Publications by authors named "Yuliya Vengrenyuk"

53 Publications

Deploying a novel custom mobile application for STEMI activation and transfer in a large healthcare system to improve cross-team workflow. STEMIcathAID implementation project.

Am Heart J 2022 Jun 30;253:30-38. Epub 2022 Jun 30.

The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address:

Background: ST-segment elevation myocardial infarction (STEMI) is a high-risk patient medical emergency. We developed a secure mobile application, STEMIcathAID, to optimize care for STEMI patients by providing a digital platform for communication between the STEMI care team members, EKG transmission, cardiac catherization laboratory (cath lab) activation and ambulance tracking. The aim of this report is to describe the implementation of the app into the current STEMI workflow in preparation for a pilot project employing the app for inter-hospital STEMI transfer.

Approach: App deployment involved key leadership stakeholders from all multidisciplinary teams taking care of STEMI patients. The team developed a transition plan addressing all aspects of the health system improvement process including the workflow analysis and redesign, app installation, personnel training including user account access to the app, and development of a quality assurance program for progress evaluation. The pilot will go live in the Emergency Department (ED) of one of the hospitals within the Mount Sinai Hospital System (MSHS) during the daytime weekday hours at the beginning and extending to 24/7 schedule over 4-6 weeks. For the duration of the pilot, ED personnel will combine the STEMIcathAID app activation with previous established STEMI activation processes through the MSHS Clinical Command Center (CCC) to ensure efficient and reliable response to a STEMI alert. More than 250 people were provisioned app accounts including ED Physicians and frontline nurses, and trained on their user-specific roles and responsibilities and scheduled in the app. The team will be provided with a feedback form that is discipline specific to complete after every STEMI case in order to collect information on user experience with the STEMIcathAID app functionality. The form will also provide quantitative metrics for the key time sensitive steps in STEMI care.

Conclusions: We developed a uniform approach for deployment of a mobile application for STEMI activation and transfer in a large urban healthcare system to optimize the clinical workflow in STEMI care. The results of the pilot will demonstrate whether the app has a significant impact on the quality of care for transfer of STEMI patients.
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http://dx.doi.org/10.1016/j.ahj.2022.06.008DOI Listing
June 2022

External Support for Saphenous Vein Grafts in Coronary Artery Bypass Surgery: A Randomized Clinical Trial.

JAMA Cardiol 2022 Aug;7(8):808-816

Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.

Importance: Intimal hyperplasia and subsequent saphenous vein graft failure may have significant adverse clinical effects in patients undergoing coronary artery bypass surgery. External support of saphenous vein grafts has the potential to prevent vein graft dilation and hence slow the rate of intimal hyperplasia and increase long-term vein patency.

Objective: To determine efficacy, as measured by intimal hyperplasia, and safety of an external saphenous vein graft support device in patients undergoing a coronary bypass graft procedure.

Design, Setting, And Participants: This within-patient randomized, open-label, multicenter study was conducted at 17 Cardiothoracic Surgical Trials Network centers in North America. Between January 2018 and February 2019, 224 patients with multivessel coronary artery disease undergoing isolated bypass surgery were enrolled. For each patient, 1 of 2 vein grafts was randomized to receive external support or no support.

Interventions: External vein graft support or no support.

Main Outcomes And Measures: The primary efficacy end point was intimal hyperplasia area assessed by intravascular ultrasound at 12 months postrandomization for each study graft. Secondary confirmatory end points were lumen diameter uniformity assessed by angiography and graft failure (≥50% stenosis) by quantitative coronary angiography. Major cardiac and cerebrovascular events were collected through month 12.

Results: Among 224 patients (mean [SD] age, 65.8 [8.3] years; 178 [79.5%] male), 203 (90.6%) were eligible for intravascular ultrasound, of which 85 (41.9%) had at least 1 study graft occluded or severely diseased at 12 months (55 supported, 56 unsupported). After imputation of data missing because of graft occlusion or severe disease, the estimated mean (SE) intimal hyperplasia area was 5.11 (0.16) mm2 in supported grafts and 5.79 (0.20) mm2 in unsupported grafts (P = .07). In a sensitivity analysis of 113 patients with both grafts imaged, the mean intimal hyperplasia area was 4.58 (0.18) mm2 and 5.12 (0.23) mm2 in supported and unsupported grafts, respectively (P = .04). By 12 months, 5 patients (2.2%) died and 16 patients (7.1%) experienced a major cardiac or cerebrovascular event.

Conclusions And Relevance: The 12-month difference in intimal hyperplasia area between supported and unsupported grafts did not achieve statistical significance. Cumulative mortality and major cardiac or cerebrovascular events rates were similar to those in other randomized coronary artery bypass trials. Further investigation to assess the effect of external graft support devices on long-term graft patency and clinical outcomes is warranted.

Trial Registration: ClinicalTrials.gov Identifier: NCT03209609.
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http://dx.doi.org/10.1001/jamacardio.2022.1437DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9178499PMC
August 2022

Relationship between hemoglobin A1C and characteristics of plaque vulnerability in stable coronary disease: an optical coherence tomography study.

Int J Cardiovasc Imaging 2022 Feb 5;38(2):473-482. Epub 2022 Jan 5.

Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine At Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY, 10029, USA.

