Satya Shreenivas

Expression of Extracellular Matrix Metalloprotease Inducer in Laryngeal Squamous Cell Carcinoma

Objectives/Hypothesis Head and neck cancer tumor cell invasion is responsible for both local destruction and distant metastasis. Invasion is largely mediated by matrix metalloproteases that are thought to be induced by tumor cell derived extracellular matrix metalloprotease inducer (EMMPRIN) in surrounding fibroblasts. We hypothesize that EMMPRIN is overexpressed in laryngeal cancer.

Distribution and determinants of Doppler-derived diastolic flow indices in African Americans: The Jackson Heart Study (JHS)

OBJECTIVES The objective of this study is to investigate the distribution and determinants of diastolic function in a middle-aged cohort of African Americans (AA). BACKGROUND The distribution and determinants of left ventricular (LV) diastolic function in AA are not well-described despite high rates of AA with diastolic heart failure and a five-fold higher risk of death in those with diastolic dysfunction (DD) compared to normal diastolic function. METHODS Four categories of diastolic function were defined in JHS participants undergoing echocardiograms at the first examination (2001-2004) using mitral and pulmonary vein velocities. Investigators used logistic regression to assess the independent relation of DD to traditional risk factors and LV systolic dysfunction. RESULTS Of the 3,571 study participants (mean age, 56 +/- 12 years; 63.9% female), 70.4% had normal diastolic function, and 18.0%, 10.6%, and 0.9% had mild, moderate, and severe DD, respectively. In the multivariable analysis, DD was significantly related to age (OR 1.2, 95% CI 1.1-1.4), male sex (OR 1.3 CI 1.0-1.5), LV systolic dysfunction (OR 1.5, CI 1.2-2.0), body mass index (OR 0.8, CI 0.8-0.9), and heart rate (OR 1.2; CI 1.1-1.2). The severity of DD was significantly related with age (OR 0.3; CI 0.3, 0.4), male sex (OR 1.6; CI 1.2-2.2), hypertension (OR 0.6, CI 0.4-0.8), and heart rate (OR 0.7; CI 0.6-0.8). CONCLUSION This is the largest community-based analysis of LV diastolic function in middle-aged AA. DD was present in 29.5% and independently related to several traditional risk factors and LV systolic dysfunction.

Mechanical circulatory support as a bridge to transplant or for destination therapy.

Mechanical circulatory support (MCS) frequently is used to treat medically refractory end-stage heart failure. Initially designed to be a bridge to transplantation, MCS also has proven itself as a durable therapy for patients who are not transplant candidates. As outcomes for patients with MCS have improved, research interest in device development has flourished, with many new device types under investigation. In addition to improvement of MCS devices, investigational work continues to achieve appropriate patient selection and complication management.

Development and Validation of Risk Prediction Models for Cardiovascular Events in Black Adults The Jackson Heart Study Cohort

IMPORTANCE Cardiovascular risk assessment is a fundamental component of prevention of cardiovascular disease (CVD). However, commonly used prediction models have been formulated in primarily or exclusively white populations. Whether risk assessment in black adults is dissimilar to that in white adults is uncertain. OBJECTIVES To develop and validate risk prediction models for CVD incidence in black adults, incorporating standard risk factors, biomarkers, and subclinical disease. DESIGN, SETTING, AND PARTICIPANTS The Jackson Heart Study (JHS), a longitudinal community-based study of 5301 black adults in Jackson, Mississippi. Inclusive study dates were the date of a participants first visit (September 2000 to March 2004) to December 31, 2011. The median (75th percentile) follow-up was 9.1 (9.7) years. The dates of the analysis were August 2013 to May 2015. Measurements included standard risk factors, including age, sex, body mass index, systolic and diastolic blood pressure, ratio of fasting total cholesterol to high-density lipoprotein cholesterol, estimated glomerular filtration rate, antihypertensive therapy, diabetes mellitus, and smoking; blood biomarkers; and subclinical disease measures, including ankle-brachial index, carotid intimal-medial thickness, and echocardiographic left ventricular hypertrophy and systolic dysfunction. MAIN OUTCOMES AND MEASURES Incident CVD event was defined as the first occurrence of myocardial infarction, coronary heart disease death, congestive heart failure, stroke, incident angina, or intermittent claudication. Model performance was compared with the American College of Cardiology/American Heart Association (ACC/AHA) CVD risk algorithm and the Framingham Risk Score (FHS) refitted to the JHS data and evaluated in the Atherosclerosis Risk in Communities (ARIC) and Multi-Ethnic Study of Atherosclerosis cohorts. RESULTS The study cohort comprised 3689 participants with mean (SD) age at baseline was 53 (11) years, and 64.8% (n = 2390) were female. Over a median of 9.1 years, 270 participants (166 women) experienced a first CVD event. A simple combination of standard CVD risk factors, B-type natriuretic peptide, and ankle-brachial index (model 6) yielded modest improvement over a model without B-type natriuretic peptide and ankle-brachial index (C statistic, 0.79; 95% CI, 0.75-0.83 [relative integrated discrimination improvement, 0.22; 95% CI, 0.15-0.30]). However, the reclassification improvement was not substantially different between model 6 and the ACC/AHA CVD Pooled Cohort risk equations or between model 6 and the FHS. The models discriminated reasonably well in the ARIC and Multi-Ethnic Study of Atherosclerosis data (C statistic range, 0.70-0.77). CONCLUSIONS AND RELEVANCE Our findings using the JHS data in the present study are valuable because they confirm that current FHS and ACC/AHA risk algorithms work well in black individuals and are not easily improved on. A unique risk calculator for black adults may not be necessary.

