG). Thirty of the 50 children were randomized to undergo extensive off-scanner training with the FG using a MRI simulator, or no off-scanner training. Navigator efficiency, signal-to-noise ratio (SNR), and global left-ventricular strains were determined for each participant and compared.

Results: Using the FG improved average navigator efficiency from 33 ± 15 to 58 ± 13 % (p < 0.001) and improved SNR by 5 % (p = 0.01) compared to acquisitions with NF. There was no difference in navigator efficiency (p = 0.90) or SNR (p = 0.77) between untrained and trained participants for FG acquisitions. Circumferential and radial strains derived from FG acquisitions were slightly reduced compared to NF acquisitions (-16 ± 2 % vs -17 ± 2 %, p < 0.001; 40 ± 10 % vs 44 ± 11 %, p = 0.005, respectively). There were no differences in longitudinal strain (p = 0.38).

Conclusions: Use of a respiratory navigator feedback game during navigator-gated CMR improved navigator efficiency in children from 33 to 58 %. This improved efficiency was associated with a 5 % increase in SNR for spiral cine DENSE. Extensive off-scanner training was not required to achieve the improvement in navigator efficiency.
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http://dx.doi.org/10.1186/s12968-016-0272-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5012042PMC
September 2016

Citation inflation: when the adoption of a new technique becomes an avenue for publication.

Echocardiography 2016 Sep 11;33(9):1282-3. Epub 2016 Jul 11.

Division of Cardiovascular Medicine, University of Kentucky and the Gill Heart Institute, Lexington, Kentucky, USA.

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http://dx.doi.org/10.1111/echo.13299DOI Listing
September 2016

Gadolinium free cardiovascular magnetic resonance with 2-point Cine balanced steady state free precession.

J Cardiovasc Magn Reson 2015 Oct 29;17:90. Epub 2015 Oct 29.

Department of Physiology, University of Kentucky, 741 South Limestone Street, BBSRB room 355, Lexington, 40536, KY, USA.

Background: Cardiovascular magnetic resonance (CMR) of ventricular structure and function is widely performed using cine balanced steady state free precession (bSSFP) MRI. The bSSFP signal of myocardium is weighted by magnetization transfer (MT) and T1/T2-relaxation times. In edematous and fibrotic tissues, increased T2 and reduced MT lead to increased signal intensity on images acquired with high excitation flip angles. We hypothesized that acquisition of two differentially MT-weighted bSSFP images (termed 2-point bSSFP) can identify tissue that would enhance with gadolinium similar to standard of care late gadolinium enhancement (LGE).

Methods: Cine bSSFP images (flip angles of 5° and 45°) and native-T1 and T2 maps were acquired in one mid-ventricular slice in 47 patients referred for CMR and 10 healthy controls. Afterwards, LGE images and post-contrast T1 maps were acquired and gadolinium partition coefficient (GPC) was calculated. Maps of ΔS/So were calculated as (S45-S5)/S5*100 (%), where Sflip_angle is the voxel signal intensity.

Results: Twenty three patients demonstrated areas of myocardial hyper-enhancement with LGE. In enhanced regions, ΔS/So, native-T1, T2, and GPC were heightened (p < 0.05 vs. non-enhanced tissues). ΔS/So, native-T1, and T2 all demonstrated association with GPC, however the association was strongest for ΔS/So. Bland-Altman analysis revealed a slight bias towards larger volume of enhancement with ΔS/So compared to LGE, and similar transmurality. Subjective analysis with 2-blinded expert readers revealed agreement between ΔS/So and LGE of 73.4 %, with false positive detection of 16.7 % and false negative detection of 15.2 %.

Conclusions: Gadolinium free 2-point bSSFP identified tissue that enhances at LGE with strong association to GPC. Our results suggest that with further development, MT-weighted CMR could be used similar to LGE for diagnostic imaging.
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http://dx.doi.org/10.1186/s12968-015-0194-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4628395PMC
October 2015

Unexpected Cardiac Masses.

JAMA Oncol 2015 Dec;1(9):1343-4

Gill Heart Institute, Division of Cardiovascular Medicine, University of Kentucky, Lexington.

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http://dx.doi.org/10.1001/jamaoncol.2015.3077DOI Listing
December 2015

Cell- and molecular-level mechanisms contributing to diastolic dysfunction in HFpEF.