Patients with diabetes mellitus are at increased risk of cardiovascular events. We aimed to analyze the impact of serum HbA1c levels on coronary plaque characteristics in stable coronary disease. Two hundred sixty-one patients who underwent optical coherence tomography (OCT) examination before elective percutaneous coronary intervention for a de novo obstructive lesions were included in this single-center retrospective analysis. Patients were divided into tertiles according to HbA1c level (tertile 1: HbA1c < 6.3%, tertile 2: 6.3 ≤ HbA1c < 7.8%, tertile 3: HbA1c ≥ 7.8%) and OCT findings were compared. Fibrous cap thickness (FCT) was significantly thinner in tertile 3 compared to tertile 1 and tertile 2 (103.9 ± 48.2 µm [tertile 1] vs. 107.5 ± 60.6 µm [tertile 2] vs. 86.2 ± 35.8 µm [tertile 3], p = 0.03). Higher prevalence of thin-cap fibroatheroma (TCFA) was observed in tertile 3 vs tertile 1 and tertile 2 (19.5% [tertile 1] vs. 19.5% [tertile 2] vs. 33.3% [tertile 3], p = 0.04). HbA1c inversely correlated with FCT (beta coefficient - 4.89, 95% confidence interval - 8.40 to - 1.39, p < 0.01). The logistic regression model revealed that the probability of having TCFA was positively associated with HbA1c with a small change in the range of low and medium HbA1c and a big change in the range of high HbA1c. Furthermore, minimal lumen area and reference lumen area were smaller in tertile 3. In patients with stable coronary disease, high serum HbA1c levels are associated with higher plaque burden and thinner FCT on OCT, while low and medium HbA1c levels result in similar plaque vulnerability.
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http://dx.doi.org/10.1007/s10554-021-02297-xDOI Listing
February 2022

Rationale and design of a randomized trial evaluating an external support device for saphenous vein coronary grafts.

Am Heart J 2022 04 20;246:12-20. Epub 2021 Dec 20.

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH.

Background: Coronary artery bypass grafting (CABG) is the most common revascularization approach for the treatment of multi-vessel coronary artery disease. While the internal mammary artery is nearly universally used to bypass the left anterior descending coronary artery, autologous saphenous vein grafts (SVGs) are still the most frequently used conduits to grafts the remaining coronary artery targets. Long-term failure of these grafts, however, continues to limit the benefits of surgery.

Methods: The Cardiothoracic Surgical Trials Network trial of the safety and effectiveness of a Venous External Support (VEST) device is a randomized, multicenter, within-patient trial comparing VEST-supported versus unsupported saphenous vein grafts in patients undergoing CABG. Key inclusion criteria are the need for CABG with a planned internal mammary artery to the left anterior descending and two or more saphenous vein grafts to other coronary arteries. The primary efficacy endpoint of the trial is SVG intimal hyperplasia (plaque + media) area assessed by intravascular ultrasound at 12 months post randomization. Occluded grafts are accounted for in the analysis of the primary endpoint. Secondary confirmatory endpoints are lumen diameter uniformity and graft failure (>50% stenosis) assessed by coronary angiography at 12 months. The safety endpoints are the occurrence of major adverse cardiac and cerebrovascular events and hospitalization within 5 years from randomization.

Conclusions: The results of the VEST trial will determine whether the VEST device can safely limit SVG intimal hyperplasia in patients undergoing CABG as treatment for coronary atherosclerotic disease.
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http://dx.doi.org/10.1016/j.ahj.2021.12.009DOI Listing
April 2022

Types of myocardial injury and mid-term outcomes in patients with COVID-19.

Eur Heart J Qual Care Clin Outcomes 2021 09;7(5):438-446

The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA.

Aims: To evaluate the acute and chronic patterns of myocardial injury among patients with coronavirus disease-2019 (COVID-19), and their mid-term outcomes.

Methods And Results: Patients with laboratory-confirmed COVID-19 who had a hospital encounter within the Mount Sinai Health System (New York City) between 27 February 2020 and 15 October 2020 were evaluated for inclusion. Troponin levels assessed between 72 h before and 48 h after the COVID-19 diagnosis were used to stratify the study population by the presence of acute and chronic myocardial injury, as defined by the Fourth Universal Definition of Myocardial Infarction. Among 4695 patients, those with chronic myocardial injury (n = 319, 6.8%) had more comorbidities, including chronic kidney disease and heart failure, while acute myocardial injury (n = 1168, 24.9%) was more associated with increased levels of inflammatory markers. Both types of myocardial injury were strongly associated with impaired survival at 6 months [chronic: hazard ratio (HR) 4.17, 95% confidence interval (CI) 3.44-5.06; acute: HR 4.72, 95% CI 4.14-5.36], even after excluding events occurring in the first 30 days (chronic: HR 3.97, 95% CI 2.15-7.33; acute: HR 4.13, 95% CI 2.75-6.21). The mortality risk was not significantly different in patients with acute as compared with chronic myocardial injury (HR 1.13, 95% CI 0.94-1.36), except for a worse prognostic impact of acute myocardial injury in patients <65 years of age (P-interaction = 0.043) and in those without coronary artery disease (P-interaction = 0.041).

Conclusion: Chronic and acute myocardial injury represent two distinctive patterns of cardiac involvement among COVID-19 patients. While both types of myocardial injury are associated with impaired survival at 6 months, mortality rates peak in the early phase of the infection but remain elevated even beyond 30 days during the convalescent phase.
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http://dx.doi.org/10.1093/ehjqcco/qcab053DOI Listing
September 2021

Meta-Analysis Comparing Same-Sitting and Staged Percutaneous Coronary Intervention of Non-Culprit Artery for ST-Elevation Myocardial Infarction with Multivessel Coronary Disease.

Am J Cardiol 2021 07 16;150:24-31. Epub 2021 May 16.

Division of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York.

