- Buford, Georgia, United States
Continuous Flow LVAD(CF-LVAD) are widely used as BTT among patients with Advance Heart Failure. The current study aimed to determine the impact of device related complications on waitlist mortality or delisting due to worsening clinical... more
Continuous Flow LVAD(CF-LVAD) are widely used as BTT among patients with Advance Heart Failure. The current study aimed to determine the impact of device related complications on waitlist mortality or delisting due to worsening clinical conditions. Methods: Patients who were bridged to heart transplant with a continuous flow LVAD (CF-LVAD) between April 2008 and September 2015 were identified from the UNOS heart transplant registry. They were then categorized by the presence or absence of CF-LVAD complications while on the wait list. Cox proportional hazards and Kaplan Meier survival curves were used for time-to-event analysis for the primary outcome. Results: Out of 7070 patients who were bridged to heart transplant, 4434(63%) got transplanted and 2510(36%) developed device related complications while on the waiting list. The primary outcome was present in 1631(23%) patients. Independent predictors of primary outcome were Age (HR/increasing unit: 1.01, 95% CI: 1.01-1.02, p value: <0.0001.), ABO blood group(O vs. A HR: 1.20, 95% CI: 1.20-1.36, p value: 0.003), Etiology of cardiomyopathy (Congenital vs. Ischemic HR: 3.46, 95% CI: 3.46(2.15-5.27, p value: <0.0001, Restrictive vs. Non-ischemic HR: 2.66, 95% CI: 1.67-3.99, p value: 0.0001), history of diabetes mellitus(HR: 1.18, 95% CI: 1.05-1.34, p value: 0.006). Developing one device-related complication was associated with a HR of 2.59 of having the primary outcome, (p<0.0001). The hazard risk however increased to 3.45 when ≥ 2 of the defined complications occurred. Conclusion: In conclusion, findings from the current study add to the existing literature: the incidence of morbidity and mortality in the current BTT era. While the development of any device-related adverse event is significantly associated with waitlist mortality or delisting, the occurrence of ≥ 2 almost doubles the risk. Improvement in clinical management strategies is needed to ensure optimal benefit of CF-LVADs for BTT therapy.
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Bariatric surgery may have a role in the management of morbidly obese patients with end-stage heart failure through increasing eligibility and improving outcomes of destination therapies. We conducted a nationally-representative,... more
Bariatric surgery may have a role in the management of morbidly obese patients with end-stage heart failure through increasing eligibility and improving outcomes of destination therapies. We conducted a nationally-representative, retrospective cohort study of patients with previous bariatric surgery undergoing either heart transplantation or left ventricular assist device implantation. Of 200 patients, < 6% experienced in-hospital mortality after destination therapy, comparable to that reported in the general heart recipient population. Risk-adjusted outcomes minimally differed from obese patients undergoing destination therapy without previous bariatric surgery. This study provides important safety benchmarking data and demonstrates the feasibility of bariatric surgery as a potential 'bridge' left ventricular assist device or transplantation in obese patients with end-stage heart failure.
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Introduction: Spontaneous Coronary Artery Dissection (SCAD) is reported to occur predominantly in young women. Gender differences in the clinical presentation and outcomes of patients with SCAD have not been studied on a population level.... more
Introduction: Spontaneous Coronary Artery Dissection (SCAD) is reported to occur predominantly in young women. Gender differences in the clinical presentation and outcomes of patients with SCAD have not been studied on a population level. We sought to compare the in-hospital outcomes of men and women presenting with acute myocardial infarction (AMI) and SCAD. Methods: We identified patients from the National Inpatient Sample (NIS) between 2005 and 2015 who presented with primary diagnoses of AMI and SCAD. We identified SCAD with ICD-9 code 414.12. A 1:1 propensity-matched cohort was created to examine the outcomes between men and women. Primary endpoint was in-hospital mortality. Secondary endpoints included in-hospital cardiac and non-cardiac complications. Results: Of the 6617 (32017 weighted national estimates) patients with SCAD over the study period, majority were males 3667 (55.4%). Males were younger than females (60.32 yr vs. 61.59 yr) and presented more often with ST-elevation myocardial infarction (STEMI) (53.0% vs. 45.9% P=&amp;lt;0.001). Propensity matching yielded 2366 males and 2366 females. In the matched group, there was no significant difference in in-hospital mortality between males and females (OR 1.20 95% CI -0.93-1.54). With regards to in-hospital complications, ventricular tachycardia (V-Tach) was significantly less frequent in females as compared to males (8.0% vs. 10.1% OR 0.76 p-value 0.003). There was no significant difference between females and males in the frequency of other complications, including intracranial hemorrhage (0.2% vs 0.2% OR 1.45 p-value 0.50), GI bleed (1.8% vs 1.3% OR 1.35 p-value 0.13), cardiogenic shock (9.8% vs 9.7% OR 1.01 p-value 0.86), acute heart failure (3% vs 2.6% OR 1.18 p-value 0.26), ventricular fibrillation(vfib) (5.6% vs 6.0% OR 0.928 p-value 0.48) or stroke ( 1.5% vs 1.0% OR 1.535 p-value 0.06) Conclusion: In our large population-based analysis, compared to females, males were more likely to present with STEMI as compared to females. With the except of V-Tach, which was higher in males, there were no significant gender differences in hospital outcomes namely inpatient mortality, cardiogenic, Vfib or acute heart failure.
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This study compares the postoperative outcomes, 30‐day readmission rates, and incidence of sternal wound infection‐related readmissions between patients receiving bilateral internal mammary arteries (BIMA) and single internal mammary... more
This study compares the postoperative outcomes, 30‐day readmission rates, and incidence of sternal wound infection‐related readmissions between patients receiving bilateral internal mammary arteries (BIMA) and single internal mammary artery (SIMA) grafting during coronary artery bypass graft (CABG) surgery.
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Research Interests: Frailty, Medicine, Humans, Internal Medicine, Female, and 15 moreMale, New Jersey, Health Status, Proportional hazards model, Retrospective Studies, Geriatric Assessment, Risk Factors, Aortic Valve, Postoperative Period, Grip strength, Frail elderly, Aortic valve stenosis, Multidetector Computed Tomography, Cardiovascular medicine and haematology, and hazard ratio
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Cardiovascular (CV) outcomes can be improved with commonality between provider and patient regarding gender and race/ethnicity. Slow growth in CV care provider diversity is an obstacle for women and underrepresented groups. The hope for... more
Cardiovascular (CV) outcomes can be improved with commonality between provider and patient regarding gender and race/ethnicity. Slow growth in CV care provider diversity is an obstacle for women and underrepresented groups. The hope for more equitable outcomes is unlikely to be realized unless trends change in selection of CV fellows and program directors (PDs). We investigate longitudinal trends of gender and racial/ethnic composition of CV FITs. De-identified demographic data were compiled in a descriptive cross-sectional study from AAMC of internal medicine (IM) residents and CV FITs from 2011 through 2021 to evaluate gender and race/ethnicity trends among CV trainees. Trends of CV fellows who later became program directors were analyzed. In the US between 2011 and 2021, 53% of IM residents were male while 40% female (7% unreported). Among CV FITs, 78% were male and 21% female. Races/ethnicities among CV FITs consisted of 36% non-Hispanic white, 28% non-Hispanic Asian, 5% Hispanic, 4%Black, and 25% were classified within other race/ethnicity categories. The proportion who became CV program directors followed similarly: 79% of PDs were male and 21% female. Demographic profiles for CV FITs have not significantly changed over the past decade despite increased diversity among IM residents. Efforts to improve diversity of CV FITs and PDs need to be analyzed. Slow growth of diversity in CV FITs is outpaced by rising patient diversity, leading to disparities in care and poorer CV outcomes for women and underrepresented minorities. Recruiting, training, and retaining diverse CV FITs is necessary.
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Background: The “July effect” is a well-described phenomenon in academic medicine, relating to the annual influx of new trainees. We examined whether the “July effect” impacts inpatient outcomes of admissions for heart failure (HF).... more
Background: The “July effect” is a well-described phenomenon in academic medicine, relating to the annual influx of new trainees. We examined whether the “July effect” impacts inpatient outcomes of admissions for heart failure (HF). Methods: Between 2012 and 2014, we included adult patients (≥18 years) with a primary diagnosis of HF, defined using ICD-9 codes, from the National Inpatient Sample. We excluded non-teaching hospitals. Primary endpoint was in-hospital mortality. Secondary endpoints included hospital length of stay (LOS) and total cost adjusted for inflation. Logistic regression and adjusted odds ratio (OR) were used to adjust for confounders. Based on academic calendar, we classified admissions into 4 quarters (Q1-4). Q1 and Q4 were designated to assess the effect of novice (July effect) vs. seasoned trainees, respectively. Results: We identified 699,675 HF admissions during Q1 and Q4 over the study period. Mean age was 71 years and 48% were females. There were 20,270 in-hospital deaths (Q1 9,695 vs. Q4 10,575). After adjusting for confounders, there was no mortality difference between Q1 and Q4 admissions; adjusted OR 0.96, p = 0.23 (Figure). Similarly, there was no difference in hospital LOS or total cost; 5.8 vs. 5.8 days, p = 0.66 and $13,755 vs. $13,586, p = 0.46, in Q1 and Q4, respectively. Conclusion: In the largest study to date, there was no evidence of a “July effect” on inpatient HF outcomes. This may be credited to the well-defined guidelines which facilitate safe patient care in these patients.
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Background: The study aim was to investigate the relationship between postoperative morbidity after transcatheter aortic valve replacement (TAVR) and short-term patient-reported health status, using the Kansas City Cardiomyopathy... more
Background: The study aim was to investigate the relationship between postoperative morbidity after transcatheter aortic valve replacement (TAVR) and short-term patient-reported health status, using the Kansas City Cardiomyopathy Questionnaire (KCCQ). Methods: The association between 30-day post-procedure changes in patient-reported heath status and post-TAVR outcomes was examined. Patients were stratified into three groups based on observed changes in KCCQ-Overall scores (OS): Group A, increase in KCCQ-OS ≥10 points; Group B, KCCQ-OS scores <10 points; and Group C, decline in KCCQ-OS ≥10 points. Variation components of KCCQ scores were determined using paired t-tests. Postoperative morbidity was investigated. Multivariable logistic regression was used to identify pre-procedural factors associated with an increase or decline in KCCQ-OS at 30 days. Results: A total of 223 patients with complete baseline and postoperative 30-day KCCQ responses was studied. At the 30-day follow up there was a significant change in baseline mean KCCQ-OS for all patients (mean difference 14.1; p <0.0001). Improvement in KCCQ-OS ≥10 was observed in 130 patients (58%), 64 patients (29%) had no change, and 29 patients (13%) had a decline in KCCQ-OS ≥10. The incidence of acute kidney injury (AKI), permanent pacemaker (PPM) placement and new-onset arrhythmia (NOA) was higher in group C than in groups A and B: AKI, 11%, 0%, 0%; p <0.001; PPM, 21%, 4%, 6%; p = 0.004; and NOA, 21%, 5%, 8%, p = 0.026. Independent predictors of decline in KCCQ scores after TAVR were PPM requirement (estimate: 0.76 CI 0.22, 1.29; p = 0.005) and NYHA functional class (III/IV) (estimate: -0.41 CI -0.71, 0.10; p = 0.009). Conclusions: TAVR patients experienced an improvement in health status after the procedure, but for a smaller proportion their health status worsened. Patients who experience perioperative complications may have a decline in their health status after the procedure in the short term.
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Background: The current study aims to identify predictors of extended postoperative length of stay (PLOS) after uncomplicated transcatheter aortic valve replacement (TAVR). Methods: Patients who underwent TAVR at a single center between... more
Background: The current study aims to identify predictors of extended postoperative length of stay (PLOS) after uncomplicated transcatheter aortic valve replacement (TAVR). Methods: Patients who underwent TAVR at a single center between June 2012 and June 2016 were analyzed. Patients were stratified by time into an early cohort (EC; 2012-2014) and current cohort (CC; 2015-2016). Those who had complications post procedure were excluded. The CC group was dichotomized based on its median PLOS. Factors associated with a longer PLOS were investigated by using multivariable logistic regression analysis. Results: Mean age of the 686 patients (299 in the EC group and 387 in the CC group) was 82 ± 8 years. PLOS in the CC group was significantly lower than in the EC group (4 days vs 6 days, respectively; P<.001). Median PLOS in the CC group was 2 days. Dichotomizing the CC group by median PLOS resulted in 148 patients (54%) ≤2 days vs 128 patients (46%) >2 days. Of these, PLOS was 1 day in 71 patients (26%) and 2 days in 61 patients (28%). Independent predictors of PLOS >2 days were non-transfemoral approach, non-elective admission, female sex, low mean transaortic gradient, presence of chronic renal failure, and pulmonary hypertension. Conclusion: Experience coupled with improvements in TAVR technology over the past few years have led to a significant decrease in PLOS after TAVR. In the current TAVR era, 1 out of every 2 patients stays for a day or two in the absence of perioperative adverse events.
