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Gangireddy S.R.,Mount Sinai School of Medicine | Halperin J.L.,Mount Sinai School of Medicine | Halperin J.L.,Zena And Michael A Wiener Cardiovascular Institute | Fuster V.,Mount Sinai School of Medicine | And 3 more authors.
European Heart Journal | Year: 2012

AimsThe PROTECT-AF (WATCHMAN Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) trial found left atrial appendage (LAA) closure an alternative to anticoagulation in selected patients with non-valvular atrial fibrillation (AF). We aim to estimate the net clinical benefit (NCB) of percutaneous LAA closure.Methods and resultsPost hoc analysis of outcomes among 707 adults with AF in the PROTECT-AF trial and 566 in the Continued Access (CAP) registry undergoing LAA closure with the Watchman device compared with sustained anticoagulation. Outcomes were ischaemic stroke, intracranial haemorrhage, major bleeding, pericardial effusion, and death, weighted to reflect the relative impact in terms of death and disability. Net clinical benefit was calculated as the sum of annualized rates of these outcomes after intervention minus rates on warfarin. The NCB of LAA closure during 1623 person-years follow-up in the trial was 1.73/year (95 CI:-0.54 to 4.39/year) and during 741 patient-years in the registry was 4.97/year (95 CI: 3.07-7.15/year). Among patients with a history of ischaemic stroke, the NCB was greater in the registry (8.68/year, CI: 2.82-14.92/year) than the trial (4.30/year, CI-2.07 to 11.25/year). In the registry, the NCB of LAA closure increased from 2.22/year (CI: 0.27-6.01/year) in patients with CHADS2 scores 1 to 6.12/year (CI: 3.19-8.92/year) in those with scores <2.ConclusionCombining rates of thrombo-embolism, intracranial haemorrhage, major adverse events, and death allows objective comparison of the benefit and risk of device therapy vs. anticoagulation in patients with AF. The NCB of LAA closure is greatest for patients at a higher risk of stroke. © 2012 The Author.


Fuster V.,CSIC - National Center for Metallurgical Research | Fuster V.,Zena And Michael A Wiener Cardiovascular Institute | Kelly B.B.,Institute of Medicine of the National Academies | Vedanthan R.,Zena And Michael A Wiener Cardiovascular Institute
Journal of the American College of Cardiology | Year: 2011

Cardiovascular disease (CVD) is the leading cause of mortality worldwide, with more than 80% of CVD deaths occurring in low- and middle-income countries (LMICs). There have been several calls for action to address the global burden of CVD, but there remains insufficient investment in and implementation of CVD prevention and disease management efforts in LMICs. To catalyze the action needed to control global CVD, the Institute of Medicine recently produced a report, Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. This paper presents a commentary of the Institute of Medicine's report, focusing specifically on the intersectoral nature of intervention approaches required to promote global cardiovascular health. We describe 3 primary domains of intervention to control global CVD: 1) policy approaches; 2) health communication programs; and 3) healthcare delivery interventions. We argue that the intersectoral nature of global CVD interventions should ideally occur at 2 levels: first, all 3 domains of intervention must be activated and engaged simultaneously, rather than only 1 domain at a time; and second, within each domain, a synergistic combination of interventions must be implemented. A diversity of public and private sector actors, representing multiple sectors such as health, agriculture, urban planning, transportation, finance, broadcasting, education, and the food and pharmaceutical industries, will be required to collaborate for policies, programs, and interventions to be optimally aligned. Improved control of global CVD is eminently possible but requires an intersectoral approach involving a diversity of actors and stakeholders. © 2011 American College of Cardiology Foundation.


Kheradvar A.,University of California at Irvine | Assadi R.,Loma Linda University | Falahatpisheh A.,University of California at Irvine | Sengupta P.P.,Zena And Michael A Wiener Cardiovascular Institute
Journal of the American Society of Echocardiography | Year: 2012

Background: Previous experimental models have related transmitral vortex formation to the longitudinal recoil of left ventricle. However, little is known about the relationships among left ventricular (LV) longitudinal relaxation, transmitral filling patterns, and LV vortex formation in clinical settings. The aim of this study was to compare the vortex formation time index among a heterogeneous group of patients with diastolic dysfunction to understand the relationship between transmitral vortex formation and abnormal diastolic filling patterns. Methods: Echocardiographic data from 107 subjects were retrospectively evaluated. The study population was categorized into four groups on the basis of transmitral early and late diastolic Doppler filling patterns as normal (n = 45), impaired relaxation (n = 14), pseudonormal (n = 26), and restrictive (n = 22). Vortex formation time was computed from the governing equations based on transmitral flow and ejection fraction. Results: Differences in vortex formation time index were found to be significant among all the studied groups (P <.0001). The trend of vortex formation during a cardiac cycle was compared in normal hearts and those with diastolic dysfunction. Mitral annular velocity (e′) was found to decrease significantly (P < .0001) in subjects with abnormal transmitral filling patterns compared with normal subjects. The difference in e′ among all the affected groups was not found to be significant (P =.68). Conclusions: The findings of this study suggest that patients with different patterns of transmitral diastolic filling show significant changes in LV vortex formation time despite the absence of significant differences in mitral annulus recoil during diastole. © 2012 by the American Society of Echocardiography.