Recent trials and meta-analysis have indicated that complete revascularization (CR) of multivessel coronary disease is beneficial in patients with ST-segment elevation myocardial infarction (STEMI) compared to culprit-only intervention. However, the optimal timing of CR remains unclear. We aimed to analyze the optimal timing of CR in patients with STEMI and multivessel disease by performing an updated network meta-analysis using the recent largest randomized controlled trial. PUBMED and EMBASE were searched through October 2020 to identify randomized controlled trials comparing CR and culprit-only revascularization. A random-effect network meta-analysis comparing three arms (same-sitting [during the index procedure] CR versus staged CR versus culprit-only) and 4 arms (same-sitting CR versus staged CR [in-hospital] versus staged CR [out-hospital] versus culprit-only) were performed. Eleven studies with a total of 7,015 patients were included in our analysis. There was no significant difference in major adverse cardiovascular event (MACE) (HR 0.82, 95% CI 0.64-1.05), cardiovascular death (HR 0.69, 95%CI 0.35-1.33), myocardial infarction (HR 0.66, 95%CI 0.37-1.16), and revascularization (HR 1.05, 95%CI 0.70-1.58) between same-sitting CR and staged CR. When staged CR was further divided into staged CR during the hospitalization and after discharge, there was no significant difference in these outcomes between staged CR (in-hospital) and staged CR (out-hospital). In conclusion, in patients with multivessel disease presenting with STEMI, complete revascularization at any timing, including same-sitting, staged in-hospital, and staged out-hospital, may have similar benefits.
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http://dx.doi.org/10.1016/j.amjcard.2021.03.043DOI Listing
July 2021

On the Shades of Coronary Calcium and Plaque Instability.

J Am Coll Cardiol 2021 04;77(13):1612-1615

Icahn School of Medicine at Mount Sinai, New York, New York, USA.

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http://dx.doi.org/10.1016/j.jacc.2021.02.011DOI Listing
April 2021

Rotational Atherectomy for the Management of Undilatable In-Stent Restenosis with Single or Multiple Stent Layers.

Cardiovasc Revasc Med 2022 01 14;34:32-37. Epub 2021 Jan 14.

Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, NY, New York, USA. Electronic address:

Background: There is no consensus on the best treatment of undilatable coronary in-stent restenosis (ISR) regardless of the number of stent layers. We aimed to evaluate the procedural and clinical outcomes of rotational atherectomy (RA) to treat undilatable coronary ISR with single or multiple stent layers.

Methods: We retrospectively evaluated consecutive patients treated with RA for undilatable ISR with single or multiple stent layers in the Mount Sinai catheterization laboratory between January 2016 and September 2018. Procedural success was defined as angiographic success without in-hospital major adverse cardiac events (MACE): a composite of death, myocardial infarction (MI), and target lesion revascularization (TLR). Clinical outcomes were assessed at one-year post-procedure.

Results: A total of 26 patients were included in the study, in which 18 (69.2%) patients were with multiple stent layers. After RA, 9 (34.6%) were received a new drug-eluting stent, and 6 (23.1%) were treated with intravascular brachytherapy. Angiographic success was achieved in 24 (92.3%) patients, and procedural success was achieved in 22 (84.6%) patients. In-hospital MACE occurred in 4 (15.4%) patients, all due to periprocedural non-Q wave MI. Within one year, MACE occurred in 9 (34.6%) patients with 5 (19.2%) TLR.

Conclusions: RA for undilatable ISR with single or multiple stent layers was performed with favorable procedural outcomes and a relatively high MACE rate driven by TLR within one year.
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http://dx.doi.org/10.1016/j.carrev.2021.01.011DOI Listing
January 2022

Relationship between high shear stress and OCT-verified thin-cap fibroatheroma in patients with coronary artery disease.

PLoS One 2020 17;15(12):e0244015. Epub 2020 Dec 17.

Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.

High-risk coronary plaques have been considered predictive of adverse cardiac events. Both wall shear stress (WSS) in patients with hemodynamically significant lesions and optical coherence tomography (OCT) -verified thin-cap fibroatheroma (TCFA) are associated with plaque rupture, the most common underlying mechanism of acute coronary syndrome. The aim of the study was to test the hypothesis that invasive coronary angiography-based high WSS is associated with the presence of TCFA detected by OCT in obstructive lesions. From a prospective study of patients who underwent OCT examination for angiographically obstructive lesions (Yellow II), we selected patients who had two angiographic projections to create a 3-dimensional reconstruction model to allow assessment of WSS. The patients were divided into 2 groups according to the presence and absence of TCFA. Mean WSS was assessed in the whole lesion and in the proximal, middle and distal segments. Of 70 patients, TCFA was observed in 13 (19%) patients. WSS in the proximal segment (WSSproximal) (10.20 [5.01, 16.93Pa]) and the whole lesion (WSSlesion) (12.37 [6.36, 14.55Pa]) were significantly higher in lesions with TCFA compared to WSSproximal (5.84 [3.74, 8.29Pa], p = 0.02) and WSSlesion (6.95 [4.41, 11.60], p = 0.04) in lesions without TCFA. After multivariate analysis, WSSproximal was independently associated with the presence of TCFA (Odds ratio 1.105; 95%CI 1.007-1.213, p = 0.04). The optimal cutoff value of WSSproximal to predict TCFA was 6.79 Pa (AUC: 0.71; sensitivity: 0.77; specificity: 0.63 p = 0.02). Our results demonstrate that high WSS in the proximal segments of obstructive lesions is an independent predictor of OCT-verified TCFA.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0244015PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7746187PMC
February 2021

Orbital Atherectomy for Treatment of Severely Calcified Coronary Artery Bifurcation Lesions: A Multicenter Analysis.

Cardiovasc Revasc Med 2021 05 1;26:34-38. Epub 2020 Nov 1.

Mount Sinai Cardiovascular Center, Icahn School of Medicine, New York, NY, United States of America.

