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Morristown, NJ, United States

Shames S.,Columbia University | Koczo A.,Columbia University | Hahn R.,Columbia University | Jin Z.,Columbia University | And 2 more authors.
Journal of the American Society of Echocardiography | Year: 2012

Background: The percutaneously implanted Edwards SAPIEN valve (Edwards Lifesciences, Irvine, CA) consists of cusps mounted within a stent. The individual impact of the stent and cusps on transvalvular flow and its implications for the echocardiographic assessment of valve function have not been previously reported. Methods: The study group consisted of 40 patients who underwent successful implantation with the SAPIEN valve. Pulsed Doppler was recorded with sample volumes immediately proximal to the stent (prestent), within the stent but proximal to the cusps (in-stent precusp), and distal to the cusps (in-stent postcusp). The Doppler velocity index and effective orifice area were calculated using both prestent and in-stent precusp velocities to represent "subvalvular" flow and continuous-wave recordings of the left ventricular outflow tract and aortic valve to represent postvalvular flow. Results: In all patients, there was flow acceleration at two levels: in-stent precusp and in-stent postcusp. The mean in-stent precusp peak velocities were significantly higher than the prestent values (1.5 ± 0.2 vs 1.0 ± 0.2 m/sec, P <.0001). Effective orifice area and Doppler velocity index calculated using the prestent versus in-stent precusp velocities were also significantly different (1.79 ± 0.34 vs 2.54 ± 0.46 cm 2, P <.0001, and 0.48 ± 0.12 vs 0.73 ± 0.13, P <.0001, respectively). Conclusions: The SAPIEN valve demonstrates flow acceleration at two levels, representing contributions of both the stent and valve cusps to the total valve gradient. Failure to recognize this phenomenon may result in inappropriate selection of the in-stent precusp pulsed Doppler spectrum to represent "subvalvular" flow, thereby overestimating the effective orifice area and Doppler velocity index. Copyright © 2012 by the American Society of Echocardiography.

Grayburn P.A.,Baylor Heart and Vascular Institute | Carabello B.,Mount Sinai School of Medicine | Hung J.,Massachusetts General Hospital | Gillam L.D.,Morristown Medical Center | And 6 more authors.
Journal of the American College of Cardiology | Year: 2014

Secondary mitral regurgitation (MR) is associated with poor outcomes, but its correction does not reverse the underlying left ventricular (LV) pathology or improve the prognosis. The recently published American Heart Association/American College of Cardiology guidelines on valvular heart disease generated considerable controversy by revising the definition of severe secondary MR from an effective regurgitant orifice area (EROA) of 0.4 to 0.2 cm2, and from a regurgitant volume (RVol) of 60 to 30 ml. This paper reviews hydrodynamic determinants of MR severity, showing that EROA and RVol values associated with severe MR depend on LV volume. This explains disparities in the evidence associating a lower EROA threshold with suboptimal survival. Redefining MR severity purely on EROA or RVol may cause significant clinical problems. As the guidelines emphasize, defining severe MR requires careful integration of all echocardiographic and clinical data, as measurement of EROA is imprecise and poorly reproducible. © 2014 American College of Cardiology Foundation.

Tabrizian P.,Mount Sinai Medical Center | Jibara G.,Brookdales University Hospital and Medical Center | Shrager B.,Morristown Medical Center | Schwartz M.,Mount Sinai Medical Center | Roayaie S.,New Hill
Annals of Surgery | Year: 2015

Objective: We sought to determine the factors associated with survival after recurrence of hepatocellular cancer (HCC) after resection and the outcome of our prospectively applied treatment protocol. Background: Very little is known about the prognosis of HCC that recurs after resection and the outcomes associated with treatments applied to recurrent tumors. Methods: A total of 661 HCC patients undergoing resection from January 1988 to January 2011 were reviewed to identify those with recurrence. Single recurrences with preserved liver function, and no portal hypertension were treated with resection. Patients with multiple intrahepatic tumors or poor liver function and no major comorbidities were listed for transplantation. Patients with up to 3 tumors, each 4 cm or smaller, and not eligible for transplantation, received ablation. Patients not eligible for ablation received embolization. Other treatments such as systemic therapy and radiation were used in remaining patients, but not in a systematic manner. Results: Recurrent HCC developed in 356 (54%) patients at a median time of 22 months from primary resection. Median survival from time of recurrence to death was 21 months. Variables independently associated with survival from recurrence included time from primary resection to recurrence, alpha-fetoprotein more than 100 ng/mL at recurrence, recurrent tumor larger than 3 cm, BCLC stage at recurrence, and type of treatment rendered for the recurrence. All variables except treatment modality were significantly correlated with characteristics of the original primary tumor. Conclusions: Most of the variables associated with outcome after recurrence are linked to the primary tumor at initial presentation. Nevertheless, meaningful survival can be achieved with appropriate treatment of recurrent tumors. © 2014 Wolters Kluwer Health, Inc. All rights reserved.

Slomovitz B.M.,Morristown Medical Center | Slomovitz B.M.,University of Houston | Coleman R.L.,University of Houston
Clinical Cancer Research | Year: 2012

Endometrial cancer is the most common gynecologic malignancy in the United States. Overactivation of the PI3K/AKT/mTOR pathway, a signaling pathway that plays an important role in cellular growth and survival, has recently been implicated in endometrial cancer pathogenesis, and as such, inhibition of the PI3K/AKT/mTOR pathway is of therapeutic interest. Preclinical and clinical studies are proving useful in elucidating the antitumor effects of different PI3K/AKT/mTOR pathway inhibitors, and in defining which patient populations these inhibitors might be most effective in. For example, an increasing amount of preclinical data suggest that loss of PTEN or genetic alteration of PIK3CA may be indicators of sensitivity to PI3K/AKT/mTOR pathway inhibition, while activating KRAS mutations may predict resistance. In the latter case, combined inhibition of the RAS/RAF/MEK and PI3K/AKT/mTOR pathways has been suggested as a therapeutic strategy. In addition, the PI3K/AKT/mTOR pathway has been implicated in conferring resistance to conventional therapies, and so PI3K/AKT/mTOR pathway inhibitors in combination with hormonal and/or cytotoxic agents are being evaluated. In conclusion, preclinical models are providing insights into the antitumor activity of PI3K/AKT/mTOR pathway inhibition, and are helping define patient populations most likely to benefit from these therapies. Clinical validation of these findings is ongoing. ©2012 AACR.

Swayne L.C.,Morristown Medical Center
Journal of the American College of Radiology | Year: 2014

Although radiologists have kept pace with the dramatic growth of medical imaging during the past two decades through the use of PACS, digital dictation, and 3-dimensional reconstruction, radiology is approaching the point of diminishing returns. As reimbursements further decline, attempts to increase radiologists' productivity risk commoditization of the specialty. The continued evolution of US health care policy, however, presents an opportunity for radiologists, using their core competencies, to shape the future direction of medicine. © 2014 American College of Radiology.

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