Ankur Kalra

Remote patient monitoring in chronic heart failure.

Heart failure (HF) poses a significant economic burden on our health-care resources with very high readmission rates. Remote monitoring has a substantial potential to improve the management and outcome of patients with HF. Readmission for decompensated HF is often preceded by a stage of subclinical hemodynamic decompensation, where therapeutic interventions would prevent subsequent clinical decompensation and hospitalization. Various methods of remote patient monitoring include structured telephone support, advanced telemonitoring technologies, remote monitoring of patients with implanted cardiac devices such as pacemakers and defibrillators, and implantable hemodynamic monitors. Current data examining the efficacy of remote monitoring technologies in improving outcomes have shown inconsistent results. Various medicolegal and financial issues need to be addressed before widespread implementation of this exciting technology can take place.

Accreditation and funding for a 24-month advanced interventional cardiology fellowship program: A call-to-action for optimal training of the next generation of interventionalists

Division of Interventional Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts Safety, Quality, Informatics and Leadership Program, Harvard Medical School, Boston, Massachusetts Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts Columbia University/New York-Presbyterian Hospital, New York Cleveland Clinic, Cleveland, Ohio Cedars-Sinai Heart Institute, Los Angeles, California Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas Weill Cornell Medical College, New York

Association Between Hospital Volume and 30-Day Readmissions Following Transcatheter Aortic Valve Replacement

Importance With the approval of transcatheter aortic valve replacement (TAVR) for patients with severe symptomatic aortic stenosis at intermediate surgical risk, TAVR volume is projected to increase exponentially in the United States. The 30-day readmission rate for TAVR was recently reported at 17.9%. The association between institutional TAVR volume and the 30-day readmission metric has not been examined. Objective To assess the association between hospital TAVR volume and 30-day readmission. Design, Setting, and Participants In this observational study, we used the 2014 Nationwide Readmissions Database to identify hospitals with established TAVR programs (performing at least 5 TAVRs in the first quarter of 2014). Based on annual TAVR volume, hospitals were classified as low (<50), medium (≥50 to <100), and high (≥100) volume. Rates, causes, and costs of 30-day readmissions were compared between low-, medium-, and high-volume hospitals. Data were analyzed from November to December 2016. Exposure Transcatheter aortic valve replacement. Main Outcomes and Measures Thirty-day readmissions. Results Of 129 hospitals included in this study, 20 (15.5%) were categorized as low volume, 47 (36.4%) as medium volume, and 62 (48.1%) as high volume. Of 16 252 index TAVR procedures, 663 (4.1%), 3067 (18.9%), and 12 522 (77.0%) were performed at low-, medium-, and high-volume hospitals, respectively. Thirty-day readmission rates were significantly lower in high-volume compared with medium-volume (adjusted odds ratio, 0.76; 95% CI, 0.68-0.85; P < .001) and low-volume (adjusted odds ratio, 0.75; 95% CI, 0.60-0.92; P = .007) hospitals. Noncardiac readmissions were more common in low-volume hospitals (65.6% vs 60.6% in high-volume hospitals), whereas cardiac readmissions were more common in high-volume hospitals (39.4% vs 34.4% in low-volume hospitals). There were no significant differences in length of stay and costs per readmission among the 3 groups (mean [SD], 5.5 [5.0] days vs 5.9 [7.5] days vs 6.0 [5.8] days; P = .74, and

Clinical or Symptomatic Leaflet Thrombosis Following Transcatheter Aortic Valve Replacement: Insights from the U.S. FDA MAUDE Database

13 886 [18 333] vs

Gender disparities in cardiovascular care access and delivery in India: Insights from the American College of Cardiology's PINNACLE India Quality Improvement Program (PIQIP).

14 135 [17 939] vs

New-Generation Coronary Stents: Current Data and Future Directions

13 432 [15 725]; P = .63, respectively). Conclusions and Relevance We report for the first time, to our knowledge, an inverse association between hospital TAVR volume and 30-day readmissions. Lower readmission at higher-volume hospitals was associated with significantly lower cost to the health care system.