Objective: This study evaluated the safety and efficacy of orbital atherectomy (OA) for the treatment of severely calcified coronary artery bifurcation lesions.

Background: Percutaneous coronary intervention (PCI) of severely calcified coronary artery lesions is associated with lower procedural success and higher rates of target lesion failure compared to non-calcified lesions. OA is an effective treatment for calcified coronary artery lesions prior to stent implantation. However, there is little data regarding the safety and efficacy of OA in patients with coronary artery bifurcation lesions.

Methods: Data were obtained from analysis of patients with severe coronary artery calcification who underwent OA and coronary stent implantation at ten high-volume institutions. Data were pooled and analyzed to assess peri-procedural outcomes and 30-day major adverse cardiac events (MACE).

Results: A total of 1156 patients were treated with OA and PCI. 363 lesions were at a coronary artery bifurcation. There were no statistically significant differences in baseline characteristics between the bifurcation and non-bifurcation groups. In the bifurcation group, treatment involved the left anterior descending artery and its branches more frequently and right coronary artery less frequently. After propensity score matching, the 30-day freedom from MACE was not statistically significant between the two groups.

Conclusion: In this multicenter cohort analysis, patients with severely calcified coronary bifurcation lesions had low rates of MACE and target vessel revascularization at 30 days at rates comparable to non-bifurcation lesions. This analysis demonstrates that OA is safe and effective for complex coronary lesions at both bifurcation and non-bifurcation locations.
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http://dx.doi.org/10.1016/j.carrev.2020.10.023DOI Listing
May 2021

Side branch fractional flow reserve after provisional stenting of calcified bifurcation lesions: The ORBID-FFR study.

Catheter Cardiovasc Interv 2021 10 9;98(4):658-668. Epub 2020 Oct 9.

Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Objectives: We examined the incidence of side branch (SB) compromise after provisional stenting of calcified bifurcation lesions treated with rotational atherectomy (RA) or cutting balloon angioplasty (CBA) and the utility of optical coherence tomography (OCT) to detect functionally significant SB stenoses.

Background: The comparative impact of RA versus CBA on SB compromise and functional significance remains poorly characterized.

Methods: Seventy-one consecutive patients with 71 calcified bifurcation lesions with angiographically intermediate SB stenoses were randomized to RA (n = 35) or CBA (n = 36). The primary endpoint was SB compromise defined as SB diameter stenosis ≥70%, SB dissection or thrombolysis in myocardial infarction flow grade < 3 after provisional stenting. Secondary endpoints included SB FFR in noncompromised SBs and its correlation with SB ostium area (SBOA) assessed by three-dimensional OCT.

Results: SB compromise after provisional stenting was observed in 7 (20.0%) lesions that underwent RA and in 9 (25.0%) lesions treated with CBA (p = .62). Mean SB FFR was 0.83 ± 0.08 and was similar between the study arms. Functionally significant SB stenosis (FFR ≤ 0.80) was detected in 17(30.9%) angiographically noncompromised SBs. SBOA after stenting was an independent predictor of FFR ≤ 0.80 (OR 0.002, 95% CI: 0.00-0.15, p = .002). The optimal cutoff value for SBOA to predict functionally significant SB stenosis was 0.76 mm (sensitivity 82%, specificity 89% and area under the curve 0.92, 95% CI: 0.84-0.99).

Conclusions: The rates of SB compromise and functionally significant stenosis after provisional stenting of calcified bifurcation lesions were similar between two lesion preparation strategies. OCT SBOA can detect SB branches with FFR ≤ 0.80 with high sensitivity and specificity.
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http://dx.doi.org/10.1002/ccd.29307DOI Listing
October 2021

Management of calcified coronary artery bifurcation lesions.

Catheter Cardiovasc Interv 2021 06 10;97(7):1407-1416. Epub 2020 Aug 10.

Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York.

Calcified coronary artery bifurcation lesions (CBL) remain a challenge for the interventional cardiologist. Evidence regarding treatment of CBL is minimal. Optimal plaque modification is the most important step prior to stent deployment. Provisional stenting is the preferred strategy for most bifurcation lesions. However, two-stent strategy should be considered for BL with compromised large SB (>2.5 mm) supplying a large territory, >70% SB stenosis and lesions more than 5 mm long. In this contemporary review article, we present a simplified approach to treating CBL and demonstrate the approach to specific case examples using our newly developed mobile application, BifurcAID.
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http://dx.doi.org/10.1002/ccd.29148DOI Listing
June 2021

Gender Difference Is Associated With Severity of Coronavirus Disease 2019 Infection: An Insight From a Meta-Analysis.

Crit Care Explor 2020 Jun 19;2(6):e0148. Epub 2020 Jun 19.

Division of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY.

Objectives: Coronavirus disease 2019 is a novel infection now causing pandemic around the world. The gender difference in regards to the severity of coronavirus disease 2019 infection has not been well described thus far. Our aim was to investigate how gender difference can affect the disease severity of coronavirus disease 2019 infection.

Data Sources: A comprehensive literature search of PubMed and Embase databases was conducted from December 1, 2019, to March 26, 2020. An additional manual search of secondary sources was conducted to minimize missing relevant studies. There were no language restrictions.

Study Selection: Studies were included in our meta-analysis if it was published in peer-reviewed journals and recorded patient characteristics of severe versus nonsevere or survivor versus nonsurvivor in coronavirus disease 2019 infection.

Data Extraction: Two investigators independently screened the search, extracted the data, and assessed the quality of the study.

Data Synthesis: Our search identified 15 observational studies with a total of 3,494 patients (1,935 males and 1,559 females) to be included in our meta-analysis. Males were more likely to develop severe coronavirus disease 2019 infection compared with females (odds ratio, 1.31; 95% CI, 1.07-1.60). There was no significant heterogeneity ( = 12%) among the studies.