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BACKGROUND We investigated patient outcomes in relation to their postoperative length of stay after minimally invasive valve surgery. METHODS All adults who survived elective, uncomplicated minimally invasive aortic or mitral valve... more
BACKGROUND We investigated patient outcomes in relation to their postoperative length of stay after minimally invasive valve surgery. METHODS All adults who survived elective, uncomplicated minimally invasive aortic or mitral valve surgery at a single center between 2012 and 2019 were classified by postoperative length of stay: early discharge (≤ 3 days) or late discharge (> 3 days). The trend in early discharge was investigated over the study period, predictors of early discharge were identified using multivariable logistic regression modeling, and one-to-one propensity score matching was used to determine which patients in the late-discharge cohort of similar health to patients discharged early. Adjusted outcomes of 30-day mortality, readmission, and direct costs were analyzed. RESULTS Among 1,262 consecutive minimally invasive valve patients, 618 were elective and uncomplicated, 25% (n=162) of whom were discharged early. The proportion of early-discharge patients increased over time (p for trend <0.05). A history of congestive heart failure, stroke, or smoking and higher Society of Thoracic Surgeons predictive risk of mortality score negatively predicted early discharge (p<0.05). Propensity score matching identified 101 (22%) late-discharge patients comparable to early-discharge counterparts. Adjusted 30-day mortality and readmission rates were comparable between cohorts. The median direct costs per patient ($20,046 vs. $22,124; p<0.05) were significantly lower in the early-discharge cohort. CONCLUSIONS In well-selected patients, early discharge after minimally invasive valve surgery was associated with lower costs but comparable postoperative outcomes. About one fifth of patients who remain in the hospital beyond postoperative day 3 may be candidates for earlier discharge.
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Recent advances in technology and the need to decrease surgical morbidity have led a rapid progress in laparoscopic adrenalectomy (LA) over the past decade. Robotics is attractive to the surgeon owing to the 3-dimensional image quality,... more
Recent advances in technology and the need to decrease surgical morbidity have led a rapid progress in laparoscopic adrenalectomy (LA) over the past decade. Robotics is attractive to the surgeon owing to the 3-dimensional image quality, articulating instruments, and stable surgical platform. The safety and efficacy of robotic adrenalectomy (RA) have been demonstrated by several reports. In addition, RA has been shown to provide similar outcomes compared to LA. Development of adrenal surgery has involved the description of several surgical approaches including the anterior transperitoneal, lateral transperitoneal (LT) and posterior retroperitoneal (PR). Among these, the most frequently preferred technique is LT adrenalectomy, primarily due to the surgeon's familiarity of the operative field, wider working space and visibility. The LT technique is suitable for the resection of larger, unilateral tumors and in scenarios where conversion to an open transperitoneal approach is warranted, it offers a lesser burden. Also, the larger view of the entire abdominal cavity and excellent exposure of both adrenal glands and surrounding structures provided by the LT technique render it safe and feasible in pediatric and pregnant individuals.
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Introduction: Patients living in neighborhoods with lower socioeconomic status have a greater risk for incident heart failure (HF), more severe symptoms, and increased risk of adverse clinical outcomes. We used high resolution... more
Introduction: Patients living in neighborhoods with lower socioeconomic status have a greater risk for incident heart failure (HF), more severe symptoms, and increased risk of adverse clinical outcomes. We used high resolution metabolomics profiling to identify novel biomarkers associated with neighborhood socioeconomic status (nSES) in patients with HFrEF. Methods: The Area Deprivation Index (ADI) was used to characterize nSES in a discovery (n=170) and a validation (n=166) cohort of patients with HFrEF. Targeted and untargeted high-resolution plasma metabolomics profiling coupled with partial least-squares discriminant analysis (PLS-DA) was used to identify metabolites and metabolic pathways uniquely perturbed in patients in the highest tertile of the ADI (indicating lower nSES). Metabolites with a variable importance in projection (VIP) &gt; 1 entered pathway enrichment analysis. Results: Compared to patients in the lower and middle ADI tertiles, patients with HFrEF living in the highest ADI tertile were more likely to be Black, and had higher body mass index and lower ejection fraction (all P &lt; 0.01). PLS-DA confirmed metabolites that may be associated with worse diet quality in patients in both the discovery and validation cohorts who lived in neighborhoods in the highest ADI tertile, including amino acids and their metabolic products (carnitine, methionine, tryptophan, phenylalanine, valine, phenethylamine, indole), and urate. Moreover, metabolites associated with the human exposome (5-valerolactone, 1-naphthylamine) were also identified. Pathway enrichment analysis revealed branched-chain amino acid metabolism, fatty acid metabolism, and purine metabolism as part of this distinct metabolic signature ( Figure ). Conclusions: Patients with HFrEF living in neighborhoods with lower SES have a distinct metabolic signature that may, in part, be related to worse diet quality and more severe HF.
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Background: Disparities in heart failure (HF) outcomes exist in the United States, in part, due to social determinants of health. Individuals from racial and ethnic minority groups report the highest rates of cost-related delays in care... more
Background: Disparities in heart failure (HF) outcomes exist in the United States, in part, due to social determinants of health. Individuals from racial and ethnic minority groups report the highest rates of cost-related delays in care and worse access to high-quality medical therapy. We have previously demonstrated that individuals residing in more deprived neighborhoods experience higher readmissions, and Black patients are more likely to reside in deprived neighborhoods than White patients. Here, we engaged patients from the most deprived neighborhoods to understand drivers of excess readmission from the patient perspective. Methods: We conducted semi-structured in-depth interviews with 25 patients (mean age 61 ± 9 years, 96% Black, 40% female) readmitted with HF at Emory Healthcare hospitals, and living in a neighborhood in the top 10% of the Social Deprivation Index. Qualitative descriptive analysis of the interviews was performed using a multilevel coding strategy. Results: Patients in this cohort had a mean EF 39 ± 19%, and experienced 3.2 ± 2.5 readmissions in the preceding 12 months. Most patients (84%) highlighted lack of access to medications as a driver of hospital readmission. Representative quotes from individual patients are highlighted in the Table. Patients reported the etiology of their lack of medication access included medication costs (64%), only having access to re-fills through the emergency room or hospitalization (36%), low health literacy (12%), and limited access to transportation (8%). Conclusion: Lack of access to medications for patients with HF who live in socioeconomically deprived neighborhoods poses a challenge to reducing the burden of HF. Providing cost-effective and sustainable access to medications for patients with HF from low resource settings is a potential solution to decrease the number of HF hospitalization and readmissions in this vulnerable patient population.
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Primary cardiac tumors (PCT) are rare, and their contemporary outcomes are not well characterized in the literature. We assessed temporal trends in patient characteristics and management of admissions for PCT in US hospitals.
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Transfemoral (TF) access for transcatheter aortic valve implantation (TAVI) is the most commonly used site, however its use may be limited by prohibitive peripheral arterial disease. Although a number of alternative access techniques have... more
Transfemoral (TF) access for transcatheter aortic valve implantation (TAVI) is the most commonly used site, however its use may be limited by prohibitive peripheral arterial disease. Although a number of alternative access techniques have been well described, each has been shown to be associated with increased risks when compared to a TF approach. Recently, planned treatment of iliofemoral artery disease using intravascular lithotripsy (IVL) has emerged as a means of preserving TF access. Ipsilateral or contralateral femoral artery access has been routinely used to perform IVL but its use may be limited in certain conditions. Here we describe the novel technique of using percutaneous axillary artery access to perform IVL of iliofemoral artery to facilitate its use for large bore access. We present a 78-year-old high surgical risk female with severe aortic stenosis who was found to have a prior stent in the contralateral iliac artery protruding into the aorta which limited a traditional 'up and over' approach, and thus axillary artery access was used to perform IVL. This is the first case in literature to describe the use of percutaneous axillary access to perform IVL of the iliac and common femoral artery to facilitate TF TAVI. Based on our previous experience we feel this technique holds promise for a routine use when use of other access sites is limited.
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BACKGROUND Surgical aortic valve replacement can be performed either through a minimally invasive (MI) or full sternotomy (FS) approach. The present study compared outcomes of MI versus FS for isolated surgery among patients enrolled in... more
BACKGROUND Surgical aortic valve replacement can be performed either through a minimally invasive (MI) or full sternotomy (FS) approach. The present study compared outcomes of MI versus FS for isolated surgery among patients enrolled in the PARTNER 3 low-risk trial. METHODS Patients with severe, symptomatic aortic stenosis at low surgical risk with anatomy suitable for transfemoral access were eligible for PARTNER 3 enrollment. The primary outcome was the composite endpoint of death, stroke, or rehospitalization (valve-, procedure-, or heart-failure-related) at 1 year. Secondary outcomes included the individual components of the primary endpoint as well as patient-reported health status at 30 days and 1 year. RESULTS In the PARTNER 3 study, 358 patients underwent isolated surgery at 68 centers through an MI (n=107) or FS (n=251) approach (8 patients were converted from MI to FS). Mean age and Society of Thoracic Surgeons score were similar between groups. The Kaplan-Meier estimate of the primary outcome was similar in the MI versus FS groups (16.9% versus 14.9%; hazard ratio [95% CI]: 1.15 [0.66 - 2.03]; P=0.618). There were no significant differences in the 1-year rates of all-cause death (2.8% versus 2.8%), all stroke (1.9% versus 3.6%), or rehospitalization (13.3% versus 10.6%, P > 0.05 for all). Quality of life as assessed by the Kansas City Cardiomyopathy Questionnaire score at 30 days or 1 year was comparable in both groups. CONCLUSIONS For patients at low risk for isolated surgery, MI and FS approaches were associated with similar in-hospital and 1-year outcomes.
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Thank you very much for your comments, with which we agree. The National Inpatient Sample is a limited database that captures only the events of each admission, coded using International Classification of Diseases, 9th and 10th revisions.... more
Thank you very much for your comments, with which we agree. The National Inpatient Sample is a limited database that captures only the events of each admission, coded using International Classification of Diseases, 9th and 10th revisions. Consequently, the use of chemotherapy and postsurgical complications are unable to be accurately determined. This information would be relevant, in combination with tumor pathology, to better delineate best practices. Furthermore, this limited dataset cannot determine the particular factors affecting the relationship between atrial fibrillation and surgery. Previous studies have shown that atrial fibrillation may be associated with particular tumor types. As noted in the manuscript, primary cardiac tumors characteristics may benefit from analysis in other datasets. Longitudinal studies will also be of benefit to the treatment of primary cardiac tumors.
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Robotic parathyroidectomy has recently been described. Although the procedure eliminates the neck scar, it is technically more demanding than the conventional approaches. This report is a review of the patients’ selection criteria,... more
Robotic parathyroidectomy has recently been described. Although the procedure eliminates the neck scar, it is technically more demanding than the conventional approaches. This report is a review of the patients’ selection criteria, technique, and outcomes. J. Surg. Oncol. 2015; 112:240–242. © 2015 Wiley Periodicals, Inc.
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Transcatheter Aortic Valve Replacement (TAVR) remains a complex procedure with the potential for life-treating complications including heart block, bleeding from vascular access sites, and pericard...
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Aims:We analyzed the impact of frailty on readmission rates for ST-elevated myocardial infarctions (STEMIs) and the utilization of percutaneous coronary intervention (PCI) in STEMI admissions.Methods and Results:The 2016–2019 Nationwide... more
Aims:We analyzed the impact of frailty on readmission rates for ST-elevated myocardial infarctions (STEMIs) and the utilization of percutaneous coronary intervention (PCI) in STEMI admissions.Methods and Results:The 2016–2019 Nationwide Readmission Database was analyzed for patients admitted with an acute STEMI. Patients were categorized by frailty risk and analyzed for 30-day readmission risk after acute STEMIs, PCI utilization and outcomes, and healthcare resource utilization.Qualifying index admissions were found in 584,918 visits. Low risk frailty was noted in 78.20%, intermediate risk in 20.67%, and high risk in 1.14% of admissions. Thirtyday readmissions occurred in 7.74% of index admissions, increasing with frailty (p < 0.001). Readmission risk increased with frailty, 1.37 times with intermediate and 1.21 times with high-risk frailty.PCI was performed in 86.40% of low-risk, 66.03% of intermediate-risk, and 58.90% of high-risk patients (p < 0.001). Intermediate patients were 55.02% less likely and high-risk patients were 61.26% less likely to undergo PCI (p < 0.001). Length of stay means for index admissions were 2.96, 7.83, and 16.32 days for low, intermediate, and high-risk groups. Intermediate and high-risk frailty had longer length of stay, higher total cost, and were more likely to be discharged to a skilled facility (p < 0.001).Conclusion:Among adult, all-payer inpatient visits, frailty discerned by the hospital frailty risk score was associated with increased readmissions, increased healthcare resource utilization, and lower PCI administration.