J Appl Physiol (1985) 2015 Nov 24;119(10):1228-32. Epub 2015 Apr 24.

Division of Cardiovascular Medicine, Linda and Jack Gill Heart Institute, University of Kentucky, Lexington, Kentucky.

Heart failure with preserved ejection fraction (HFpEF) is the default diagnosis for patients who have symptoms of heart failure, an ejection fraction >0.5, and evidence of diastolic dysfunction. The clinical condition, which was largely unrecognized 30 years ago, is now a major health problem and currently accounts for 50% of all patients with heart failure. Clinical studies show that patients with HFpEF exhibit increased passive stiffness of the ventricles and a slower rate of pressure decline during diastole. This review discusses some of the cell- and molecular-level mechanisms that contribute to these effects and focuses on data obtained using human samples. Collagen cross linking, modulation of protein kinase G-related pathways, Ca(2+) handling, and strain-dependent detachment of cross bridges are highlighted as potential factors that could be modulated to improve ventricular function in patients with HFpEF.
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http://dx.doi.org/10.1152/japplphysiol.01168.2014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4816411PMC
November 2015

The changing 'face' of endocarditis in Kentucky: an increase in tricuspid cases.

Am J Med 2014 Aug 21;127(8):786.e1-6. Epub 2014 Apr 21.

Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky Medical Center, Lexington.

Background: Advancements in medical technology and increased life expectancy have been described as contributing to the evolution of endocarditis. We sought to determine whether there has been a change in the incidence, demographics, microbiology, complications, and outcomes of infective endocarditis over a 10-year time span.

Methods: We screened 28,420 transthoracic and transesophageal echocardiogram reports performed at the Gill Heart Institute for the following indications: fever, masses, emboli (including stroke), sepsis, bacteremia, and endocarditis in 2 time periods: 1999 to 2000 and 2009 to 2010. Data were collected from diagnosed endocarditis cases.

Results: Overall, 143 cases of infective endocarditis were analyzed (48 in 1999-2000 and 95 in 2009-2010). The endocarditis incidence per number of admissions remained nearly constant at 0.113% for 1999-2000 and 0.148% for 2009-2010 (P = .153). However, tricuspid valve involvement increased markedly from 6% to 36% (P < .001). Also, reported history of intravenous drug use increased from 15% to 40% (P = .002). Valvular complications doubled from 17% to 35% (P = .031). Septic pulmonary emboli increased from 10% to 25% (P = .047). Despite these noted differences, inpatient mortality remained unchanged at 25% and 28% (P = .696) for the 2 time periods, respectively.

Conclusions: The incidence of endocarditis at the University of Kentucky Medical Center has not changed and mortality remains high, but the "face of endocarditis" in Kentucky has evolved with an increased incidence of tricuspid valve involvement, valvular complications, and embolic events.
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http://dx.doi.org/10.1016/j.amjmed.2014.04.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4384329PMC
August 2014

A randomized pilot study of aortic waveform guided therapy in chronic heart failure.

J Am Heart Assoc 2014 Mar 20;3(2):e000745. Epub 2014 Mar 20.

Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.

Background: Medication treatment decisions in heart failure (HF) are currently informed by measurements of brachial artery pressure, but ventricular afterload is more accurately represented by central aortic pressure, which differs from brachial pressure. We sought to determine whether aggressive titration of vasoactive medicines beyond goal-directed heart failure medical therapy (GDMT) based upon aortic pressure improves exercise capacity and cardiovascular structure-function.

Methods And Results: Subjects with chronic HF (n=50) underwent cardiopulmonary exercise testing, echocardiography, and arterial tonometry to measure aortic pressure and augmentation index, and were then randomized to aortic pressure-guided treatment (active, n=23) or conventional therapy (control, n=27). Subjects returned for 6 monthly visits wherein GDMT was first optimized. Additional vasoactive therapies were then sequentially added with the goal to reduce aortic augmentation index to 0% (active) or if brachial pressure remained elevated (control). Subjects randomized to active treatment experienced greater improvement in peak oxygen consumption compared with controls (1.37±3.76 versus -0.65±2.21 mL min(-1) kg(-1), P=0.025) though reductions in aortic augmentation index were similar (-7±9% versus -5±6%, P=0.46). Forward stroke volume increased while arterial elastance and left ventricular volumes decreased in all participants, with no between-group difference. Subjects randomized to active treatment were more likely to receive additional vasoactive therapies including nitrates, aldosterone antagonists and hydralazine, with no increased risk of hypotension or worsening renal function.