Conclusions: This meta-analysis suggests that the male gender may be a predictor of more severe coronavirus disease 2019 infection. Further accumulation of evidence from around the world is warranted to confirm our findings.
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http://dx.doi.org/10.1097/CCE.0000000000000148DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314340PMC
June 2020

RAGE impairs murine diabetic atherosclerosis regression and implicates IRF7 in macrophage inflammation and cholesterol metabolism.

JCI Insight 2020 07 9;5(13). Epub 2020 Jul 9.

Diabetes Research Program, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine.

Despite advances in lipid-lowering therapies, people with diabetes continue to experience more limited cardiovascular benefits. In diabetes, hyperglycemia sustains inflammation and preempts vascular repair. We tested the hypothesis that the receptor for advanced glycation end-products (RAGE) contributes to these maladaptive processes. We report that transplantation of aortic arches from diabetic, Western diet-fed Ldlr-/- mice into diabetic Ager-/- (Ager, the gene encoding RAGE) versus WT diabetic recipient mice accelerated regression of atherosclerosis. RNA-sequencing experiments traced RAGE-dependent mechanisms principally to the recipient macrophages and linked RAGE to interferon signaling. Specifically, deletion of Ager in the regressing diabetic plaques downregulated interferon regulatory factor 7 (Irf7) in macrophages. Immunohistochemistry studies colocalized IRF7 and macrophages in both murine and human atherosclerotic plaques. In bone marrow-derived macrophages (BMDMs), RAGE ligands upregulated expression of Irf7, and in BMDMs immersed in a cholesterol-rich environment, knockdown of Irf7 triggered a switch from pro- to antiinflammatory gene expression and regulated a host of genes linked to cholesterol efflux and homeostasis. Collectively, this work adds a new dimension to the immunometabolic sphere of perturbations that impair regression of established diabetic atherosclerosis and suggests that targeting RAGE and IRF7 may facilitate vascular repair in diabetes.
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http://dx.doi.org/10.1172/jci.insight.137289DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7406264PMC
July 2020

Procedural and 1-year clinical outcomes of orbital atherectomy for treatment of coronary in-stent restenosis: A single-center, retrospective study.

Catheter Cardiovasc Interv 2021 02 18;97(3):E280-E287. Epub 2020 Jun 18.

Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Objectives: We evaluated the procedural and 1-year clinical outcomes of orbital atherectomy (OA) for treatment of coronary in-stent restenosis (ISR).

Background: The optimal treatment for ISR remains uncertain. While rotational and laser atherectomy have been used as neointimal debulking techniques for ISR, there have been few reports on OA for ISR.

Methods: This is a retrospective observational study of consecutive patients who underwent percutaneous coronary intervention (PCI) for ISR with OA in Mount Sinai catheterization laboratory between November 2013 and January 2018. Procedural success was defined as angiographic success without in-hospital major adverse cardiac events (MACE; the composite of all-cause death, myocardial infarction [MI], or target vessel revascularization). Clinical outcomes were assessed at 1 month and 12 months postprocedure.

Results: A total of 87 patients were included in the study. All 87 patients were treated with OA, after which 49 (56.3%) patients also received new drug-eluting stents. Angiographic success was achieved in 87 (100%) patients and procedural success was achieved in 79 (90.8%) patients. In-hospital MACE occurred in 8 (9.2%) patients, all due to periprocedural non-Q-wave MI. Acute lumen gain was 1.19 ± 0.57 mm after OA plus balloon angioplasty and 1.75 ± 0.50 mm after stent placement. MACE within 1 year occurred in 17 (19.5%) patients.

Conclusions: OA for ISR was performed with favorable procedural and 1-year clinical outcomes. Randomized trials are warranted to determine whether OA improves the poor prognosis of patients with ISR treated without debulking.
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http://dx.doi.org/10.1002/ccd.28983DOI Listing
February 2021

Cardiovascular outcomes after percutaneous coronary intervention on bifurcation lesions with moderate to severe coronary calcium: A single-center registry study.

Catheter Cardiovasc Interv 2021 07 10;98(1):35-42. Epub 2020 Jun 10.

Cardiovascular Institute, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Background: Both target vessel calcification and target vessel bifurcation are associated with worse outcomes following percutaneous coronary intervention (PCI). Whether these entities in combination interact to influence outcomes after PCI of complex coronary disease is not known.

Objectives: This study evaluated the association of target vessel bifurcation and target vessel calcification, alone and in combination, with adverse events following PCI.

Methods: Registry data from 21,165 patients who underwent PCI with drug-eluting stents (DES) between January 2009 and December 2017 were analyzed. Patients were divided into four groups according to the presence or absence of target vessel bifurcation and presence of none/mild or moderate/severe target vessel calcification on angiography. Associations between lesion groups and 1 year major adverse cardiac events (MACE) were examined using Cox regression analysis.

Results: At 1 year, unadjusted rates of MACE, death, myocardial infarction (MI), as well as stent thrombosis were highest in the group with both bifurcation lesion and moderate/severe calcification. After adjusting for confounders such as age, renal disease, and smoking, hazard ratios for MACE were 1.14 (95%CI 0.99-1.33) for bifurcation with none/mild calcification, 1.21 (95%CI 1.06-1.38) for no bifurcation and moderate/severe calcification, and 1.37 (95%CI 1.14-1.64) for bifurcation and moderate severe calcification, compared to patients with no bifurcation and none/mild calcification.