Hypertrophic cardiomyopathy in the developing world: focus on India

ABSTRACT Background: Data on clinical or symptomatic leaflet thrombosis after transcatheter aortic valve replacement (TAVR) are limited. Whether clinical leaflet thrombosis has significance beyond peri-TAVR stroke or transient ischemic attacks (TIA) is yet to be elucidated. Methods: Between January 2012 and October 2015, we searched the MAUDE database for all entries with the identifier code, “NPT,” designated by the U.S. FDA to identify TAVR-related adverse events (AEs). Selected entries were searched further for the terms “leaflet,” “central aortic regurgitation,” and “aortic stenosis” to capture all events related to leaflet thrombosis causing structural valve dysfunction (SVD). Presentation of leaflet thrombosis (aortic stenosis or regurgitation or mixed valve lesion), mode of diagnosis (echocardiography, computed tomography, surgical explantation, or autopsy), and timing of presentation after TAVR were recorded. For all AEs of SVD due to leaflet thrombosis, the following outcomes were recorded: stroke or TIA, cardiogenic shock, and death from any cause. Results: A total of 5691 TAVR-related AEs were reported in the MAUDE database. SVD due to leaflet thrombosis was reported in 30 cases. Most cases (n = 18/30, 60.0%, 95% CI 0.41–0.77) occurred in the first year following TAVR. SVD manifested as either aortic stenosis (n = 16/30, 53.3%, 95% CI 0.34–0.72), or regurgitation (n = 7/30, 23.3%, 95% CI 0.10–0.42), or both (n = 4/30, 13.3%, 95% CI 0.04–0.31). Interventions to address leaflet thrombosis included either escalation of antiplatelet or anticoagulant therapy (n = 9/30, 30.0%, 95% CI 0.15–0.49), valve-in-valve TAVR (n = 5/30, 16.7%, 95% CI 0.06–0.35), or surgery (n = 14/30, 46.7%, 95% CI 0.28–0.66), or their combination. Outcome following leaflet thrombosis included stroke/TIA (n = 3/30, 10.0%, 95% CI 0.02–0.27), cardiogenic shock (n = 2/30, 6.7%, 95% CI 0.01–0.22), and death (n = 9/30, 30.0%, 95% CI 0.15–0.49). Conclusion: Clinically manifest leaflet thrombosis was associated with serious manifestations that included stroke, cardiogenic shock, and death.

Diagnosis and Management of Bone Cement Implantation Syndrome: Case Report and Brief Review.

BACKGROUND Limited data are available to assess whether access to and quality of cardiovascular disease (CVD) care are comparable among men and women in India. We analyzed data from the American College of Cardiologys PINNACLE (Practice Innovation and Clinical Excellence) India Quality Improvement Program (PIQIP) to evaluate gender disparities in CVD care delivery. METHODS AND RESULTS Between 2011 and 2015, we collected data on performance measures for patients with coronary artery disease (CAD) (n=14,010), heart failure (HF) (n=11,965) and atrial fibrillation (AF) (n=496) in PIQIP, among 17 participating practices. The total number of women was 31,796 (32.0%). Women had fewer total encounters compared to men during the study interval (mean number of encounters=2.59 vs. 2.82 for women and men, respectively, p≤0.001). Women were significantly younger (48.9years vs. 51.5years, p≤0.01), but had a higher co-morbidity burden compared to men - hypertension (62.0% vs. 45.6%, p≤0.01), diabetes (39.4% vs. 35%, p≤0.01), and hyperlipidemia (3.7% vs. 3.1%, p=0.19). On the contrary, the guideline-directed medication prescriptions were strikingly lower in women with CAD compared to men - aspirin (38% vs. 50.4%, p≤0.001), aspirin or thienopyridine combination (46.9% vs. 57.2%, p≤0.001), and beta-blockers (36.8% vs. 47.8%, p≤0.001). Similarly, among women with ejection fraction ≤40%, the use of guideline-directed medical therapy was significantly lower compared to men for beta-blockers (30.8% vs. 37.0%, p≤0.001), angiotensin-converting enzyme inhibitors (ACE-i) or angiotensin receptor blockers (ARBs) (29.3% vs. 34.9%, p≤0.001), and beta-blockers/ACE-i or ARBs (24.6% vs. 31.0%, p≤0.001). Among patients with atrial fibrillation and CHADS2 score≥2, more women were on oral anticoagulation (19.6% vs. 14.6%, p=0.34), although this was not significantly different, and the overall number of patients with atrial fibrillation was low. CONCLUSIONS Despite a significantly higher co-morbidity burden in women, we found fewer women receiving guideline-directed medical therapy for CVD compared with men. If such disparities are confirmed in the larger Indian population, it is important to find potential causes for, and seek solutions to narrow this gap.