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Introduction: Aortic root rupture or hematoma (ARR or ARH) is a serious complication of transcatheter aortic valve replacement (TAVR). In addition to excessive oversizing (annular area/TAVR stent area) and aortic annular calcification.... more
Introduction: Aortic root rupture or hematoma (ARR or ARH) is a serious complication of transcatheter aortic valve replacement (TAVR). In addition to excessive oversizing (annular area/TAVR stent area) and aortic annular calcification. Hypothesis: We hypothesize that combination of small sinus of Valsalva (SOV) and excessive calcification of aortic leaflets is a significant risk factor for ARR or ARH. Methods: Patients who experienced ARR or ARH during TAVR were selected. A matched cohort who had no complications during the procedure were identified from a prospectively maintained database. Dynamic 4-D cardiac computed tomography was used to assess respective thickness of the three aortic cusps, SOV, annular area, LVOT, and the presence and extent of calcification of the LVOT. The ratio of maximum leaflet thickness (MLT) to residual radius (RR): (SOV diameter - TAVR stent diameter)/2), and TAVR stent oversizing: (TAVR stent area - aortic annular area)/TAVR stent area were calculated and severity of annular calcification graded. Stepwise logistic regression using backward selection was used to determine factors associated with ARR or ARH during TAVR. Results: Out of 800 TAVR patients, ARR/ARH occurred in 18 (2.2%) during the procedure. There were 19 well-matched (no complication) patients who served as a control group. Baseline clinical characteristics were similar in ARR/ARH - patients and ARR/ARH + patients. LVOT calcification was ≥ moderate in 61 % of ARR+ patients and 31 % in ARR- patients. The overall incidence of bio prosthetic valve oversizing 37% (n=14). On multivariable logistic regression analysis, an MLT/RR ratio &amp;gt; 1.4, prosthetic valve oversizing ≥ 20% and ≥ moderate or greater annular calcification were significantly associated with ARR during TAVR. Conclusions: In addition to excessive oversizing of &amp;gt;20% and annular calcification, a high MLT/RR ratio, a parameter for a combination of small sinus of Valsalva and excessive leaflet calcification, is an independent predictor of ARR or ARH.
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Introduction: Heart transplantation is associated with prolonged survival and improved quality of life in patients with advanced cardiac disease albeit with an increased risk of malignancies due to the use of immunosuppressant... more
Introduction: Heart transplantation is associated with prolonged survival and improved quality of life in patients with advanced cardiac disease albeit with an increased risk of malignancies due to the use of immunosuppressant medications. Our study aimed to determine the types and trends of in patients’ hospitalization for malignancies among heart transplant patients. Methods: We queried the 2005 to 2014 National Inpatient Sample(NIS) database to identify all patients with a history of heart transplant (ICD-9 codes V412, 99683) who were hospitalized with a diagnosis of cancer. The main outcome was the trend in cancer admissions. Secondary outcome were inpatient mortality, total charge and length of stay. Cochran’s and Mantel-Haenszel test was used to assess trends of cancer admissions. Adjusted OR were used to compare the incidence of death between the two groups. Results: A total of 36543(weighted national estimate of 177,604) patients were admitted with a history of heart transplantation over the study period, out of which 2347(6.4%) had a diagnosis of a malignancy. Cancer patients were older (Mean age 66±12 Vs. 61.1±18 P-Value &amp;lt;0.001) and were more likely to be male. There was an increasing trend in the rate of cancer admissions over the study period from 60 per 1000 patients in 2005 to 70 per 1000patients in 2014(P-Vale &amp;lt;0.0001). Overall the most prevalent cancer was Non-Hodgkin’s 20.9% followed by lung Cancer 19.1%. ninety-seven patients(4.1%) had a 2 or more cancers. Patients with a diagnosis of cancer were more likely to die while inpatients as compared those without a diagnosis of cancer (6.6% vs. 3.1%, adjusted OR 2.42 95%CI 1.53-3.38 P-value &amp;lt;0.001). Lastly, patients with cancer had an increased total median coast and a longer length of stay(Total charge(39735 vs, 32,035, P value =&amp;lt;0.001 and 5 vs. 4. P-value &amp;lt;0.001). Conclusion: Development of cancer among patients with a history of transplant adds significant morbidity and mortality. Further studies are needed to determine effective ways to reduce morbidity in this patient cohort.
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Introduction: The association between socioeconomic status (SES) and adverse surgical outcomes represents an emerging area of concern. Furthermore, with regard to carotid stenosis, Carotid Artery Stenting (CAS) has been demonstrated to... more
Introduction: The association between socioeconomic status (SES) and adverse surgical outcomes represents an emerging area of concern. Furthermore, with regard to carotid stenosis, Carotid Artery Stenting (CAS) has been demonstrated to pose a greater risk of postoperative complications, such as stroke, than Carotid Endarterectomy (CEA). This study aims to compare the impact of low SES on patients undergoing Carotid Artery Stenting (CAS) versus Carotid Endarterectomy (CEA). Methods: The National Inpatient Sample (NIS) was queried from 2010 to 2015. Patients who underwent CAS and CEA were identified. Patients of the highest and lowest median income quartiles by zip code were selected and compared based on demographics, hospital characteristics, and comorbidities (Charleston Comorbidity Index: CCI). Primary and secondary outcomes were in-hospital mortality and postoperative stroke, respectively. Multivariable analysis was used to determine the effect of SES on in-hospital mortality. Results: 3,516 and 1,909 underwent CAS; 22,852 and 15,547 patients underwent CEA in the low and high SES groups, respectively. Low SES was a significant independent predictor of mortality (OR = 2.07 [1.25-3.53], p = 0.005) for patients who underwent a CEA, but not for those undergoing CAS. CCI and age were strong predictors of mortality for both procedures (CAS odds ratio (OR)(age) 1.05[1.00-1.10] p = 0.05, OR(CCI) 1.45[1.17-1.80] p < 0.001; CEA: OR(age) 1.03[1.01-1.06] p = 0.01, OR(CCI) 1.60[1.45-1.77] p < 0.001). Of secondary outcomes, stroke was strongly associated with CEA, while bleeding was with CAS. [Figure 1]. Conclusions: Low SES is a significant independent predictor of postoperative mortality in patients who underwent CEA, but not CAS. CEA is also associated with a higher incidence of stroke in these patients. These findings suggest that there may be a benefit to a minimally invasive approach (CAS) rather than the present standard of care (CEA), in selected low SES patients.
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Background: An established link exists between acute mental stress and the development of transient endothelial dysfunction (TED) as assessed by brachial artery flow-mediated vasodilation (FMD). Black individuals have a high burden of... more
Background: An established link exists between acute mental stress and the development of transient endothelial dysfunction (TED) as assessed by brachial artery flow-mediated vasodilation (FMD). Black individuals have a high burden of cardiovascular (CV) risk factors and social disadvantages, which may result in adverse vascular responses to stress. We investigated differences in TED with mental stress in Black and non-Black individuals with coronary artery disease (CAD), and whether TED is associated with CV outcomes in both groups. Methods: We enrolled 812 patients with stable CAD between June 2011 and March 2016 and followed them through February 2020. Study participants were subjected to a public-speaking mental stress task and FMD (derived from % vasodilation with brachial artery hyperemia testing) was assessed by ultrasound before and 30 minutes after mental stress. TED was defined as a lower post-stress FMD than pre-stress FMD. We compared pre-stress FMD, post-stress FMD, and TED between Black and non-Black participants. In both groups, we examined the association of TED with an adjudicated composite end point of CV death and myocardial infarction (MI) after adjusting for demographic, clinical, and socioeconomic factors. Both first and recurring events were counted and multivariable models for repeated events were used for analysis. Results: The mean (SD) age was 59 (10) years, and 328 (40%) were Black. Pre-stress FMD was lower in Black than non-Black participants [3.7 (2.8) vs. 4.9 (3.8) p<0.001], and significantly declined with mental stress in both groups. TED occurred more often in Black (76%) than non-Black patients (67%), age- and sex-adjusted OR, 1.6, 95% CI, 1.4-1.7). Race related differences in TED persisted after adjustment for demographic factors, CAD risk factors and medications (Black vs. non-Black OR, 1.6, 95% CI, 1.5-1.7). After further adjusting for socioeconomic indicators (education, income, and employment status), TED remained elevated in Black patients (OR, 1.4 (95% CI, 1.3-1.6). Over a median (interquartile range) follow-up period of 75 (65-82) months, 142 (18%) patients had at least one event. Development of TED with mental stress was associated with an increased risk for the study outcome both in Black (age- and sex-adjusted HR, 3.0; 95% CI, 1.3-6.8) and non-Black participants (HR, 1.7, 95% CI, 0.96-3.0), p=0.26 for interaction. Adjustment for demographic, clinical and socioeconomic factors did not diminish these associations. Conclusions: Among CAD patients, Black individuals are more likely than non-Black individuals to develop endothelial dysfunction with mental stress, which in turn is associated with an increased risk of adverse cardiovascular events. Endothelial dysfunction in response to psychological stress may represent an important mechanism for the disproportionate risk of adverse CV outcomes in Black patients.
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The impact of atrial fibrillation (AF) on the hospitalization outcomes in patients ≥ 60 years of age with implantable cardioverter defibrillators (ICD) is not well studied. We queried the National Inpatient Sample database for all... more
The impact of atrial fibrillation (AF) on the hospitalization outcomes in patients ≥ 60 years of age with implantable cardioverter defibrillators (ICD) is not well studied. We queried the National Inpatient Sample database for all patients aged ≥ 60 who had a history of ICD placement, and were admitted with a primary diagnosis of heart failure (HF) during the years 2016-2017. Patients were stratified into 2 groups based on their history of AF. The primary outcome of the study was all-cause in-hospital mortality. Secondary outcomes included cardiogenic shock, myocardial infarction (MI), ventricular fibrillation (VF), stroke and acute kidney injury (AKI). The association between different age strata and outcomes was investigated. The hospitalization outcomes were modeled using logistic regression. A total of 178,045 patients were included, of whom 56.2% had AF. AF correlated with increased mortality (A-OR 1.22 (95% CI: 1.06-1.4), p=0.005), cardiogenic shock (A-OR 1.21 (95%CI: 1.08-1.36), p<0.001), AKI (A-OR 1.12 (95%CI: 1.06-1.17), p<0.001 and lower risk for MI (A-OR 0.79 (95% CI: 0.68-0.9), p<0.001. There was no correlation between AF and risk for VF or stroke. A significant correlation between AF and higher risk for mortality, cardiogenic shock and AKI was demonstrated in ages ≤ 75, ≤ 75, and ≤ 80 years, respectively. In contrast, a significant correlation between AF and lower risk for MI is only demonstrated at age > 70 years. We conclude that AF is an independent predictor for increased all-cause in-hospital mortality and cardiogenic shock. Such risk is influenced by age.
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Introduction: Racial disparities in cardiac surgery (CS) are well documented, but socioeconomic status (SES)’s role, independent of race and other factors, requires further study. Our purpose is to investigate effects of low SES on... more
Introduction: Racial disparities in cardiac surgery (CS) are well documented, but socioeconomic status (SES)’s role, independent of race and other factors, requires further study. Our purpose is to investigate effects of low SES on patient outcomes after CS. Methods: National Inpatient Sample 2010-15, was queried. Adult patients undergoing coronary artery bypass grafting (CABG), surgical aortic valve replacement (SAVR), mitral valve repair (MVRR) or replacement (MVRT) were identified. Patient & hospital characteristics, charges, and outcomes of patients in the lowest quartile of income by zip code (low SESP) and highest (high SESP) were compared, per procedure. Multivariable analysis was used to determine effects of SES on outcomes; primary was in-hospital mortality (death). Results: Number of procedures, low v. high SESP: CABG (30,799).
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Purpose The use of temporary mechanical circulatory support (tMCS) as a bridge to transplant (BTT) has increased after the 2018 UNOS heart allocation policy. To understand the influence of these policy changes on sex equity, we examined... more
Purpose The use of temporary mechanical circulatory support (tMCS) as a bridge to transplant (BTT) has increased after the 2018 UNOS heart allocation policy. To understand the influence of these policy changes on sex equity, we examined outcomes based on sex in these high-risk patients. Methods UNOS registry was queried for adults listed for heart transplant (HTx) with a tMCS device (IABP+ ECMO+ percutaneous LVAD+ surgical temporary LVAD) 1-year before and after the October 2018 policy change. We examined association of sex with use of tMCS, time to transplant, waitlist mortality or delisting due to worsening clinical status and 1-year post-transplant survival. Results Of 8,015 patients listed for HTx, 31.8% were women. In the pre-policy change era, 290 of 4,027 (7.2%) were listed with tMCS vs 649 of 3,988 (16.3%) in the post change era (p Conclusion In the current and previous heart allocation policy era, the rate of Women listed for HTx with tMCS appears to be lower compared to Men. The reasons for these inequities of care needs to be further determined. In patients who were listed with tMCS, we did not identify sex differences in waitlist mortality, transplant rates, or survival after transplant.