Conclusions: The presence of a bifurcating target vessel with moderate/severe calcification is associated with a higher risk of adverse outcomes than either attribute alone. New approaches are needed to improve outcomes in this subset of patients with complex coronary artery disease.
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http://dx.doi.org/10.1002/ccd.29069DOI Listing
July 2021

Coronary angiography and percutaneous coronary intervention after transcatheter aortic valve replacement with medtronic self-expanding prosthesis: Insights from correlations with computer tomography.

Int J Cardiol 2020 Oct 1;317:18-24. Epub 2020 Jun 1.

Division of Cardiology, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, NY, New York, United States of America. Electronic address:

Objectives: We aim to describe the feasibility, challenges, success rates and techniques utilized in coronary angiography (CA) and percutaneous coronary intervention (PCI) in patients post transcatheter aortic valve replacement (TAVR).

Background: CA and PCI after TAVR are becoming increasingly encountered in clinical practice. There have been technical difficulties reported in re-accessing the coronary arteries through the self-expanding CoreValve prosthesis.

Methods: From January 2012 to November 2017, 672 patients who underwent TAVR with a self-expanding prosthesis were retrospectively reviewed and those who had a CA and/or PCI post TAVR were analysed. Clinical characteristics, angiographic and procedural details were obtained. A subgroup of patients had computed tomographic angiography (CTA) post TAVR to evaluate positions of the coronary ostia relative to the self-expanding prosthesis. Study endpoint was successful selective engagement of coronary ostia for CA and PCI.

Results: Thirty-two patients (4.8%) had attempted 46 CA and 26 PCI after TAVR with a self-expanding valve. Mean age was 85.2 years and 41% were females. Selective left and right coronary angiography using standard catheters could be achieved in 50% and 28% of cases respectively. Successful PCI was performed in 25 cases (96%); however, significant technique modification was required in 64% of cases. CTA in 9 patients confirmed the difficulty in coronary re-access was due to a combination of the sealing skirt relationship to coronary ostia and sinotubular junction as well as commissural post orientation and significant native leaflet calcification.

Conclusions: CA and PCI post TAVR with self-expanding CoreValve is technically challenging but feasible with modification of standard techniques.
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http://dx.doi.org/10.1016/j.ijcard.2020.05.065DOI Listing
October 2020

Ventricular Fibrillation Associated With Coronary Plaque Erosion Detected by Optical Coherence Tomography.

JACC Cardiovasc Interv 2020 01 11;13(1):e5-e7. Epub 2019 Dec 11.

Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York. Electronic address:

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http://dx.doi.org/10.1016/j.jcin.2019.08.050DOI Listing
January 2020

Influence of final kissing balloon inflation on long-term outcomes after PCI of distal left main bifurcation lesions in the EXCEL trial.

EuroIntervention 2020 Jun;16(3):218-224

Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Aims: The impact of final kissing balloon inflation (FKBI) after percutaneous coronary intervention (PCI) of bifurcation lesions on long-term clinical outcomes remains controversial. We sought to determine the impact of FKBI on four-year outcomes after PCI of distal left main (LM) bifurcation lesions.

Methods And Results: The EXCEL trial compared PCI with everolimus-eluting stents and coronary artery bypass graft surgery (CABG) in patients with left main (LM) disease. We examined four-year clinical outcomes after PCI of distal LM bifurcation lesions according to use of FKBI. The primary endpoint was the composite rate of death, myocardial infarction (MI), or stroke. The major secondary endpoint was the composite rate of death, MI, stroke, or ischaemia-driven revascularisation (IDR). Among 948 patients randomised to PCI, 759 had distal LM lesions treated, 430 of which were treated with one stent and 329 of which were treated with two or more stents. The four-year rates of the primary and major secondary endpoints were similar with versus without FKBI in both the one-stent and ≥2-stent groups in both unadjusted and adjusted analyses.

Conclusions: In the EXCEL trial, the performance of FKBI after PCI of distal LM bifurcation lesions was not associated with improved four-year clinical outcomes regardless of whether one stent or ≥2 stents were implanted.
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http://dx.doi.org/10.4244/EIJ-D-19-00851DOI Listing
June 2020

Stent Expansion and Endothelial Shear Stress in Bifurcation Lesions.

Circ Cardiovasc Interv 2019 06 14;12(6):e007911. Epub 2019 Jun 14.

Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY.

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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.119.007911DOI Listing
June 2019

A transcriptomic model to predict increase in fibrous cap thickness in response to high-dose statin treatment: Validation by serial intracoronary OCT imaging.

EBioMedicine 2019 Jun 22;44:41-49. Epub 2019 May 22.

Mount Sinai Heart, Mount Sinai Health System, New York, NY, United States of America. Electronic address:

Background: Fibrous cap thickness (FCT), best measured by intravascular optical coherence tomography (OCT), is the most important determinant of plaque rupture in the coronary arteries. Statin treatment increases FCT and thus reduces the likelihood of acute coronary events. However, substantial statin-related FCT increase occurs in only a subset of patients. Currently, there are no methods to predict which patients will benefit. We use transcriptomic data from a clinical trial of rosuvastatin to predict if a patient's FCT will increase in response to statin therapy.

Methods: FCT was measured using OCT in 69 patients at (1) baseline and (2) after 8-10 weeks of 40  mg rosuvastatin. Peripheral blood mononuclear cells were assayed via microarray. We constructed machine learning models with baseline gene expression data to predict change in FCT. Finally, we ascertained the biological functions of the most predictive transcriptomic markers.

Findings: Machine learning models were able to predict FCT responders using baseline gene expression with high fidelity (Classification AUC = 0.969 and 0.972). The first model (elastic net) using 73 genes had an accuracy of 92.8%, sensitivity of 94.1%, and specificity of 91.4%. The second model (KTSP) using 18 genes has an accuracy of 95.7%, sensitivity of 94.3%, and specificity of 97.1%. We found 58 enriched gene ontology terms, including many involved with immune cell function and cholesterol biometabolism.

