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Intracardiac Versus Transesophageal Echocardiography Guided Percutaneous Debulking of Tricuspid Endocarditis

Zhang, Robert S; Bailey, Eric; Maqsood, Muhammad H; Harari, Rafael; Bernard, Samuel; Xia, Yuhe; Keller, Norma; Alviar, Carlos L; Bangalore, Sripal
PMID: 38401653
ISSN: 1879-1913
CID: 5634712

Quality and rapidity of anticoagulation in patients with acute pulmonary embolism undergoing mechanical thrombectomy

Zhang, Robert S; Ho, Alvin M; Elbaum, Lindsay; Greco, Allison A; Hall, Sylvie; Postelnicu, Radu; Mukherjee, Vikramjit; Maqsood, Muhammad H; Keller, Norma; Alviar, Carlos L; Bangalore, Sripal
The primary objective of our study was to determine the proportion of intermediate-risk PE patients undergoing mechanical thrombectomy (MT) who achieved therapeutic anticoagulation (AC) at the time of the procedure. The salient findings of our study showed that only a minority of patients (14.3%) were in the therapeutic range by ACT at the time of MT (primary outcome). Furthermore, in this higher-risk PE cohort selected for MT, 18.2% of patients were subtherapeutic after initially reaching therapeutic AC, 43% experienced supratherapeutic AC at some point before MT, and less than half (43%) attained therapeutic AC at 6 hours, highlighting the necessity for optimizing anticoagulation practices in acute PE.
PMID: 38071002
ISSN: 1097-6744
CID: 5589832

Percutaneous Debulking of a Tricuspid Valve Papillary Fibroelastoma: A Rare Presentation and Management Approach

Zhang, Robert S; Harari, Rafael; Kelly, Sean M; Talmor, Nina; Rhee, Aaron J; Panhwar, Muhammad S; Yee-Chang, Melissa; Nayar, Ambika C; Keller, Norma M; Alviar, Carlos L; Bangalore, Sripal
PMID: 38047386
ISSN: 1942-0080
CID: 5597802

Adult congenital heart disease care in a municipal public health system

Tinsay, Maria Andrea Francesca M; Halpern, Dan G; Feinberg, Jodi L; Vorsanger, Matthew; Keller, Norma; Small, Adam J
Specialty care is associated with improved outcomes for adults with adult CHD and must be extended to the underserved. A retrospective cohort study was performed to describe the provision of care to adult CHD patients in America's largest municipal public health system including patient demographics, diagnostic and therapeutic procedures, and adherence to guideline-recommended surveillance. We identified 229 adult CHD patients aged >18 years through electronic medical records. The most common diagnoses were atrial septal defect, ventricular septal defect, patent ductus arteriosus, and valvular pulmonary stenosis. In total, 65% had moderate or greater anatomic complexity. A large number of patients were uninsured (45%), non-white (96%), and non-English speaking (44%). One hundred forty-six patients (64%) presented with unrepaired primary defects. Fifty eight patients underwent primary repair during the study period; 48 of those repairs were surgical and 10 were transcatheter. Collaboration with an affiliated Comprehensive Care Center was utilised for 28% of patients. A high proportion of patients received adult CHD speciality visits (78%), echocardiograms (66%), and electrocardiograms (56%) at the guideline-recommended frequency throughout the study period. There was no significant difference in the rate of adherence to guideline-recommended surveillance based on insurance status, race/ethnicity, or primary language status. The proportion of patients who had guideline-recommended adult CHD visits, echocardiograms, and electrocardiograms was significantly lower for those with more advanced physiological stages. These results can inform the provision of adult CHD care in other public health system settings.
PMID: 37909409
ISSN: 1467-1107
CID: 5614462

Treatment of Purulent Pericarditis With Intrapericardial Alteplase

Zhang, Robert S; Singh, Arushi; Alam, Usman; Grossman, Kelsey; Keller, Norma; Alviar, Carlos L; Bangalore, Sripal
PMID: 37477022
ISSN: 1942-0080
CID: 5536132

Outcomes With Percutaneous Debulking of Tricuspid Valve Endocarditis

Zhang, Robert S; Alam, Usman; Maqsood, Muhammad H; Xia, Yuhe; Harari, Rafael; Keller, Norma; Elbaum, Lindsay; Rao, Sunil V; Alviar, Carlos L; Bangalore, Sripal
BACKGROUND:In patients with tricuspid valve infective endocarditis, percutaneous debulking is a treatment option. However, the outcomes of this approach are less well known. METHODS:We performed a retrospective analysis of all patients who underwent percutaneous vegetation debulking for tricuspid valve infective endocarditis from August 2020 to November 2022 at a large academic tertiary care public hospital. The primary efficacy outcome was procedural success defined by clearance of blood cultures. The primary safety outcome was any procedural complication. For the composite outcome of in-hospital mortality or heart block, outcomes were compared (sequential noninferiority and superiority) with published surgical outcomes data. RESULTS:=0.016). CONCLUSIONS:Percutaneous debulking is feasible, effective, and safe in treating patients with tricuspid valve infective endocarditis refractory to medical therapy.
PMID: 37417231
ISSN: 1941-7632
CID: 5535212