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OBJECTIVE The MitraClip from Abbott is FDA approved intracardiac implantable device for transcatheter edge-to-edge repair (TEER). Despite a few previously published studies, there is limited safety data for its use in clinical practice,... more
OBJECTIVE The MitraClip from Abbott is FDA approved intracardiac implantable device for transcatheter edge-to-edge repair (TEER). Despite a few previously published studies, there is limited safety data for its use in clinical practice, hence, we designed this study using data obtained from a safety nationwide database to demonstrate the safety profile of MitraClip. METHODS The first two of the five authors independently queried all reported adverse events from the United State Food and Drug Administration [FDA] Manufacturer and User Facility Device Experience [MAUDE] registry from January 2014 to December 2020. The primary end point was trend in reported fatal events obtained from this database. The secondary end points included the causes of reported nonfatal reports from the MAUDE registry. The trend of reported fatal events was assessed using the Cochran Armitage trend test over the period of the study. RESULTS During the study period, subjects included 3370 patients whose MitraClip-associated adverse events were reported and captured by MAUDE registry. Of these, 211 were fatal and 3159 nonfatal events. Fatal event reports resulted deaths and reported nonfatal events were from injuries and device system malfunction. This study demonstrated an initial upward trend from 2014 to 2015 then a subsequent statistically significant downward trend in reported fatal events from 2015 to 2020 (Cochran-Armitage test P = 0.039). The peak proportion of reported fatal events occurred in 2015, (n = 44; representing 1.25% of reported adverse events) and lowest proportion of reported fatal events took place in 2020 (n = 19; representing 0.56% of reported adverse events). The most reported nonfatal events were from malfunctioning of MitraClip system (n = 1170; representing 37% of reported nonfatal events), new unremarkable repolarization abnormalities on periprocedural EKG (n = 864; representing 27% of reported nonfatal events), leaflet rupture (n = 651; representing 21% of reported nonfatal events), and cardiogenic shock (n = 170; representing 5% of reported nonfatal events). CONCLUSIONS This analysis of the MAUDE Registry indicated, especially within the confines of this study's limitations and poor data quality of information, an apparent downward trend of reported fatal events over the study period. Even though conclusive attributions cannot be made regarding this important finding, perhaps, this points to early evidence of a potential institutional or operator learning curve with this device. However, in view of the inferior quality of the data accrued from the MAUDE Registry, more high-precision studies are needed to better understand these changes, as the utility of MitraClip, becomes more established in clinical practice.
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Research Interests: Cardiology, Dialysis, Heart Failure, Humans, Internal Medicine, and 15 moreFemale, Male, Clinical Sciences, Aged, Adult, Continuous Flow, Biological markers, Heart Transplantation, Continuous Flow Heart Assist Devices, Cardiac failure, Confidence Interval, Biochemistry and cell biology, Cohort Studies, Cardiovascular medicine and haematology, and hazard ratio
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Background: To derive and validate a risk score that accurately predicts 1-year mortality after heart transplantation (HT) in patients bridged to transplant (BTT) with a left ventricular assist device (LVAD). Methods: The UNOS database... more
Background: To derive and validate a risk score that accurately predicts 1-year mortality after heart transplantation (HT) in patients bridged to transplant (BTT) with a left ventricular assist device (LVAD). Methods: The UNOS database was queried to identify patients BTT with an LVAD between 2008 and 2018. Patients with ⩾1-year follow up were randomly divided into derivation (70%) and validation (30%) cohorts. The primary endpoint was 1-year mortality. A simple additive risk score was developed based on the odds of 1-year mortality after HT. Risk groups were created, and survival was estimated and compared. Results: A total of 7759 patients were randomly assigned to derivation ( n = 5431) and validation ( n = 2328) cohorts. One-year post-transplant mortality was 9.8% ( n = 760). A 33-point scoring was created from six recipient variables and two donor variables. Risk groups were classified as low (0–5), intermediate (6–10), and high (>10). In the validation cohort, the predicted...
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Objective: Coronary heart disease is a leading cause of death and disability. Although psychological stress has been identified as an important potential contributor, mechanisms by which stress increases risk of heart disease and... more
Objective: Coronary heart disease is a leading cause of death and disability. Although psychological stress has been identified as an important potential contributor, mechanisms by which stress increases risk of heart disease and mortality are not fully understood. The purpose of this study was to assess mechanisms by which stress acts through the brain and heart to confer increased CHD risk. Methods: Coronary Heart Disease patients (N=10) underwent cardiac imaging with [Tc-99m] sestamibi single photon emission tomography at rest and during a public speaking mental stress task. Patients returned for a second day and underwent positron emission tomography imaging of the brain, heart, bone marrow, aorta (indicating inflammation) and subcutaneous adipose tissue, after injection of [18F]2-fluoro-2-deoxyglucose for assessment of glucose uptake followed mental stress. Patients with (N=4) and without (N=6) mental stress-induced myocardial ischemia were compared for glucose uptake in brain,...
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Continuous Flow LVAD(CF-LVAD) are widely used as BTT among patients with Advance Heart Failure. The current study aimed to determine the impact of device related complications on waitlist mortality or delisting due to worsening clinical... more
Continuous Flow LVAD(CF-LVAD) are widely used as BTT among patients with Advance Heart Failure. The current study aimed to determine the impact of device related complications on waitlist mortality or delisting due to worsening clinical conditions. Methods: Patients who were bridged to heart transplant with a continuous flow LVAD (CF-LVAD) between April 2008 and September 2015 were identified from the UNOS heart transplant registry. They were then categorized by the presence or absence of CF-LVAD complications while on the wait list. Cox proportional hazards and Kaplan Meier survival curves were used for time-to-event analysis for the primary outcome. Results: Out of 7070 patients who were bridged to heart transplant, 4434(63%) got transplanted and 2510(36%) developed device related complications while on the waiting list. The primary outcome was present in 1631(23%) patients. Independent predictors of primary outcome were Age (HR/increasing unit: 1.01, 95% CI: 1.01-1.02, p value: &...
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Objectives The aim of this study was to determine the safety and efficacy of same-day discharge (SDD) after transcatheter aortic valve replacement (TAVR) during the COVID-19 pandemic. Background The COVID-19 pandemic has placed... more
Objectives The aim of this study was to determine the safety and efficacy of same-day discharge (SDD) after transcatheter aortic valve replacement (TAVR) during the COVID-19 pandemic. Background The COVID-19 pandemic has placed significant stress on health care systems worldwide. SDD in highly selected TAVR patients can facilitate the provision of essential cardiovascular care while managing competing COVID-19 resource demands. Methods Patient selection for SDD was at the discretion of the local multidisciplinary heart team, across 7 international sites. The primary outcome was a composite of cardiovascular death, stroke, myocardial infarction, all-cause readmission, major vascular complications, and new permanent pacemaker (PPM) implantation. Results From March 2020 to August 2021, 124 of 2,100 patients who underwent elective transfemoral TAVR were selected for SDD. The average age was 78.9 ± 7.8 years, the median Society of Thoracic Surgeons score was 2.4 (IQR: 1.4-4.2), and 32.3% (n = 40) had preexisting PPMs. There were no major vascular complications, strokes, or deaths during the index admission. One patient (0.8%) required PPM implantation for complete heart block and was discharged the same day. No patient required a PPM between discharge home and 30-day follow-up. The composite of cardiovascular death, stroke, myocardial infarction, all-cause readmission, major vascular complications, and new PPM at 30 days occurred in 5.7% patients (n = 6 of 106). Conclusions SDD post-TAVR is safe and feasible in selected patients at low risk for adverse clinical events postdischarge. This strategy may have a potential role in highly selected patients even when the COVID-19 pandemic abates.
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Research Interests: Cardiology, Medicine, Heart Failure, Transplantation, Internal Medicine, and 11 moreLeft Ventricular Assist Device, Etiology, Clinical Sciences, Public health systems and services research, Proportional hazards model, Cardiomyopathy, Heart Transplantation, Cardiac failure, Peripartum Cardiomyopathy, Cardiovascular medicine and haematology, and hazard ratio
OBJECTIVES To assess the safety and efficacy of the Amplatzer Septal Occluder in the closure of secundum type atrial septal defects. BACKGROUND The Amplatzer Septal Occluder (ASO; Abbott, St. Paul, MN) is an FDA-approved device for... more
OBJECTIVES To assess the safety and efficacy of the Amplatzer Septal Occluder in the closure of secundum type atrial septal defects. BACKGROUND The Amplatzer Septal Occluder (ASO; Abbott, St. Paul, MN) is an FDA-approved device for percutaneous closure of secundum type atrial septal defects (ASD). Previous small cohort trials have shown a favorable safety and technical efficacy profile. METHODS We conducted a systemic review and meta-analysis of all prospective case series and controlled trials that evaluated the ASO's safety and implant efficacy. The primary endpoint was the technical success rate of implantations. Secondary outcomes included proportions of arrhythmias and embolism specific-adverse events. RESULTS We included a total of 12 studies with 2972 patients. The ratio of device implantation was 2:1 by sex [female: male]. Pooled technical success rate of implantation was 98% (95% CI: 0.968-0.990, P < 0.01). The cumulative adverse event rate was 5.1% (95% CI: 0.035-0.068, P < 0.01), which included arrhythmia and embolism specific adverse event rates of 1.8% (95% CI: 0.007-0.032, P < 0.01) and 0.7% (95% CI: 0.002-0.013, P < 0.01), respectively. Sensitivity analysis did not significantly affect pooled outcomes for success rate and adverse events; both forest plot and Begg's and Egger's regression tests supported symmetricity. CONCLUSION A high likelihood of technical success can be expected when implanting the ASO in secundum type ASDs. Adverse event rates are expected for one in twenty patients, and thus, our results support the safe use of ASO in secundum type ASDs closure. CONDENSED ABSTRACT The AMPLATZER Septal Occluder is an FDA-approved device for percutaneous closure of secundum type atrial septal defects (ASD). We conducted a systemic review and meta-analysis of all prospective case series and controlled trials that evaluated the ASO's safety and implant efficacy. We included a total of 12 studies with 2972 patients. Pooled technical success rate of implantation was 98% (P < 0.01). The cumulative adverse event rate was 5.1% (P < 0.01), 1.8% (P < 0.01) rate of arrhythmias, and 0.7% (P < 0.01) rate of embolisms. A high likelihood of technical success can be expected with a low rate of adverse events.
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Background: Intensive blood pressure management is associated with decreased overall incidence of myocardial infarction, stroke and hospitalization for heart failure among non-diabetic patients though with several associated adverse... more
Background: Intensive blood pressure management is associated with decreased overall incidence of myocardial infarction, stroke and hospitalization for heart failure among non-diabetic patients though with several associated adverse events (SAEs). The present study aimed to identify patients who are at increased risk of having adverse events while on the intensive blood pressure therapy. Methods: Data from the SPRINT trial was analyzed. Study participants who were in the intensive arm of the trial were divided into two groups based on the outcome of SAEs as defined per trial protocol. Baseline characteristics of the patients in both groups were compared using chi-square analysis. Logistic regression models were used to determine factors associated with developing a SAE while on the intensive therapy. Results: Out of 4678 patients who received intensive therapy, 1684 (36.0%) were females. The mean ± SD age was 67.9 +/- 9.4 years. The incidence of SAEs was 38.3% (n=1793). On multivari...
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Background: Minority populations are two to three times as likely to die of preventable cardiovascular events. Two main forces behind the challenge in managing hypertension among minority populations are disparities in health and... more
Background: Minority populations are two to three times as likely to die of preventable cardiovascular events. Two main forces behind the challenge in managing hypertension among minority populations are disparities in health and healthcare. Aims: To identify the common health and healthcare disparities (HHD) among hypertensive patients who presented to a community medical center and propose a collaborative alliance for improvement. Methods: Internal medicine residents at the Newark Beth Israel Medical Center utilized a (P: Provider, I: Insurance, F: Food, E: Economic stability, N: Neighborhood, C: Culture and Language, E: Education, S: Social (PI-FENCES) model to identify health and health care disparities in hypertensive patients who presented to the ambulatory and inpatient settings over a 12-week-period. Demographic and baseline clinical characteristics were recorded. The distribution of each of the elements of PI-FENCES was documented and their association with respective demog...
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Introduction: Aortic root rupture or hematoma (ARR or ARH) is a serious complication of transcatheter aortic valve replacement (TAVR). In addition to excessive oversizing (annular area/TAVR stent area) and aortic annular calcification.... more
Introduction: Aortic root rupture or hematoma (ARR or ARH) is a serious complication of transcatheter aortic valve replacement (TAVR). In addition to excessive oversizing (annular area/TAVR stent area) and aortic annular calcification. Hypothesis: We hypothesize that combination of small sinus of Valsalva (SOV) and excessive calcification of aortic leaflets is a significant risk factor for ARR or ARH. Methods: Patients who experienced ARR or ARH during TAVR were selected. A matched cohort who had no complications during the procedure were identified from a prospectively maintained database. Dynamic 4-D cardiac computed tomography was used to assess respective thickness of the three aortic cusps, SOV, annular area, LVOT, and the presence and extent of calcification of the LVOT. The ratio of maximum leaflet thickness (MLT) to residual radius (RR): (SOV diameter - TAVR stent diameter)/2), and TAVR stent oversizing: (TAVR stent area - aortic annular area)/TAVR stent area were calculated...