Dutt D.P.,Zena And Michael A Wiener Cardiovascular Institute | Pinney S.P.,Mount Sinai School of Medicine
Current Opinion in Cardiology | Year: 2014

PURPOSE OF REVIEW: The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) I classification encompasses patients with varying clinical presentations and prognoses. The purpose of this review is to discuss four sub-classifications of cardiogenic shock patients (acute myocardial infarction, acute decompensated heart failure, biventricular failure, and myocarditis), and explore management considerations for these groups, with particular emphasis on strategies for device placement. RECENT FINDINGS: In single-center studies, the use of intra-aortic balloon counterpulsation, percutaneous ventricular assist devices, and extra-corporeal membrane oxygenation (ECMO) has allowed approximately half of cardiogenic shock patients to receive an implantable left ventricular assist device (LVAD) or heart transplant, or experience myocardial recovery. Primary implantation of a durable LVAD in well-selected myocardial infarction shock patients was associated with a 1-year survival of 86% in one small case series. Analysis of a multi-institutional database suggests patients older than 65 years have a lower post-implantation survival compared with younger recipients. SUMMARY: Device selection strategies for INTERMACS I patients are predicated on a patients prognosis, hemodynamic stability, end organ, and neurologic status. Percutaneous assist devices may be preferred for patients with favorable prognoses, ECMO for patients with hemodynamic compromise, and durable mechanical support for patients failing to recover sustainable myocardial function after short-term device use. © 2014 Wolters Kluwer Health.


Chen-Scarabelli C.,University of Michigan | Scarabelli T.M.,Zena And Michael A Wiener Cardiovascular Institute | Ellenbogen K.A.,Virginia Commonwealth University | Halperin J.L.,Zena And Michael A Wiener Cardiovascular Institute
Journal of the American College of Cardiology | Year: 2015

Atrial fibrillation (AF) is the most common clinically significant arrhythmia and conveys an increased risk of stroke, regardless of whether it is symptomatic. Despite multiple studies supporting an association between subclinical atrial tachyarrhythmias (ATs) detected by cardiac implantable electronic devices and increased risk of thromboembolic events, clinical intervention for device-detected AT remains sluggish, with some clinicians delaying treatment and instead opting for continued surveillance for additional or longer episodes. However, the 2014 updated clinical practice guidelines on AF recommend use of the CHA2DS2-VASc stroke risk score for nonvalvular AF, with oral anticoagulation recommended for scores ≥2, regardless of whether AF is paroxysmal, persistent, or permanent. This paper reviews the epidemiology of AF and mechanisms of stroke in AF, and discusses device-detected AF and its clinical implications. © 2015 American College of Cardiology Foundation.


Feig J.E.,Zena And Michael A Wiener Cardiovascular Institute | Feig J.L.,New York University
Frontiers in Physiology | Year: 2012

Atherosclerosis is the number one cause of death in the Western world. It results from the interaction between modified lipoproteins and cells such as macrophages, dendritic cells (DCs), T cells, and other cellular elements present in the arterial wall. This inflammatory process can ultimately lead to the development of complex lesions, or plaques, that protrude into the arterial lumen. Ultimately, plaque rupture and thrombosis can occur leading to the clinical complications of myocardial infarction or stroke. Although each of the cell types plays roles in the pathogenesis of atherosclerosis, the focus of this review will be primarily on the macrophages and DCs. The role of these two cell types in atherosclerosis is discussed, with a particular emphasis on their involvement in atherosclerosis regression. © 2012 Feig and Feig.


Goldwater D.S.,Zena And Michael A Wiener Cardiovascular Institute | Pinney S.P.,Zena And Michael A Wiener Cardiovascular Institute
Clinical Medicine Insights: Cardiology | Year: 2015

There are over 5 million Americans with heart failure (HF), the majority of whom are over age 65. Frailty is a systemic syndrome associated with aging that produces subclinical dysfunction across multiple organ systems and leads to an increased risk for morbidity and mortality. The prevalence of frailty is about 10% in community-dwelling elderly and 20% in those with advanced HF, and increases in both cohorts with age. Yet the relationship between the primary frailty of aging and frailty secondary to HF remains poorly defined. Whether the frailty of these two populations share similar etiolo-gies or exist as separate entities is unknown. Teasing apart potential molecular, cellular, and functional differences between the frailty of aging and that of advanced HF has implications for risk stratification, quality of life, and pharmacological and therapeutic interventions for advanced HF patients. © the authors,publisher and licensee Libertas Academica Limited.