In-hospital Outcomes of Patients With and Without Previous Coronary Artery Bypass Graft Surgery Who Present With a Non-ST-Segment Elevation Myocardial Infarction

Dhaduk, Nehal; Xia, Yuhe; Feit, Frederick; Mamas, Mamas; Alviar, Carlos; Keller, Norma; Rao, Sunil V; Bangalore, Sripal
The clinical course of patients with a previous coronary artery bypass graft surgery (CABG) presenting with non-ST-elevation myocardial infarction (NSTEMI) is not well defined. We aimed to compare the management and outcomes of patients with and without previous CABG who present with an NSTEMI. Patients hospitalized with an NSTEMI between 2002 and 2018 were identified from the National Inpatient Sample. The baseline characteristics and outcomes of patients with and without a previous CABG were compared. The outcomes included the rates of invasive procedures (defined as coronary angiography, percutaneous coronary intervention [PCI], or CABG), and its individual components, and in-hospital mortality. A total of 1,445,545 cases of NSTEMI were found, of which 133,691 (9.3%) had a previous CABG. Patients with a previous CABG were older (72.4 vs 68.6 years, p <0.001), more likely men (68.8% vs 56.9%, p <0.001), and of White race (79.7% vs 74.8%, p <0.001). The previous CABG cohort had lower rates of invasive procedures (50.4% vs 65.6%, p <0.001), PCI (23.7% vs 32.0%, p <0.001), or CABG (1.2% vs 10.6%; p <0.001) in the unmatched analysis. The results were consistent in the propensity score-matched analysis with the previous CABG group less likely to receive any invasive procedures (odds ratio [OR] 0.48, 95% confidence interval [CI] 0.47 to 0.49), including coronary angiography (OR 0.54, 95% CI 0.53 to 0.55), PCI (OR 0.66, 95% CI 0.64 to 0.67), or repeat CABG (OR 0.11, 95% CI 0.10 to 0.12). Moreover, the risk of in-hospital mortality was higher in the previous CABG group (OR 1.15, 95% CI 1.10 to 1.21). In the subset of patients who were revascularized in both groups, this excess mortality was no longer observed (OR 0.82, 95% CI 0.66 to 1.03). In conclusion, a previous CABG in patients who present with NSTEMI is associated with lower rates of invasive procedures and revascularization and higher in-hospital mortality than patients without a previous CABG.
PMID: 36989550
ISSN: 1879-1913
CID: 5463292

Outcomes After Tricuspid Valve Operations in Patients With Drug-Use Infective Endocarditis

Siddiqui, Emaad; Alviar, Carlos L; Ramachandran, Abhinay; Flattery, Erin; Bernard, Samuel; Xia, Yuhe; Nayar, Ambika; Keller, Norma; Bangalore, Sripal
The increase of intravenous drug use has led to an increase in right-sided infective endocarditis and its complications including septic pulmonary embolism. The objective of this study was to compare the outcomes of tricuspid valve (TV) operations in patients with drug-use infective endocarditis (DU-IE) complicated by septic pulmonary emboli (PE). Hospitalizations for DU-IE complicated by septic PE were identified from the National Inpatient Sample from 2002 to 2019. Outcomes of patients who underwent TV operations were compared with medical management. The primary outcome was the incidence of major adverse cardiovascular events (MACEs), defined as in-hospital mortality, myocardial infarction, stroke, cardiogenic shock, or cardiac arrest. An inverse probability of treatment weighted analysis was utilized to adjust for the differences between the cohorts. A total of 9,029 cases of DU-IE with septic PE were identified (mean age 33.6 years), of which 818 patients (9.1%) underwent TV operation. Surgery was associated with a higher rate of MACE (14.5% vs 10.8%, p <0.01), driven by a higher rate of cardiogenic shock (6.1% vs 1.2%, p <0.01) but a lower rate of mortality (2.7% vs 5.7%, p <0.01). Moreover, TV operation was associated with an increased need for permanent pacemakers, blood transfusions, and a higher risk of acute kidney injury. In the inverse probability treatment weighting analysis, TV operation was associated with an increased risk for MACE driven by a higher rate of cardiogenic shock and cardiac arrest, but a lower rate of mortality when compared with medical therapy alone. In conclusion, TV operations in patients with DU-IE complicated by septic PE are associated with an increased risk for MACE but a decreased risk of mortality. Although surgical management may be beneficial in some patients, alternative options such as percutaneous debulking should be considered given the higher risk.
PMID: 36280471
ISSN: 1879-1913
CID: 5365292

Toward Personalized DAPT: Is There an Inter-Manufacturer Difference in Generic Clopidogrel Response?