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By 2030, projections suggest that >8 million adults in the United States will have heart failure (HF).1 Given the enormous morbidity, mortality, and cost associated with this condition, strategies to prevent HF will have the most... more
By 2030, projections suggest that >8 million adults in the United States will have heart failure (HF).1 Given the enormous morbidity, mortality, and cost associated with this condition, strategies to prevent HF will have the most public health impact. The potential for prevention may be particularly impactful for Black Americans, who experience a disproportionate burden of HF, characterized by a younger age at disease onset and a higher burden of hospitalization and death, compared with other raceethnic groups.2– 4 The burden of HF in the Black community is largely driven by the high prevalence of cardiovascular disease (CVD) risk factors, including hypertension, diabetes mellitus, and obesity. However, recent sexand racespecific estimates of the 10year risk of HF from communitybased cohorts demonstrate a greater risk of HF for Black men and women compared with White individuals, regardless of whether the risk factor profile is optimal, intermediate, or high risk.5 Other factors that play a significant role include subclinical left ventricular abnormalities and social determinants of health, although these can be difficult to quantify and integrate into risk prediction tools.4,6 With the introduction of its HF staging system in 2004, the American College of Cardiology (ACC) and the American Heart Association (AHA) intended to place greater emphasis on prevention of HF, by prioritizing the identification of asymptomatic patients with clinical risk factors for HF without (stage A) or with (stage B) evidence of cardiac structural abnormalities, in addition to those with symptomatic HF (stage C or D).7 The prevalence of stage B HF can be difficult to ascertain epidemiologically, because imaging studies or biomarkers are usually obtained to diagnose HF, rather than to prevent HF. In this issue of the Journal of the American Heart Association (JAHA), Vasan et al estimate the prevalence and prognosis of the American College of Cardiology and the American Heart Association HF stages in 1871 middleaged Black participants who underwent routine echocardiography in the Jackson, Mississippi site of the ARIC (Atherosclerosis Risk in Communities) Study.8 The authors hypothesized that, for middleaged Black individuals, the prevalence of stage B HF would be high, and be associated with an increased risk of incident HF as well as non– HFrelated CVD morbidity and mortality.
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Introduction: Spontaneous Coronary Artery Dissection (SCAD) is reported to occur predominantly in young women. Gender differences in the clinical presentation and outcomes of patients with SCAD have not been studied on a population level.... more
Introduction: Spontaneous Coronary Artery Dissection (SCAD) is reported to occur predominantly in young women. Gender differences in the clinical presentation and outcomes of patients with SCAD have not been studied on a population level. We sought to compare the in-hospital outcomes of men and women presenting with acute myocardial infarction (AMI) and SCAD. Methods: We identified patients from the National Inpatient Sample (NIS) between 2005 and 2015 who presented with primary diagnoses of AMI and SCAD. We identified SCAD with ICD-9 code 414.12. A 1:1 propensity-matched cohort was created to examine the outcomes between men and women. Primary endpoint was in-hospital mortality. Secondary endpoints included in-hospital cardiac and non-cardiac complications. Results: Of the 6617 (32017 weighted national estimates) patients with SCAD over the study period, majority were males 3667 (55.4%). Males were younger than females (60.32 yr vs. 61.59 yr) and presented more often with ST-elevat...
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BACKGROUND Surgical aortic valve replacement can be performed either through a minimally invasive (MI) or full sternotomy (FS) approach. The present study compared outcomes of MI versus FS for isolated surgery among patients enrolled in... more
BACKGROUND Surgical aortic valve replacement can be performed either through a minimally invasive (MI) or full sternotomy (FS) approach. The present study compared outcomes of MI versus FS for isolated surgery among patients enrolled in the PARTNER 3 low-risk trial. METHODS Patients with severe, symptomatic aortic stenosis at low surgical risk with anatomy suitable for transfemoral access were eligible for PARTNER 3 enrollment. The primary outcome was the composite endpoint of death, stroke, or rehospitalization (valve-, procedure-, or heart-failure-related) at 1 year. Secondary outcomes included the individual components of the primary endpoint as well as patient-reported health status at 30 days and 1 year. RESULTS In the PARTNER 3 study, 358 patients underwent isolated surgery at 68 centers through an MI (n=107) or FS (n=251) approach (8 patients were converted from MI to FS). Mean age and Society of Thoracic Surgeons score were similar between groups. The Kaplan-Meier estimate of the primary outcome was similar in the MI versus FS groups (16.9% versus 14.9%; hazard ratio [95% CI]: 1.15 [0.66 - 2.03]; P=0.618). There were no significant differences in the 1-year rates of all-cause death (2.8% versus 2.8%), all stroke (1.9% versus 3.6%), or rehospitalization (13.3% versus 10.6%, P > 0.05 for all). Quality of life as assessed by the Kansas City Cardiomyopathy Questionnaire score at 30 days or 1 year was comparable in both groups. CONCLUSIONS For patients at low risk for isolated surgery, MI and FS approaches were associated with similar in-hospital and 1-year outcomes.
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Introduction: Early studies from Wuhan, China have reported an association between blood type and outcomes in COVID-19 infected patients. Conflicting reports in literature have investigated the protective role of blood type O against... more
Introduction: Early studies from Wuhan, China have reported an association between blood type and outcomes in COVID-19 infected patients. Conflicting reports in literature have investigated the protective role of blood type O against worst outcomes associated with COVID-19 infections. Approximately 50% of Black/African Americans (AA) have blood group O. Our study is the only study to date looking at the association between Black/AA and blood type. We aimed to determine the association between blood type and Black/AA patients hospitalized for COVID-19. Methods: We retrospectively reviewed data on patients with known blood type, who were admitted for COVID-19 at a single center between March and April 2020. We excluded other races in our study because only about 2% of the population was Caucasian and 8% representing other races, representing a small subset of patients under study whereas Black/AA represented about 90% of our hospitalized patients. Patients were stratified into 4 group...
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BACKGROUND This study sought to describe a single center's experience with transcatheter mitral valve-in-valve (TM-ViV) implantation. METHODS Consecutive patients who had TM-ViV due to degenerative biological valve prosthesis at a... more
BACKGROUND This study sought to describe a single center's experience with transcatheter mitral valve-in-valve (TM-ViV) implantation. METHODS Consecutive patients who had TM-ViV due to degenerative biological valve prosthesis at a single center during a 4-year period were identified from a prospectively maintained database. Operative outcomes were assessed both in-hospital and at 30 days. The primary outcome was in-hospital mortality. Secondary outcomes included valve function, functional status, and quality of life at follow-up. RESULTS Mean (± standard deviation) patient age was 69 ± 12 years and all patients were high risk for redo surgery (STS risk score, 9.6 ± 6.2%). The primary mechanism of bioprosthetic valve failure was stenosis in 7 patients (47%) and regurgitation in 8 patients (53%). Mean duration between mitral valve replacement (MVR) and transcatheter MVR was 89 months (range, 66-72 months). Failed bioprosthetic valves were replaced with Sapien XT (n = 10; 67%), Sap...
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Background Coagulase negative Staphylococcus (CoNS) bacteremia is a common clinical finding, but is less commonly associated with infective endocarditis (IE). Echocardiography (Echo) is utilized when clinicians suspect the diagnosis of... more
Background Coagulase negative Staphylococcus (CoNS) bacteremia is a common clinical finding, but is less commonly associated with infective endocarditis (IE). Echocardiography (Echo) is utilized when clinicians suspect the diagnosis of IE. We sought to evaluate the utilization and yield of Echo in patients who had 1 or ≥ 2 (+) blood cultures (BC) for CoNS, and correlate Echo results with a diagnosis of IE. Methods A retrospective review in a tertiary care hospital between 2013-2020. Patients with or without cardiac device, who had either 1 or ≥ 2 BC positive for CoNS and who underwent Echo were included. Modified Duke’s (MDC) criteria was used for the diagnosis of IE. Logistic regression was used to examine the association between BC positivity, device existence and the presence of a vegetation on Echo. Results We included 116 patients, median age 58 (41-70) years, 64 (55%) women. Cardiac device was present in 69 (59%): Automated implantable cardioverter defibrillator in 49 (71%), p...
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The purpose of this study is to assess the utility of ambulatory cardiac monitoring (ACM) in detecting delayed advanced conduction abnormalities (DACA) and associated 30‐day mortality.
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Background Patients undergoing transcatheter aortic valve replacement (TAVR) are likely to be discharged to a location other than home. We aimed to determine the association between preoperative risk factors and non-home discharge after... more
Background Patients undergoing transcatheter aortic valve replacement (TAVR) are likely to be discharged to a location other than home. We aimed to determine the association between preoperative risk factors and non-home discharge after TAVR. Methods Patients discharged alive after TAVR at three centers were identified from a prospectively maintained database randomly divided into 80% derivation and 20% validation cohorts. Logistic regression models were fit to identify preoperative factors associated with non-home discharge in the derivation cohort. Multivariable models were developed and a nomogram based risk-scoring system was developed for use in preoperative counseling. Results Between June 2012 and December 2018, a total of 1, 163 patients had TAVR at three centers. Thirty-seven patients who died before discharge were excluded. Of the remaining 1, 126 patients (97%) who were discharged alive, the incidence of non-home discharge was 25.6% (n = 289). The patient population was r...
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Objective We investigated health and healthcare disparities in the treatment of aortic stenosis with transcatheter aortic valve replacement (TAVR) and how they affect resource utilization and costs. Methods We retrospectively reviewed all... more
Objective We investigated health and healthcare disparities in the treatment of aortic stenosis with transcatheter aortic valve replacement (TAVR) and how they affect resource utilization and costs. Methods We retrospectively reviewed all patients who were discharged alive after TAVR between 2012 and 2017 from the National Inpatient Sample. Patients were stratified by race and outcomes investigated were in-hospital complications, total procedural costs, and resource utilization. High resource utilization (HRU) was defined as length of stay (LOS) ≥7 days or discharge to a nonhome location. Multivariable regression models were used to identify predictors of HRU. Results TAVR patients ( N = 29,464) were stratified into Caucasians ( n = 25,691), others ( n = 1,274), Hispanics ( n = 1,267), and African Americans (AA, n = 1,232). More AA and Hispanics had TAVR at urban teaching centers ( P = 0.003) and were less likely to be Medicare beneficiaries ( P < 0.001). Distribution of TAVR pat...
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ObjectiveTo determine utilization and reimbursement trends of coronary revascularization procedures in the US Medicare population from 2000 to 2018.BackgroundUS Medicare population is increasing, and coronary revascularization decreased... more
ObjectiveTo determine utilization and reimbursement trends of coronary revascularization procedures in the US Medicare population from 2000 to 2018.BackgroundUS Medicare population is increasing, and coronary revascularization decreased in the 2000s.MethodsThis is a population‐based, cross sectional study of US Medicare beneficiaries from 2010 to 2018. The Centers for Medicare and Medicaid Services' database was queried for revascularization procedures using the coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) current procedural terminology (CPT) codes. Trends in Medicare enrollees, PCIs, CABGs, and physician reimbursements were analyzed.ResultsTotal utilization and reimbursement decreased for both revascularization procedures. The national CABG and PCI utilization per enrollee has decreased by 40.7% (best fit line: b coefficient, 95% CI; −0.297, −0.358 to −0.235) and 26.4% (best fit line: −0.229, −0.373 to −0.0858), respectively. For CABG, ann...
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Purpose Patients awaiting heart transplant (HTx) with temporary mechanical circulatory support (tMCS) are at high risk of waitlist mortality and are accorded higher priority under the 2018 US adult heart allocation system. To examine the... more
Purpose Patients awaiting heart transplant (HTx) with temporary mechanical circulatory support (tMCS) are at high risk of waitlist mortality and are accorded higher priority under the 2018 US adult heart allocation system. To examine the effect of policy changes on racial equity, we examined outcomes based on race in these high risk patients. Methods UNOS registry was queried for adults listed for heart transplant (HTx) 1-year before and after the October 18, 2018 policy change. We examined association of race with use of tMCS (IABP+ ECMO+ percutaneous LVAD+ surgical temporary LVAD), access to transplant organs within 1-year of listing in the pre- and post-era, and 1-year post-transplant mortality. Results Of 8,015 patients listed for HTx, 62.7 % were White and 37.3% Non-White. In the pre-policy era, 290 of 4,027 (7.2%) were listed with tMCS vs 649 of 3,988 (16.3%) in the post era (p Conclusion In the current allocation policy era, the proportion of non-White patients listed for HTx with tMCS appears to be lower compared to Non-White patients, the reasons for which need to be further elucidated. However, in patients who receive tMCS bridge, waitlist mortality, transplant rate, and 1-year post-transplant survival are similar, regardless of race.