Olin J.W.,Zena And Michael A Wiener Cardiovascular Institute | Sealove B.A.,Zena And Michael A Wiener Cardiovascular Institute
Mayo Clinic Proceedings | Year: 2010

Peripheral artery disease (PAD), which comprises atherosclerosis of the abdominal aorta, iliac, and lower-extremity arteries, is underdiagnosed, undertreated, and poorly understood by the medical community. Patients with PAD may experience a multitude of problems, such as claudication, ischemic rest pain, ischemic ulcerations, repeated hospitalizations, revascularizations, and limb loss. This may lead to a poor quality of life and a high rate of depression. From the standpoint of the limb, the prognosis of patients with PAD is favorable in that the claudication remains stable in 70% to 80% of patients over a 10-year period. However, the rate of myocardial infarction, stroke, and cardiovascular death in patients with both symptomatic and asymptomatic PAD is markedly increased. The ankle brachial index is an excellent screening test for the presence of PAD. Imaging studies (duplex ultrasonography, computed tomographic angiography, magnetic resonance angiography, catheter-based angiography) may provide additional anatomic information if revascularization is planned. The goals of therapy are to improve symptoms and thus quality of life and to decrease the cardiovascular event rate (myocardial infarction, stroke, cardiovascular death). The former is accomplished by establishing a supervised exercise program and administering cilostazol or performing a revascularization procedure if medical therapy is ineffective. A comprehensive program of cardiovascular risk modification (discontinuation of tobacco use and control of lipids, blood pressure, and diabetes) will help to prevent the latter. © 2010 Mayo Foundation for Medical Education and Research.


Feig J.E.,Zena And Michael A Wiener Cardiovascular Institute
Annals of Global Health | Year: 2014

Background: Based on studies that date back to the 1920s, regression and stabilization of atherosclerosis in humans has gone from just a dream to one that is achievable. Review of the literature indicates that the successful attempts at regression generally applied robust measures to improve plasma lipoprotein profiles. Examples include extensive lowering of plasma concentrations of atherogenic apolipoprotein B and enhancement of reverse cholesterol transport from atheromata to the liver. Findings: Possible mechanisms responsible for lesion shrinkage include decreased retention of atherogenic apolipoprotein B within the arterial wall, efflux of cholesterol and other toxic lipids from plaques, emigration of lesional foam cells out of the arterial wall, and influx of healthy phagocytes that remove necrotic debris as well as other components of the plaque. This review will highlight the role key players such as LXR, HDL and CCR7 have in mediating regression. Conclusion: Although much progress has been made, there are many unanswered questions. There is, therefore, a clear need for preclinical and clinical testing of new agents expected to facilitate atherosclerosis regression with the hope that additional mechanistic insights will allow further progress. © 2014 Icahn School of Medicine at Mount Sinai.


Tomey M.I.,Zena And Michael A Wiener Cardiovascular Institute | Kini A.S.,Zena And Michael A Wiener Cardiovascular Institute | Sharma S.K.,Zena And Michael A Wiener Cardiovascular Institute
JACC: Cardiovascular Interventions | Year: 2014

Rotational atherectomy facilitates percutaneous coronary intervention for complex de novo lesions with severe calcification. A strategy of routine rotational atherectomy has not, however, conferred reduction in restenosis or major adverse cardiac events. As it is technically demanding, rotational atherectomy is also uncommon. At this 25-year anniversary since the introduction of rotational atherectomy, we sought to review the current state-of-the-art in rotational atherectomy technique, safety, and efficacy data in the modern era of drug-eluting stents, strategies to prevent and manage complications, including slow-flow/no-reflow and burr entrapment, and appropriate use in the context of the broader evolution in the management of stable ischemic heart disease. Fundamental elements of optimal technique include use of a single burr with burr-to-artery ratio of 0.5 to 0.6-rotational speed of 140,000 to 150,000 rpm, gradual burr advancement using a pecking motion, short ablation runs of 15 to 20 s, and avoidance of decelerations >5,000 rpm. Combined with meticulous technique, optimal antiplatelet therapy, vasodilators, flush solution, and provisional use of atropine, temporary pacing, vasopressors, and mechanical support may prevent slow-flow/no-reflow, which in contemporary series is reported in 0.0% to 2.6% of cases. On the basis of the results of recent large clinical trials, a subset of patients with complex coronary artery disease previously assigned to rotational atherectomy may be directed instead to medical therapy alone or bypass surgery. For patients with de novo severely calcified lesions for which rotational atherectomy remains appropriate, referral centers of excellence are required. © 2014 by the American College of Cardiology Foundation.

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