Hall, Sylvie; Xia, Yuhe; Ahmed, Hamza; Iskhakov, Daniela; Feit, Frederick; Alviar, Carlos L; Berger, Jeffrey S; Keller, Norma; Bangalore, Sripal
OBJECTIVE:To compare rates of clopidogrel response among patients receiving medication produced by 2 different manufacturers after acute coronary syndrome (ACS) and/or percutaneous coronary intervention. METHODS:This quality-improvement project included 515 adult patients receiving clopidogrel for ACS or ischemic heart disease and referred for coronary angiography/ percutaneous coronary intervention. The project was divided into 2 phases: (1) retrospective collection of baseline data (April 2019-October 2020); and (2) two 12-week, prospective phases in which all clopidogrel in the hospital was restricted to a single manufacturer at a time (November 2020-May 2021). The primary outcome was clopidogrel response measured by platelet function testing, defined as adenosine diphosphate (ADP) response <40% on light transmission aggregometry. RESULTS:Of 515 total patients included in both phases (mean age, 64.5 ± 11.4 years; 351 men [68.2%]; 450 with ACS [87.4%]), 52% were found to be clopidogrel responders based on results of platelet function testing. Among 135 patients in the prospective phase, there was a significantly lower proportion of patients who were clopidogrel responders in the Manufacturer 1 group compared with the Manufacturer 2 group (34.8% vs 55.1%, respectively; P=.03). After adjustment for age, sex, body mass index, aspirin response, therapeutic hypothermia, left heart catheterization indication, clopidogrel loading dose, time between loading dose and lab measurement, and manufacturer, aspirin response (odds ratio 0.96; 95% confidence interval, 0.95-0.97; P<.001) and manufacturer (odds ratio, 2.45; 95% confidence interval, 1.18-5.22; P=.02) were associated with clopidogrel response. CONCLUSIONS:In a large public hospital, we observed that pharmacodynamic response to clopidogrel varied by drug manufacturer. Further investigation and/or regulation is needed to minimize inter-manufacturer variability.
PMCID:9761404
PMID: 36416902
ISSN: 1557-2501
CID: 5381662

Critical Care Cardiology Trials Network (CCCTN): a cohort profile

Metkus, Thomas S; Baird-Zars, Vivian M; Alfonso, Carlos E; Alviar, Carlos L; Barnett, Christopher F; Barsness, Gregory W; Berg, David D; Bertic, Mia; Bohula, Erin A; Burke, James; Burstein, Barry; Chaudhry, Sunit-Preet; Cooper, Howard A; Daniels, Lori B; Fordyce, Christopher B; Ghafghazi, Shahab; Goldfarb, Michael; Katz, Jason N; Keeley, Ellen C; Keller, Norma M; Kenigsberg, Benjamin; Kontos, Michael C; Kwon, Younghoon; Lawler, Patrick R; Leibner, Evan; Liu, Shuangbo; Menon, Venu; Miller, P Elliott; Newby, L Kristin; O'Brien, Connor G; Papolos, Alexander I; Pierce, Matthew J; Prasad, Rajnish; Pisani, Barbara; Potter, Brian J; Roswell, Robert O; Sinha, Shashank S; Shah, Kevin S; Smith, Timothy D; Snell, R Jeffrey; So, Derek; Solomon, Michael A; Ternus, Bradley W; Teuteberg, Jeffrey J; van Diepen, Sean; Zakaria, Sammy; Morrow, David A
AIMS/OBJECTIVE:The aims of the Critical Care Cardiology Trials Network (CCCTN) are to develop a registry to investigate the epidemiology of cardiac critical illness and to establish a multicenter research network to conduct randomized clinical trials (RCTs) in patients with cardiac critical illness. METHODS AND RESULTS/RESULTS:The CCCTN was founded in 2017 with 16 centers and has grown to a research network of over 40 academic and clinical centers in the United States and Canada. Each center enters data for consecutive cardiac intensive care unit (CICU) admissions for at least two months of each calendar year. More than 20 000 unique CICU admissions are now included in the CCCTN Registry. To date, scientific observations from the CCCTN Registry include description of variations in care, the epidemiology and outcomes of all CICU patients, as well as subsets of patients with specific disease states, such as shock, heart failure, renal dysfunction, and respiratory failure. The CCCTN has also characterized utilization patterns, including use of mechanical circulatory support in response to changes in the heart transplantation allocation system, and the use and impact of multidisciplinary shock teams. Over years of multicenter collaboration, the CCCTN has established a robust research network to facilitate multicenter registry-based randomized trials in patients with cardiac critical illness. CONCLUSIONS:The CCCTN is a large, prospective registry dedicated to describing processes-of-care and expanding clinical knowledge in cardiac critical illness. The CCCTN will serve as an investigational platform from which to conduct randomized controlled trials in this important patient population.
PMID: 36029517
ISSN: 2058-1742
CID: 5338532