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Background: In rural areas, the distance factor has been identified as key in the utilization of health services. We aim to determine whether distance to an inner-city hospital in Newark, was associated with mortality in patients admitted... more
Background: In rural areas, the distance factor has been identified as key in the utilization of health services. We aim to determine whether distance to an inner-city hospital in Newark, was associated with mortality in patients admitted for COVID-19 during the peak of the pandemic. Methods: Patients who were admitted for COVID-19 at the Newark Beth Israel Medical Center (NBIMC) were stratified into two groups based on distance between the zip codes of their primary residence and the hospital. Baseline demographics, clinical characteristics and in-hospital outcomes were compared between subjects living within a 2-mile radius of the zip code of the hospital [Neighbors] and those living further than 2 miles [Distant]. The primary outcome was in-hospital mortality. Secondary outcomes were admission to the intensive care unit (ICU), length of hospitalization, and discharge disposition. Results: Between March 09 and May 04, 2020, a total of 769 patients were admitted for COVID-19 at NBI...
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Background In general, rates of in-hospital cardiac arrest are reportedly 9 to 10 arrests per 1000 admissions, with survival rates of approximately 20–25%. Data regarding clinical characteristics and outcomes in patients with COVID-19 who... more
Background In general, rates of in-hospital cardiac arrest are reportedly 9 to 10 arrests per 1000 admissions, with survival rates of approximately 20–25%. Data regarding clinical characteristics and outcomes in patients with COVID-19 who received in-hospital CPR (cardiopulmonary resuscitation) are limited. This information can help guide end-of-life care conversations between families and health care workers based on real-world experience. Purpose To observe the outcomes (survival to discharged alive from the hospital) in critically sick COVID-19 patients who experienced in-hospital cardiac arrest. Methods This is a multi-centre institutional review board (IRB) approved retrospective study. The RT-PCR confirmed adult COVID-19 patients consecutively admitted from March 1st to April 30, 2020, were included. Data were extracted manually using the hospital's electronic medical record. The final date of follow-up to monitor clinical outcomes was January 2021. Results A total of 721 ...
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Transfemoral (TF) access for transcatheter aortic valve implantation (TAVI) is the most commonly used site, however its use may be limited by prohibitive peripheral arterial disease. Although a number of alternative access techniques have... more
Transfemoral (TF) access for transcatheter aortic valve implantation (TAVI) is the most commonly used site, however its use may be limited by prohibitive peripheral arterial disease. Although a number of alternative access techniques have been well described, each has been shown to be associated with increased risks when compared to a TF approach. Recently, planned treatment of iliofemoral artery disease using intravascular lithotripsy (IVL) has emerged as a means of preserving TF access. Ipsilateral or contralateral femoral artery access has been routinely used to perform IVL but its use may be limited in certain conditions. Here we describe the novel technique of using percutaneous axillary artery access to perform IVL of iliofemoral artery to facilitate its use for large bore access. We present a 78-year-old high surgical risk female with severe aortic stenosis who was found to have a prior stent in the contralateral iliac artery protruding into the aorta which limited a traditional 'up and over' approach, and thus axillary artery access was used to perform IVL. This is the first case in literature to describe the use of percutaneous axillary access to perform IVL of the iliac and common femoral artery to facilitate TF TAVI. Based on our previous experience we feel this technique holds promise for a routine use when use of other access sites is limited.
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Objective The current study aims to report trends of early discharges and identify associated direct costs using a nationally representative database of real-world data experience. Methods We used nationally weighted data on all patients... more
Objective The current study aims to report trends of early discharges and identify associated direct costs using a nationally representative database of real-world data experience. Methods We used nationally weighted data on all patients who had transfemoral transcatheter aortic valve replacement (TAVR) from 2012 to 2017 and discharged alive from the National Inpatient Sample. Patients were divided into early (discharge ≤3 days of admission) and late discharge. Demographics and clinical characteristics were compared. Trends in early discharge and costs associated with admissions were analyzed over the study period. Results Of the 125,188 patients identified, 59,424 (46.9%) were discharged early. The proportion of early discharge increased from 15% in early 2012 to 68% in late 2017 ( P < 0.001), with the largest increase occurring from 2014 to 2015. Overall, the average cost of TAVR decreased from $58,408 in 2012 to $49,875 in 2017 ( P < 0.001). Compared to late discharge, pati...
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The study investigates the incidence of change in renal function and its impact on survival in renal dysfunction patients who were bridged to heart transplantation with a left ventricular assist device (BTT-LVAD). BTT-LVAD patients with... more
The study investigates the incidence of change in renal function and its impact on survival in renal dysfunction patients who were bridged to heart transplantation with a left ventricular assist device (BTT-LVAD). BTT-LVAD patients with greater than or equal to moderately reduced renal function (estimated glomerular filtration rate [eGFR] ≤ 60 ml/min/1.73 m2) at the time of listing between 2008 and 2018 were identified from a prospectively maintained database of the United Network for Organ Sharing. Patients with a baseline eGFR less than or equal to 15 ml/min/1.73 m2 or on dialysis were excluded. Patients were divided into three groups based on percent change ([Pretransplant eGFR – listing eGFR/listing glomerular filtration rate (GFR)] × 100) in eGFR: Improvement greater than or equal to 10%, no change, decline greater than or equal to 10%, and their operative outcomes were compared. Posttransplant survival was estimated and compared among the three groups with the Kaplan-Meier survival curves and the log-rank test. Cox proportional hazards modeling was used to identify predictors of posttransplant survival. Out of 14,395 LVAD patients, 1,622 (11%) met the inclusion criteria. At the time of transplant, 900 (55%) had reported an improvement in eGFR greater than or equal to 10%, 436 (27%) had no change, and 286 (18%) experienced a decline greater than or equal to 10%. Postoperatively, the incidence of dialysis was higher in the decline than in the unchanged or improved groups (22% vs. 12% vs. 12%; p = 0.002). After a median follow-up of 5 years, there was no difference in posttransplant survival among the stratified groups (improved eGFR: 24.8%, unchanged eGFR: 23.2%, declined eGFR: 20.3%; p = 0.680). On Cox proportional hazard modeling, independent predictors of worse survival were: [hazard ratio: 95% CI; p] history of diabetes (1.43 [1.13–1.81]; p = 0.002) or tobacco use (1.40 [1.11–1.79]; p = 0.005) and ischemic time greater than 4 hours (1.36 [1.03–1.76]; p = 0.027). More than half of the patients with compromised renal function who undergo BTT-LVAD demonstrate an improvement in renal function at the time of transplant. A 10% change in GFR while listed was not associated with worse posttransplant survival.
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Introduction: Racial, gender and lower socioeconomic status have been shown to negatively impact the delivery of care. How this impacts the management of hypertensive crisis (HC) remains unclear. Objective: Identify disparities on... more
Introduction: Racial, gender and lower socioeconomic status have been shown to negatively impact the delivery of care. How this impacts the management of hypertensive crisis (HC) remains unclear. Objective: Identify disparities on admission frequency and length of stay (LOS) among those presenting with HC, as a function of household income. Methods: This is a cross-sectional analysis of 2016 ED visits and supplemental Inpatient data from the Nationwide Emergency Department Sample. Median household income quartiles were established. A multivariable logistic regression model was used to estimate odds of admission in each income quartile. A multivariable linear regression model was used to predict LOS. Results: After applying sample weighting, the total number of ED visits was 33,728 with 25442, 6906, and 1380 visits for hypertensive urgency (HU), emergency (HE) and unspecified crisis, respectively. There were 13191, 8889, 6401, 5247 visits in the (1 st ) lowest, 2 nd , 3 rd and 4 th (...
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A known proportion of patients who are admitted for the novel coronavirus disease 2019 (COVID‐19) requires intensive care unit (ICU) level of care. Prolonged ICU stay is a risk factor for the development of nosocomial candidemia. The... more
A known proportion of patients who are admitted for the novel coronavirus disease 2019 (COVID‐19) requires intensive care unit (ICU) level of care. Prolonged ICU stay is a risk factor for the development of nosocomial candidemia. The current study aimed to investigate the incidence and risk factors associated with the development of nosocomial candidemia among patients admitted to the ICU for COVID‐19. Patients who developed nosocomial candidemia were identified, and their clinical course was reported. A 1:3 case control matching was used to identify non‐candidemia patients who served as controls. 89 patients were admitted to the ICU for COVID‐19 during the study period. The incidence of nosocomial candidemia was 8.9% (n = 8). Case‐control matching identified 24 patients with similar disease severity at the time of ICU admission. Median time to first isolation of yeast was 26 days. Candidemia patients reported longer median ICU stay than controls. (40 vs. 10 days, p = .004). In hosp...
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AimsThis study investigated outcomes after continuous flow left ventricular assist device (CF‐LVAD) implantation as bridge to heart transplantation (BTT) in advanced heart failure patients stratified by race.Methods and... more
AimsThis study investigated outcomes after continuous flow left ventricular assist device (CF‐LVAD) implantation as bridge to heart transplantation (BTT) in advanced heart failure patients stratified by race.Methods and resultsDe‐identified data from the United Network for Organ Sharing database was obtained for all patients who had a CF‐LVAD as BTT from 2008 to 2018. Patients were stratified into four groups on the basis of ethnicity [Caucasian, African American (AA), Hispanic, and others (Asian, Pacific Islanders, and American Indian)]. Outcomes investigated were waitlist mortality or delisting and post‐transplant 5 year survival. Cox proportional hazards modelling was used to identify independent predictors of waitlist mortality or delisting and post‐transplant survival. We used Kaplan–Meier survival curves and the log‐rank test to estimate and compare survival among groups. A total of 14 234 patients who had CF‐LVADs as BTT were identified. Of these, 64% (n = 9058) were Caucasia...
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We sought to evaluate the effect of tocilizumab (TCB), a recombinant humanized monoclonal antibody against soluble interleukin‐6 receptors, in patients hospitalized for coronavirus disease 2019 (COVID‐19).
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BackgroundPatients with human immunodeficiency virus (HIV) infection may be at an increased risk for morbidity and mortality from the coronavirus disease 2019 (COVID‐19). We present the clinical outcomes of HIV patients hospitalized for... more
BackgroundPatients with human immunodeficiency virus (HIV) infection may be at an increased risk for morbidity and mortality from the coronavirus disease 2019 (COVID‐19). We present the clinical outcomes of HIV patients hospitalized for COVID‐19 in a matched comparison with historical controls.MethodsWe conducted a retrospective cohort study of HIV patients admitted for COVID‐19 between March 2020 and April 2020 to Newark Beth Israel Medical Center. Data on baseline clinical characteristics and hospital course were documented and compared with that of a matched control group of COVID‐19 patients who had no history of HIV. Kaplan–Meier survival curves and the log‐rank tests were used to estimate and compare in‐hospital survival between both unmatched and matched groups.ResultsTwenty‐three patients with HIV were hospitalized with COVID‐19. The median age was 59 years. The rates of in‐hospital death, the need for mechanical ventilation, and intensive care unit (ICU) admission were 13% ...
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Introduction: Frailty is an important predictor of clinical outcomes, but its contribution to resource utilization remains understudied. This study investigates the impact of frailty on high resource utilization (HRU) in patients... more
Introduction: Frailty is an important predictor of clinical outcomes, but its contribution to resource utilization remains understudied. This study investigates the impact of frailty on high resource utilization (HRU) in patients undergoing Coronary Artery Bypass Graft Surgery (CABG). Methods: We reviewed data on patients who underwent CABG at a single center between 04/2018 and 12/2019. A Frailty score (FS) was calculated using the Essential Frailty Toolset (EFT). Patients were divided into two groups: Frail (FS ≥ 3/5) & Non-Frail (FS <3/5). Baseline clinical characteristics and outcomes were compared in both groups. The primary outcome was HRU (post-operative length of stay > 7 days or readmission within 30-days). Secondary outcomes included operative time, prolonged ventilation, & direct procedure costs. Multivariable logistic regression was used to assess the effect of frailty on HRU. Results: The study included 740 patients of whom 18% (n=132) were frail. Compared to Non-...
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This study compares the postoperative outcomes, 30‐day readmission rates, and incidence of sternal wound infection‐related readmissions between patients receiving bilateral internal mammary arteries (BIMA) and single internal mammary... more
This study compares the postoperative outcomes, 30‐day readmission rates, and incidence of sternal wound infection‐related readmissions between patients receiving bilateral internal mammary arteries (BIMA) and single internal mammary artery (SIMA) grafting during coronary artery bypass graft (CABG) surgery.