Interpretation: In this pilot study, transcriptomic models could predict if FCT increased following 8-10 weeks of rosuvastatin. These findings may have significance for therapy selection and could supplement invasive imaging modalities.
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http://dx.doi.org/10.1016/j.ebiom.2019.05.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6607084PMC
June 2019

Predictors of side branch compromise in calcified bifurcation lesions treated with orbital atherectomy.

Catheter Cardiovasc Interv 2019 07 3;94(1):45-52. Epub 2018 Dec 3.

Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York.

Objectives: The aim of the study was to identify the predictors of side branch (SB) compromise in severely calcified bifurcation lesions treated with orbital atherectomy (OA).

Background: SB compromise remains a major complication of bifurcation lesion percutaneous coronary intervention (PCI). Higher prevalence of lipid-rich plaques and spotty calcification by optical coherence tomography (OCT) and SB ostial stenosis by angiography have been previously suggested as predictors of SB occlusion after main vessel (MV) stenting.

Methods: Patients with chronic stable angina and severely calcified bifurcation lesions, in whom provisional stenting strategy was planned, were enrolled in the study. OA was used for lesion preparation in all cases. OCT imaging of the MV was performed before and after stenting. SB compromise was defined as a composite of SB occlusion (TIMI flow grade ≤ 2) and SB intervention after MV stenting.

Results: Thirty stable CAD patients with 30 severely calcified bifurcation lesions were included in the study. Twelve patients (40%) had a compromised SB after MV stenting. Compromised SB was characterized by a greater angiographic diameter stenosis (55.4 ± 8.1% vs. 35.0 ± 14.4%, P < 0.01) and a smaller minimal lumen diameters (0.79 ± 0.17 vs. 1.12 ± 0.30 mm, P = 0.002) before PCI compared to noncompromised SB. The prevalence of OCT lipid-rich plaques was low and did not differ between the groups (18 vs. 19%, P = 0.68). There was no difference in other OCT plaque characteristics including the presence of spotty calcification.

Conclusion: The severity of SB ostial disease and not MV plaque morphology contributed to SB compromise in severely calcified bifurcation lesions.
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http://dx.doi.org/10.1002/ccd.27992DOI Listing
July 2019

Procedural and one-year outcomes of patients treated with orbital and rotational atherectomy with mechanistic insights from optical coherence tomography.

EuroIntervention 2019 Apr;14(17):1760-1767

Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Aims: We sought to evaluate procedural complications and one-year clinical outcomes for patients who underwent percutaneous coronary intervention (PCI) with orbital (OA) and rotational atherectomy (RA).

Methods And Results: From a total of 13,467 patients who underwent PCI in our hospital between January 2013 and June 2016, 1,149 consecutive patients were treated with atherectomy for moderately-severely calcified lesions (184 with OA, 965 with RA). Procedural complications were similarly observed in the two groups except for higher dissection and perforation rates with OA. Major adverse cardiovascular events (MACE) were defined as the composite of death, myocardial infarction or target lesion revascularisation. Multivariable adjusted analysis showed that OA use was associated with comparable adjusted one-year MACE compared to RA use (hazard ratio 0.79 [95% confidence interval 0.54-1.17], p=0.25). There were no significant differences in individual MACE endpoints. Furthermore, we studied 67 patients with OCT images. OCT analysis showed comparable tissue modification with a trend towards higher stent expansion with OA vs. RA.

Conclusions: OA use was associated with lower unadjusted but similar adjusted one-year MACE outcomes compared to RA with higher rates of dissection and device-induced perforation.
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http://dx.doi.org/10.4244/EIJ-D-17-01060DOI Listing
April 2019

Real-World Bioresorbable Vascular Scaffold Experience Compared With Second-Generation Metallic Drug-Eluting Stents in Complex Coronary Lesions.

J Invasive Cardiol 2018 07 15;30(7):251-255. Epub 2018 Apr 15.

Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029 USA.

Objectives: The aim of the study was to compare the acute outcomes of Absorb bioresorbable vascular scaffolds (BVS) and second-generation drug-eluting stent (DES) implantation in routine clinical practice. There is a paucity of data regarding BVS use in a real-world patient population.

Methods: The study population comprised 40 consecutive patients who underwent percutaneous coronary intervention (PCI) with BVS implantation at a tertiary-care center in New York, New York between July and December of 2016. An optimal implantation technique including adequate lesion preparation, mandatory postdilation, and optical coherence tomography (OCT) imaging was used in all cases. De novo lesions treated with BVS were compared to lesions treated with DES matched by OCT calcium arc, scaffold/stent size, use of atherectomy device, and lesion postdilation. Acute lumen gain, minimal device area, malapposition, eccentricity, and symmetry index were assessed using OCT.

Results: We analyzed OCT images of 40 BVS cases and 40 matching DES cases from 35 and 40 patients, respectively. Compared to the DES group, the BVS group demonstrated similar acute lumen gain, minimal scaffold/stent area, eccentricity index, and symmetry index after PCI. There were fewer malapposed struts detected after BVS implantation; however, malapposition distance and length were not different between the groups.

Conclusion: BVS implantation in a real-world patient population with optimal implantation technique resulted in similar stent expansion and better strut apposition compared to DES implantation.
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July 2018

Prognostic Relation Between Severity of Diabetes Mellitus (On or Off Insulin) ± Chronic Kidney Disease with Cardiovascular Risk After Percutaneous Coronary Intervention.

Am J Cardiol 2018 01 19;121(2):168-176. Epub 2017 Oct 19.