Incidence, predictors and clinical outcomes of residual stenosis after aortic valve-in-valve

Purpose of ReviewDrug-eluting stents are the mainstay in the treatment of coronary artery disease using percutaneous coronary intervention. Innovations developed to overcome the limitations of prior generations of stents include biodegradable polymer stents, drug-eluting stents without a polymer, and bioabsorbable scaffolds. Our review briefly discusses the clinical profiles of first- and second-generation coronary stents, and provides an up-to-date overview of design, technology, and clinical safety and efficacy profiles of newer generation coronary stents discussing the relevant clinical trials in this rapidly evolving area of interventional cardiology.Recent FindingsDrug-eluting stents have previously been shown to be superior to bare metal stents. Second-generation everolimus-eluting stents have proven to have superior outcomes compared with first-generation paclitaxel- and sirolimus-eluting stents, and the second-generation zotarolimus-eluting stents appear to be similar to the everolimus-eluting stents, though with a lesser degree of evidence. Stents with biodegradable polymers have not been shown to be superior to everolimus-eluting stents. Bioabsorbable scaffolds have not demonstrated better outcomes than current standard treatment with second-generation drug-eluting stents but have showed a concerning signal of late and very late stent thrombosis.SummaryEverolimus-eluting stents have the most favorable outcomes in terms of safety as well as efficacy in patients undergoing percutaneous coronary intervention. Newer innovations such as biodegradable polymers and bioabsorbable scaffolds lack clinical data to replace second-generation drug-eluting stents as standard of care.

Overview of Coronary Heart Disease Risk Initiatives in South Asia

Atherosclerotic coronary artery disease (CAD) and peripheral arterial disease are global public health and socio-economic issues associated with important treatment advances that affect millions of lives every year. Hypertrophic cardiomyopathy (HCM), although less common, has also become a treatable form of heart disease with demonstrable reduction in mortality and increased survival,1–4 entering a modern era with the inception of high resolution imaging, widely available genetic testing and counselling, implantable cardioverter defibrillators (ICDs), heart transplant, surgical myectomy, and alcohol septal ablation.4 Much has changed for HCM patients who historically have too often been considered ‘interesting’ or as having an ‘exotic’ disease, making them ideal subjects for research studies, but with prognosis considered largely grim. Effective treatment advances, and recognition that many (if not most) patients affected by HCM may not require major therapeutic interventions, permits a realistic aspiration for normal or extended longevity and good quality of life.1 However, most interest in HCM has resided disproportionately in North America, Europe, portions of Asia (largely Japan), Israel, and Australia. Hence, it is patients in those countries who benefit most from the technological and management advances applicable to HCM. Hypertrophic cardiomyopathy can now be regarded as a global disease, recognized in >50 countries,5 with patients exposed to the intricacies of a wide variety of healthcare systems. This includes countries with developing economies and healthcare which involves many other medical and non-medical priorities that dominate their resources and logistics, and inadvertently direct attention from less common complex genetic heart diseases (such as HCM). In this respect, India can be considered a model of the medical dilemma in which important diseases such as HCM are in danger of being over-run and obscured by the mass of patients with valvular and atherosclerotic CAD, at a time when cardiovascular diseases have …