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BackgroundThe purpose of this study is to report the clinical features and outcomes of Black/African American (AA) and Latino Hispanic patients with Coronavirus disease 2019 (COVID-19) hospitalized in an inter-city hospital in the state... more
BackgroundThe purpose of this study is to report the clinical features and outcomes of Black/African American (AA) and Latino Hispanic patients with Coronavirus disease 2019 (COVID-19) hospitalized in an inter-city hospital in the state of New Jersey.MethodsThis is a retrospective cohort study of AA and Latino Hispanic patients with COVID-19 admitted to a 665-bed quaternary care, teaching hospital located in Newark, New Jersey. The study included patients who had completed hospitalization between March 10, 2020, and April 10, 2020. We reviewed demographics, socioeconomic variables and incidence of in-hospital mortality and morbidity. Logistic regression was used to identify predictor of in-hospital death.ResultsOut of 416 patients, 251 (60%) had completed hospitalization as of April 10, 2020. The incidence of In-hospital mortality was 38.6% (n = 97). Most common symptoms at initial presentation were dyspnea 39% (n = 162) followed by cough 38%(n = 156) and fever 34% (n = 143). Patien...
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Background. The prevalence of peripheral vascular disease has led to the re-emergence of percutaneous axillary vascular access as a suitable alternative access site to femoral artery. We sought to investigate the efficacy and safety of... more
Background. The prevalence of peripheral vascular disease has led to the re-emergence of percutaneous axillary vascular access as a suitable alternative access site to femoral artery. We sought to investigate the efficacy and safety of manual hemostasis in the axillary artery. Methods. Data were collected from a prospective internal registry of patients who had a Maquet® (Rastatt, Germany) Mega 50 cc intra-aortic balloon pumps (IABP) placed in the axillary artery position. They were anticoagulated with weight-based intravenous heparin to maintain an activated partial thromboplastin time (aPTT) of 50–80 seconds. Anticoagulation was discontinued 2 hours prior to the device explantation. Manual compression was used to achieve the hemostasis of the axillary artery. Vascular and bleeding complications attributable to manual hemostasis were classified based on the Valve Academic Research Consortium-2 (VARC-2) and Bleeding Academic Research Consortium-2 (BARC-2) classifications, respective...
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PURPOSE There is marked variability in the behavior of different transplant centers regarding utilization of ex vivo lung perfusion (EVLP) for donation after circulatory death (DCD) lung donors. While interest in utilization of DCD lungs... more
PURPOSE There is marked variability in the behavior of different transplant centers regarding utilization of ex vivo lung perfusion (EVLP) for donation after circulatory death (DCD) lung donors. While interest in utilization of DCD lungs is growing as a means to expand the lung donor pool, the utility and indications for EVLP of DCD lungs is not well defined. Our objectives were to determine the baseline differences between DCD lungs that received EVLP and those that did not as well as the effect of EVLP on survival following DCD LTx. METHODS Using the United Network for Organ Sharing (UNOS) database, we retrospectively reviewed all adult patients undergoing first-time isolated LTx between 2015 and 2017. Chi-squared tests and Wilcoxon-Mann-Whitney tests were used to investigate the differences in baseline characteristics between DCD and EVLP-DCD donors. Survival of DCD and EVLP-DCD transplants was analyzed using Kaplan Meier curves with a log rank test and a Cox proportional hazards model. RESULTS A total of 5,866 patients met inclusion criteria and 218 (3.7%) LTx recipients received a DCD LTx. Of those receiving DCD lungs, 30 (13.7%) underwent EVLP prior to transplantation. Centers performing DCD LTx utilized EVLP-DCD with great variability; EVLP-DCD rates ranged from 0%-53.8% by center. Compared to DCD donors without EVLP, EVLP-DCD donors did not differ significantly by cause of death, age, gender, history of cigarette use, or PaO2/FiO2 ratio (Figure A). Recipients of EVLP-DCD lungs had equivalent survival to those who received DCD lungs as well as non-DCD lungs (Figure B). CONCLUSION DCD donation alone should not be an indication for EVLP. DCD and EVLP-DCD lungs were nearly identical in terms of donor lung characteristics including PaO2/FiO2 ratio. DCD donor lungs, which provide equivalent survival to conventional LTx, should undergo EVLP selectively.
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This study sought to determine predictors of advanced conduction disturbances requiring late (≥ 30-days) permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR). A prospectively maintained TAVR database... more
This study sought to determine predictors of advanced conduction disturbances requiring late (≥ 30-days) permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR). A prospectively maintained TAVR database was queried to identify all patients who had TAVR at a high
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This study aims to investigate the association between social behaviors of increased‐risk donors (IRD) and recipient outcomes after heart transplantation.
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The present study is a sub-analysis of the Systolic Blood Pressure Intervention Trial (SPRINT) that aimed to evaluate the role of intensive vs. standard hypertensive treatment on cardiovascular outcomes according to the body mass indices... more
The present study is a sub-analysis of the Systolic Blood Pressure Intervention Trial (SPRINT) that aimed to evaluate the role of intensive vs. standard hypertensive treatment on cardiovascular outcomes according to the body mass indices of trial participants. SPRINT participants were categorized according to their baseline BMI values into normal (BMI ≥ 18.5 to <25), overweight (BMI ≥ 25 to <30), and obese (BMI ≥ 30) groups. The primary cardiovascular outcome was a composite of myocardial infarction, acute coronary syndrome not resulting in myocardial infarction, stroke, acute decompensated heart failure, or death from cardiovascular cause. Cox regression analysis was used to calculate hazard ratios for the study outcome in intensive and standard BP treatment among those with varying BMI. Among 9237 participants with, 1682, 3599, and 3956 were normal, overweight and obese, respectively. After a median follow-up of 3.26 years, the hazard ratios for the primary endpoint were 0.82 (95% CI 0.58, 1.16), 0.71 (95% CI 0.54, 0.94), and 0.76 (95% CI 0.59, 0.98) for the normal, overweight, and obese participants, respectively ( P value for interaction 0.79). The effect of intensive versus standard SBP treatment for the other secondary endpoints and serious adverse events were all similar in participants of different BMI (all P -interaction > 0.05). In this sub-analysis of the SPRINT trial, intensive blood pressure control had a beneficial effect in reducing the primary endpoint and all-cause mortality irrespective of the participants’ BMI.
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Objective The transapical (TA) approach is an alternative access technique for transcatheter aortic valve replacement (TAVR) in patients with symptomatic aortic valve stenosis. The impact of prior coronary artery bypass graft (CABG)... more
Objective The transapical (TA) approach is an alternative access technique for transcatheter aortic valve replacement (TAVR) in patients with symptomatic aortic valve stenosis. The impact of prior coronary artery bypass graft (CABG) surgery and how it affects left ventricular function recovery is not well defined. Methods Patients who had TAVR at a single center between June 2012 and December 2016 were reviewed. High-risk patients who underwent the procedure via a TA approach were divided into 2 groups based on their history of CABG surgery. Postoperative outcomes were compared between groups. CABG/TA-TAVR patients were subdivided into 2 per baseline left ventricular ejection fraction (LVEF) <50%. The changes in LVEF and valve function at follow-up (1 to 12 months) were analyzed using paired t-tests. Results Of 923 cases in total, 183 (19.8%) were performed via a TA approach. The mean ± SD Society of Thoracic Surgeons risk score of TA patients was 10.2 ± 4.6. Forty-nine (27%) had...
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The world celebrates over 50 years since the first human-to-human heart transplant. Bibliometric analysis is a statistical concept that has recently evolved, enabling scientists to study citation patterns and identify characteristics of... more
The world celebrates over 50 years since the first human-to-human heart transplant. Bibliometric analysis is a statistical concept that has recently evolved, enabling scientists to study citation patterns and identify characteristics of highly cited scholarly work in different fields. Although it has been widely utilized, such analyses have not been conducted to date on heart transplant literature. We sought to assess the characteristics of the top 100 most referenced citations in the field of heart transplantation. We searched the Scopus database (www.scopus.com) to identify all articles relating to heart transplantation. The articles were arranged in descending order from most cited to least cited and selected articles were scrutinized for data extraction. One hundred articles were included in the final list. Of the total 40,660 citations identified, 3,210 (8.0%) were self-citations, which impacted the final rank order. The articles were published in 25 different journals between 1960 and 2013. The most productive 5-year time period was between 2000 and 2005, when 24 of the 100 most cited publications were produced. There was no correlation between the journals&amp;amp;amp;amp;amp;amp;#39; impact factors and the number of articles produced per journal. The presence and type of funding were not associated with the number of citations. Over 85% of first and senior investigators were men. In conclusion, our study highlights key features of the most highly cited scientific literature on heart transplantation and provides insights into trends of published work in this field. Additionally, this work may serve as a useful guide to researchers and funding bodies by highlighting the most prolific areas of cardiac transplant research to date.
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Congenital absence of the left circumflex artery is a rare coronary anomaly with few reported cases in the literature. These patients are usually diagnosed incidentally when they undergo coronary angiography or coronary CT to rule out... more
Congenital absence of the left circumflex artery is a rare coronary anomaly with few reported cases in the literature. These patients are usually diagnosed incidentally when they undergo coronary angiography or coronary CT to rule out underlying coronary artery disease. In this article, we report a case of a 46-year-old man who was incidentally found to have a congenitally absent left circumflex artery with a superdominant right coronary artery after a workup was initiated for frequent premature ventricular contractions and regional wall motion on echocardiogram. A review of the clinical presentation, symptoms, and diagnostic modalities used to diagnose this entity is presented.
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Research Interests: Surgery, Treatment Outcome, Medicine, Heart Failure, Complication, and 15 moreHumans, Female, Male, Risk factors, Clinical Sciences, Aged, Middle Aged, Adult, Proportional hazards model, Retrospective Studies, Risk Factors, Heart Transplantation, Continuous Flow Heart Assist Devices, Postoperative Complications, and Cardiovascular medicine and haematology
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We analyzed the utility of repeated sestambi scans in patients with primary hyperparathyroidism and its effects on operative referral. We carried out a retrospective review of patients with primary hyperparathyroidism who underwent... more
We analyzed the utility of repeated sestambi scans in patients with primary hyperparathyroidism and its effects on operative referral. We carried out a retrospective review of patients with primary hyperparathyroidism who underwent repeated sestambi scans exclusively within our health system between 1996-2015. Patient demographic, presentation, laboratory, imaging, operative, and pathologic data were reviewed. Univariate analysis with JMP Pro v12 was used to identify factors associated with conversion from an initial negative to a subsequent positive scan. After exclusion criteria (including reoperations), we identified 49 patients in whom 59% (n = 29) of subsequent scans remained negative and 41% (n = 20) converted to positive. Factors associated with an initial negative to a subsequent positive scan included classic presentation and second scans with iodine subtraction (P = .04). Nonsurgeons were less likely to order an iodine-subtraction scan (P < .05). Fewer patients with neg...
Research Interests: Radiology, Medicine, Humans, Female, Male, and 15 moreRisk factors, Parathyroid Hormone, Clinical Sciences, Aged, Middle Aged, Single Photon Emission Computed Tomography, Adult, Analysis of Variance, Retrospective Studies, Internal medicine Doppler ultrasonography, Risk Factors, Primary hyperparathyroidism, Sensitivity and Specificity, Cohort Studies, and Parathyroidectomy
The management of disappearing colorectal liver metastases in the postadjuvant chemotherapy setting is challenging. We describe a novel technique that facilitates laparoscopic resection of disappearing metastatic liver lesions with great... more
The management of disappearing colorectal liver metastases in the postadjuvant chemotherapy setting is challenging. We describe a novel technique that facilitates laparoscopic resection of disappearing metastatic liver lesions with great precision. Details of this new technique are described in 2 patients with colorectal cancer synchronously metastatic to the liver. Both patients had small indistinct intraparenchymal liver lesions after adjuvant chemotherapy. A video displays the steps of the procedure. Both patients presented with colorectal cancer with synchronous liver metastasis. They received FOLFOX regimen after resection of their primary. They both responded to adjuvant chemotherapy. On repeat posttreatment imaging, the liver lesions became smaller and indistinct. With laparoscopic ultrasound, subtle parenchymal heterogeneities were identified. The lesions were initially ablated with a wide radiofrequency ablation zone. Then, without removing the needle, the prongs were deplo...
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Intraoperative adjuncts for the localization of parathyroid glands in parathyroid surgery are limited. The aim of this study is to assess the usefulness of indocyanine green (ICG) near-infrared (NIR) fluorescent imaging in patients... more
Intraoperative adjuncts for the localization of parathyroid glands in parathyroid surgery are limited. The aim of this study is to assess the usefulness of indocyanine green (ICG) near-infrared (NIR) fluorescent imaging in patients undergoing surgery for primary hyperparathyroidism (PHPT). ICG imaging was performed in 33 patients undergoing parathyroidectomy (PTX). Thyroid and parathyroid ICG uptake were assessed and independently verified on a grading scale. Clinical variables were recorded and analyzed for factors associated with ICG uptake. Of 112 glands identified by naked eye, 104 (92.9%) demonstrated ICG uptake. Concomitant ICG fluorescence was identified in the thyroid in all patients. There was a trend toward increased ICG fluorescence in patients <60 years of age (P = 0.05). A higher degree of fluorescence was seen in patients presenting with pre-operative calcium values >11 mg/dl (P = 0.04) and in those parathyroids larger than 10 mm (P < 0.01). All patients had b...