Mount Sinai Heart, Mount Sinai Hospital, New York, New York. Electronic address:

The presence of either diabetes mellitus (DM) or chronic kidney disease (CKD) is associated with a worse prognosis after percutaneous coronary intervention (PCI). It is also known that outcomes in patients treated with insulin (insulin requiring type 2 diabetes mellitus [ITDM]) are worse than those who are not on insulin (non-insulin type 2 diabetes mellitus [NITDM]). We sought to compare long-term outcomes in patients who underwent PCI with varying severity of DM with and without CKD. We retrospectively studied 17,898 patients who underwent PCI from January 2009 to December 2014 in the Mount Sinai Cath Lab. Patients were categorized into groups by the presence or the absence of CKD and by the DM status (none, NITDM, or ITDM). In the absence of CKD, adjusted hazard ratios (95% confidence interval [CI]) for death or myocardial infarction associated with NITDM and ITDM were 1.65 (95% CI 1.02 to 2.67) and 3.78 (95% CI 2.23 to 6.40), respectively. Analogous risks in the presence of CKD were 3.34 (95% CI 1.99 to 5.61) and 6.26 (95% CI 3.84 to 10.2). This study shows that irrespective of renal status, the need for insulin in the setting of DM identifies a group with substantial risk of death or myocardial infarction at 1 year.
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http://dx.doi.org/10.1016/j.amjcard.2017.10.004DOI Listing
January 2018

Asymptomatic Large Thrombus Formation in Drug-Eluting Stent 2 Days After Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction Patient.

JACC Cardiovasc Interv 2017 12 30;10(23):2461-2463. Epub 2017 Aug 30.

Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York. Electronic address:

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http://dx.doi.org/10.1016/j.jcin.2017.07.011DOI Listing
December 2017

IVUS, OCT, and Coronary Artery Calcification: Is There a Bone of Contention?

JACC Cardiovasc Imaging 2017 08;10(8):880-882

Cardiac Catheterization Laboratory, Mount Sinai Heart, Icahn School of Medicine, New York, New York.

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http://dx.doi.org/10.1016/j.jcmg.2017.06.008DOI Listing
August 2017

Intracoronary Imaging, Cholesterol Efflux, and Transcriptomics after Intensive Statin Treatment in Diabetes.

Sci Rep 2017 08 1;7(1):7001. Epub 2017 Aug 1.

Mount Sinai Heart, Mount Sinai Hospital, New York, USA.

Residual atherothrombotic risk remains higher in patients with versus without diabetes mellitus (DM) despite statin therapy. The underlying mechanisms are unclear. This is a retrospective post-hoc analysis of the YELLOW II trial, comparing patients with and without DM (non-DM) who received rosuvastatin 40 mg for 8-12 weeks and underwent intracoronary multimodality imaging of an obstructive nonculprit lesion, before and after therapy. In addition, blood samples were drawn to assess cholesterol efflux capacity (CEC) and changes in gene expression in peripheral blood mononuclear cells (PBMC). There was a significant reduction in low density lipoprotein-cholesterol (LDL-C), an increase in CEC and beneficial changes in plaque morphology including increase in fibrous cap thickness and decrease in the prevalence of thin cap fibro-atheroma by optical coherence tomography in DM and non-DM patients. While differential gene expression analysis did not demonstrate differences in PBMC transcriptome between the two groups on the single-gene level, weighted gene coexpression network analysis revealed two modules of coexpressed genes associated with DM, Collagen Module and Platelet Module, related to collagen catabolism and platelet function respectively. Bayesian network analysis revealed key driver genes within these modules. These transcriptomic findings might provide potential mechanisms responsible for the higher cardiovascular risk in DM patients.
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http://dx.doi.org/10.1038/s41598-017-07029-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5539108PMC
August 2017

Inflammatory Ly6Chi monocytes and their conversion to M2 macrophages drive atherosclerosis regression.

J Clin Invest 2017 Aug 26;127(8):2904-2915. Epub 2017 Jun 26.

Departments of Medicine (Cardiology) and Cell Biology, and the Marc and Ruti Bell Program in Vascular Biology, New York University School of Medicine, New York, New York, USA.

Atherosclerosis is a chronic inflammatory disease, and developing therapies to promote its regression is an important clinical goal. We previously established that atherosclerosis regression is characterized by an overall decrease in plaque macrophages and enrichment in markers of alternatively activated M2 macrophages. We have now investigated the origin and functional requirement for M2 macrophages in regression in normolipidemic mice that received transplants of atherosclerotic aortic segments. We compared plaque regression in WT normolipidemic recipients and those deficient in chemokine receptors necessary to recruit inflammatory Ly6Chi (Ccr2-/- or Cx3cr1-/-) or patrolling Ly6Clo (Ccr5-/-) monocytes. Atherosclerotic plaques transplanted into WT or Ccr5-/- recipients showed reduced macrophage content and increased M2 markers consistent with plaque regression, whereas plaques transplanted into Ccr2-/- or Cx3cr1-/- recipients lacked this regression signature. The requirement of recipient Ly6Chi monocyte recruitment was confirmed in cell trafficking studies. Fate-mapping and single-cell RNA sequencing studies also showed that M2-like macrophages were derived from newly recruited monocytes. Furthermore, we used recipient mice deficient in STAT6 to demonstrate a requirement for this critical component of M2 polarization in atherosclerosis regression. Collectively, these results suggest that continued recruitment of Ly6Chi inflammatory monocytes and their STAT6-dependent polarization to the M2 state are required for resolution of atherosclerotic inflammation and plaque regression.
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http://dx.doi.org/10.1172/JCI75005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5531402PMC
August 2017
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