Conclusions: Maximization of goal-directed medical therapy in heart failure patients may enhance afterload reduction and lead to reverse remodeling, while additional medicine titration based upon aortic pressure data improves exercise capacity in patients with heart failure.
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http://dx.doi.org/10.1161/JAHA.113.000745DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4187471PMC
March 2014

Open wide: transient wide-open mitral regurgitation during transcatheter aortic valve implantation.

J Am Coll Cardiol 2014 May 13;63(17):e45. Epub 2014 Mar 13.

Division of Cardiovascular Medicine, Linda and Jack Gill Heart Institute, University of Kentucky, Lexington, Kentucky.

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http://dx.doi.org/10.1016/j.jacc.2013.10.096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4142192PMC
May 2014

QRS duration predicts death and hospitalization among patients with atrial fibrillation irrespective of heart failure: evidence from the AFFIRM study.

Europace 2014 Jun 23;16(6):803-11. Epub 2013 Dec 23.

Division of Cardiovascular Medicine, Gill Heart Institute University of Kentucky, 326 C.T. Wethington Building, 900 South Limestone Street, Lexington, KY 40536-0200, USA

Aims: The association of QRS duration (QRSd) with morbidity and mortality is understudied in patients with atrial fibrillation (AF). We sought to assess any association of prolonged QRS with increased risk of death or hospitalization among patients with AF.

Methods And Results: QRS duration was retrieved from the baseline electrocardiograms of patients enroled in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) study and divided into three categories: <90, 90-119, ≥120 ms. Cox models were applied relating the hazards of mortality and hospitalizations to QRSd. Among 3804 patients with AF, 593 died and 2305 were hospitalized. Compared with those with QRS < 90 ms, patients with QRS ≥ 120 ms, had an increased mortality [hazard ratio (HR) 1.61, 95% confidence interval (CI): 1.29-2.03, P < 0.001] and hospitalizations (HR 1.14, 95% CI: 1.07-1.34, P = 0.043) over an average follow-up of 3.5 years. Importantly, for patients with QRS 90-119 ms, mortality and hospitalization were also increased (HR 1.31, P = 0.005 and 1.11, P = 0.026, respectively). In subgroup analysis based on heart failure (HF) status (previously documented or ejection fraction <40%), mortality was increased for QRS ≥ 120 ms patients with (HR 1.87, P < 0.001) and without HF (HR 1.63, P = 0.02). In the QRS 90-119 ms group, mortality was increased (HR 1.38, P = 0.03) for those with HF, but not significantly among those without HF (HR 1.23, P = 0.14).

Conclusion: Among patients with AF, QRSd ≥ 120 ms was associated with a substantially increased risk for mortality (all-cause, cardiovascular, and arrhythmic) and hospitalization. Interestingly, an increased mortality was also observed among those with QRS 90-119 ms and concomitant HF.
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http://dx.doi.org/10.1093/europace/eut335DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4305520PMC
June 2014

Symptomatic pericardial cyst in the presence of partial congenital absence of the pericardium.

Eur Heart J Cardiovasc Imaging 2014 May 12;15(5):531. Epub 2013 Nov 12.

Division of Cardiovascular Medicine, The Gill Heart Institute, University of Kentucky, 900 South Limestone Street, Room 326 CTW, Lexington, KY 40536-0200, USA.

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http://dx.doi.org/10.1093/ehjci/jet242DOI Listing
May 2014

Acute myocardial injury from carbon monoxide poisoning by cardiac magnetic resonance imaging.

Eur Heart J Cardiovasc Imaging 2014 Apr 18;15(4):466. Epub 2013 Oct 18.

Department of Internal Medicine, University of Kentucky, 304B Charles T. Wethington Building, 900 South Limestone, Lexington, KY 40536-0200, USA.

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http://dx.doi.org/10.1093/ehjci/jet190DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4305519PMC
April 2014
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