Research Interests: Treatment Outcome, Surgical Oncology, Medicine, Thyroid, Optical Imaging, and 14 moreProspective studies, Humans, Thyroid gland, Near Infrared Spectroscopy, Female, Male, Middle Aged, Adult, Parathyroid Gland, Primary hyperparathyroidism, Hypoparathyroidism, Parathyroidectomy, Indocyanine green, and fluorescent dyes
There are limited adjuncts available for identifying and assessing the viability of parathyroid glands (PGs) during total thyroidectomy (TT). The aim of this study is to determine the feasibility of indocyanine green (ICG) imaging in... more
There are limited adjuncts available for identifying and assessing the viability of parathyroid glands (PGs) during total thyroidectomy (TT). The aim of this study is to determine the feasibility of indocyanine green (ICG) imaging in identifying and assessing perfusion of PGs during TT. ICG was administered in patients undergoing TT and fluorescence of PGs was assessed. A grading scale was developed for assessing degree of ICG uptake. Patients were evaluated for hypocalcemia and hypoparathyroidism on post-operative day (POD) #1. Twenty-seven patients underwent TT with ICG imaging for multinodular goiter (n = 13), thyroid cancer (n = 10), and Graves' disease (n = 4). Eight-five PGs were identified visually, 71 (84%) of which showed ICG fluorescence. False negative rate was 6%. Post-operatively, three patients (11%) had a serum calcium value <8 mg/dl. ICG uptake after TT correlated with post-operative PTH levels: mean POD#1 PTH of those patients with at least two PGs exhibiting...
Research Interests: Dentistry, Surgical Oncology, Medicine, Optical Imaging, Prospective studies, and 14 moreHumans, Female, Feasibility Studies, Male, Perfusion, Clinical Sciences, Adult, Thyroid Diseases, Thyroidectomy, Hypoparathyroidism, Postoperative Complications, Indocyanine green, fluorescent dyes, and Intraoperative Care
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Abstract Introduction: Recently, indocyanine green fluorescence imaging (ICG-FI) using an intravenous technique has been described for various procedures, such as cholecystectomy, liver surgery, an...
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There are scant data regarding oncologic outcomes of laparoscopic liver resection (LLR). The aim of this study is to analyze the oncologic outcomes of LLR for malignant liver tumors (MLT). This was a prospective IRB-approved study of 123... more
There are scant data regarding oncologic outcomes of laparoscopic liver resection (LLR). The aim of this study is to analyze the oncologic outcomes of LLR for malignant liver tumors (MLT). This was a prospective IRB-approved study of 123 patients with MLT undergoing LLR. Kaplan-Meier disease-free (DFS) and overall survival (OS) was calculated. Tumor type was colorectal in 61%, hepatocellular cancer in 21%, neuroendocrine in 5% and others in 13%. Mean tumor size was 3.2 ± 1.9 cm and number of tumors 1.6 ± 1.2. A wedge resection or segmentectomy was performed in 63.4%, bisegmentectomy in 24.4%, and hemihepatectomy in 12.2%. Procedures were totally laparoscopic in 67% and hand-assisted in 33%. Operative time was 235.2 ± 94.3 min, and conversion rate 7.3%. An R0 resection was achieved in 90% of patients and 94% of tumors. Median hospital stay was 3 days. Morbidity was 22% and mortality 0.8%. For patients with colorectal liver metastasis, DFS and OS at 2 years was 47% and 88%, respective...
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Recent advances in technology and the need to decrease surgical morbidity have led a rapid progress in laparoscopic adrenalectomy (LA) over the past decade. Robotics is attractive to the surgeon owing to the 3-dimensional image quality,... more
Recent advances in technology and the need to decrease surgical morbidity have led a rapid progress in laparoscopic adrenalectomy (LA) over the past decade. Robotics is attractive to the surgeon owing to the 3-dimensional image quality, articulating instruments, and stable surgical platform. The safety and efficacy of robotic adrenalectomy (RA) have been demonstrated by several reports. In addition, RA has been shown to provide similar outcomes compared to LA. Development of adrenal surgery has involved the description of several surgical approaches including the anterior transperitoneal, lateral transperitoneal (LT) and posterior retroperitoneal (PR). Among these, the most frequently preferred technique is LT adrenalectomy, primarily due to the surgeon's familiarity of the operative field, wider working space and visibility. The LT technique is suitable for the resection of larger, unilateral tumors and in scenarios where conversion to an open transperitoneal approach is warran...
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Due to the variations in anatomic location, the identification of parathyroid glands may be challenging. Although there have been advances in preoperative imaging modalities, there is still a need for an accurate intraoperative guidance.... more
Due to the variations in anatomic location, the identification of parathyroid glands may be challenging. Although there have been advances in preoperative imaging modalities, there is still a need for an accurate intraoperative guidance. Indocyanine green (ICG) is a new agent that has been used for intraoperative fluorescence imaging in a number of general surgical procedures. Its utility for parathyroid localization in humans has not been reported in the literature. We report 3 patients who underwent reoperative neck surgery for primary hyperparathyroidism. Using a video-assisted technique with intraoperative ICG fluorescence imaging, the parathyroid glands were recognized and removed successfully in all cases. Surrounding soft tissue structures remained nonfluorescent, and could be distinguished from the parathyroid glands. This report suggests a potential utility of ICG imaging in intraoperative localization of parathyroid glands in reoperative neck surgery. Future work is necess...
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Arterial stiffness (AS) and coronary artery calcification (CAC) are predictors of cardiovascular risk and can be measured noninvasively. The aim of this study was to analyze the effects of parathyroidectomy on AS and CAC in patients with... more
Arterial stiffness (AS) and coronary artery calcification (CAC) are predictors of cardiovascular risk and can be measured noninvasively. The aim of this study was to analyze the effects of parathyroidectomy on AS and CAC in patients with primary hyperparathyroidism (PHP). This prospective, institutional review board-approved study included 21 patients with PHP, who underwent parathyroidectomy. Before and 6 months after parathyroidectomy, AS was assessed by measuring central systolic pressure (CSP), central pulse pressure, augmentation pressure (AP), and augmentation index (AIx); the CAC score (Agatston) was calculated on noncontrast computed tomography. AS parameters were compared with unaffected controls from donor nephrectomy database. Preoperative CSP and AIx parameters in PHP patients were higher than those in donor nephrectomy patients (P = .004 and P = .039, respectively). Preoperative total CAC score was zero in 15 patients (65%) and ranged from the 72nd to the 99th percentile in 6 patients (26%). Although there were no changes in CAC or AS after parathyroidectomy on average, there was variability in individual patient responses on AS. This pilot study demonstrates that CAC is not altered in PHP patients at short-term follow-up after parathyroidectomy. The heterogeneous changes in AS after parathyroidectomy warrant further investigation in a larger study with longer follow-up.
Research Interests: Cardiology, Medicine, Prospective studies, Humans, Internal Medicine, and 15 moreBlood Pressure, Female, Male, Arterial stiffness, Clinical Sciences, Aged, Middle Aged, Calcinosis, Adult, Cardiovascular Diseases, Risk Factors, Primary hyperparathyroidism, Coronary Artery Disease, Pilot Projects, and Parathyroidectomy
This study sought to clarify the clinical and echocardiographic prognostic implication of myocardial injury after transcatheter aortic valve replacement (TAVR). The clinical significance of cardiac biomarker elevation after TAVR remains... more
This study sought to clarify the clinical and echocardiographic prognostic implication of myocardial injury after transcatheter aortic valve replacement (TAVR). The clinical significance of cardiac biomarker elevation after TAVR remains unclear. Patients treated with TAVR in the PARTNER (Placement of Aortic Transcatheter Valves) trial were divided into tertiles (T1, T2, T3) based on the difference between the values on post-procedure day 1 and the baseline values of 2 cardiac biomarkers: cardiac troponin I (ΔcTnI); and creatine kinase-myocardial band (ΔCK-MB) fraction. Patients were stratified according to their access route: transfemoral (TF) (n = 1,840) or transapical (TA) (n = 1,173). At 30 days after TF-TAVR, patients in the highest tertile (T3) of cardiac biomarker elevation had a higher rate of all-cause mortality (ΔcTnI: T3: 5.4% vs. T1: 0.5%, p = 0.006; ΔCK-MB: T3: 5.7% vs. T1: 0.9%, p = 0.006) and cardiovascular mortality (ΔcTnI: T3: 4.9% vs. T1: 0.5%, p = 0.01; ΔCK-MB: T3:...
Research Interests: Cardiology, Biomarkers, Medicine, Multivariate Analysis, Humans, and 15 moreInternal Medicine, Hemodynamics, Female, Male, North America, Cardiac Catheterization, Biomarker, Myocardium, Chi Square Distribution, Aortic Valve, Heart Diseases, Femoral Artery, Aortic valve stenosis, Heart Valve Prosthesis Implantation, and Cardiovascular medicine and haematology
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To investigate the feasibility of a method for intraoperative tumor localization and tissue distinction during robotic adrenalectomy (RA) via indocyanine green (ICG) imaging under near-infrared light. Ten patients underwent RA. After... more
To investigate the feasibility of a method for intraoperative tumor localization and tissue distinction during robotic adrenalectomy (RA) via indocyanine green (ICG) imaging under near-infrared light. Ten patients underwent RA. After exposure of the retroperitoneal space, but before adrenal dissection was started, ICG was given intravenously (IV). Fluorescence Firefly™ imaging was performed at 1-, 5-, 10-, and 20-min time points. The precision with which the borders of the adrenal tissue were distinguished with ICG imaging was compared to that with the conventional robotic view. The number and the total volume of injections for each patient were recorded. There were six male and four female patients. Diagnosis was primary hyperaldosteronism in four patients and myelolipoma, adrenocortical neoplasm, adrenocortical hyperplasia, Cushing&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s syndrome, pheochromocytoma, and metastasis in one patient each. Procedures were done through a robotic lateral transabdominal approach in nine and through a robotic posterior retroperitoneal approach in one patient. Dose per injection ranged between 2.5 and 6.3 mg and total dose per patient 7.5-18.8 mg. The adrenal gland took up the dye in 1 min, with contrast between adrenal mass and surrounding retroperitoneal fat becoming most distinguished at 5 min. Fluorescence of adrenal tissue lasted up to 20 min after injection. Overall, ICG imaging was felt to help with the conduct of operation in 8 out of 10 procedures. There were no conversions to open or morbidity. There were no immediate or delayed adverse effects attributable to IV ICG administration. In this pilot study, we demonstrated the feasibility and safety of ICG imaging in a small group of patients undergoing RA. We described a method that enabled an effective fluorescence imaging to localize the adrenal glands and guide dissection. Future research is necessary to study how this imaging affects perioperative outcomes.
Research Interests: Treatment Outcome, Adolescent, Medicine, Optical Imaging, Prospective studies, and 15 moreHumans, Near Infrared Spectroscopy, Female, Feasibility Studies, Male, Clinical Sciences, Aged, Middle Aged, Adult, Pilot Projects, Adrenalectomy, Indocyanine green, fluorescent dyes, surgical endoscopy, and Robotic surgical procedures
Robotic parathyroidectomy has recently been described. Although the procedure eliminates the neck scar, it is technically more demanding than the conventional approaches. This report is a review of the patients’ selection criteria,... more
Robotic parathyroidectomy has recently been described. Although the procedure eliminates the neck scar, it is technically more demanding than the conventional approaches. This report is a review of the patients’ selection criteria, technique, and outcomes. J. Surg. Oncol. 2015; 112:240–242. © 2015 Wiley Periodicals, Inc.
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To describe a robotic technique for posterior retroperitoneal (PR) adrenalectomy. Prospective study. Academic hospital. Twenty-three patients had robotic adrenalectomy within a year. Of these, 8 cases were done using a PR approach.... more
To describe a robotic technique for posterior retroperitoneal (PR) adrenalectomy. Prospective study. Academic hospital. Twenty-three patients had robotic adrenalectomy within a year. Of these, 8 cases were done using a PR approach. Feasibility of the robotic approach, patient and tumor characteristics, operative time, and complications. There were 5 women and 3 men (mean age, 52 years). There were no conversions to laparoscopic or open surgery. Pathology included benign adrenocortical adenoma in 3 patients, aldosteronoma in 2, and pheochromocytoma, subclinical Cushing syndrome, and lymphangioma in 1 patient each. The right and left sides were each involved in 4 patients. The mean (SD) tumor size was 2.9 (1.7) cm. The procedures were done using 3 trocars and 5-mm robotic instruments. The mean (SD) operative time was 214.8 (40.8) minutes; docking time, 21.7 (16.6) minutes; and console time, 97.1 (24.2) minutes. Estimated blood loss was 24 (35) mL. All patients were discharged to home in 24 hours. There were no complications. Subjectively, the dissection was felt to be easier with the robotic technique compared with the laparoscopic approach owing to the improved dexterity of the instruments. To our knowledge, this is the first article describing robotic PR adrenalectomy, and we have demonstrated the technique to be feasible and safe. Owing to the limitations of a conventional laparoscopic PR approach, we believe that use of the robot is a refinement of the technique.