Cardiopulmonary bypass and intra‐aortic balloon pump use is associated with higher short and long term mortality after transcatheter aortic valve replacement: A PARTNER trial substudy

Transcatheter aortic valve replacement (TAVR) with the balloon‐expandable Sapien transcatheter heart valve improves survival compared to standard therapy in patients with severe aortic stenosis (AS) and is noninferior to surgical aortic valve replacement (AVR) in patients at high operative risk. Nonetheless, a significant proportion of patients may require pre‐emptive or emergent support with cardiopulmonary bypass (CPB) and/or intra‐aortic balloon pump (IABP) during TAVR due to pre‐existing comorbid conditions or as a result of procedural complications. Objectives: We hypothesized that patients who required CPB or IABP would have increased periprocedural complications and reduced long‐term survival. In addition, we sought to determine whether preprocedural variables could predict the need for CPB and IABP. Methods: The study population included 2,525 patients in the PARTNER Trial (Cohort A and B) and the continuing access registry (CAR). Patients that received CPB or IABP were compared to patients that did not receive either, and then further divided into those that received support pre‐TAVR and those that were placed on support emergently. Results: One‐hundred sixty‐three patients (6.5%) were placed on CPB and/or IABP. The use of CPB or IABP was associated with higher 1 year mortality (49.1% vs. 21.6%, P < 0.001). In multivariable analysis, utilization of CPB or IABP was an independent predictor of 30 day (HR 6.95) and 1‐year (HR 2.56) mortality. Although mortality was highest in emergent cases, mortality was also greater in planned CPB and IABP cases compared with non‐CPB/IABP cases (53.3% and 40.3% vs. 21.6%, P < 0.001). Conclusions: These findings indicate that CPB and IABP use in TAVR portends a poor prognosis and its utilization, particularly in the setting of pre‐emptive use, needs reconsideration.

Complete Spontaneous Left Heart and Aortic Thromboses on Extracorporeal Membrane Oxygenation Support

nosed 3-vessel coronary artery disease and ischemic cardiomyopathy. The patient underwent emergent TandemHeart cannulation (left atrium to femoral artery bypass). A transthoracic echocardiogram revealed worsening biventricular failure without echo dense material or intracardiac thrombosis. Worsening cardiac function and recurrent VT prompted arterial– venous extracorporeal membrane oxygenation with insertion of a Quadrox oxygenator and an additional right atrial cannula. Therapeutic anticoagulation was maintained on intravenous heparin with a partial thromboplastin time of 79.9 seconds. Figure 1. Deep transgastric short-axis view.

How should I treat prosthetic tricuspid stenosis in an extreme surgical risk patient

BACKGROUND A 64-year-old female with rheumatic heart disease and multiple prior valve replacements presented with progressive oedema, ascites and dyspnoea on exertion. INVESTIGATION Physical examination, transthoracic echocardiography, intracardiac echocardiography, transoesophageal echocardiography, right heart cathetherisation, computed tomography. DIAGNOSIS She had a mitral homograft and Physio ring in the tricuspid position, and presented with severe bioprosthetic tricuspid valve stenosis (mean gradient 16 mmHg) and right-sided heart failure. TREATMENT A transcatheter 26 mm Edwards SAPIEN valve was placed in the tricuspid position, resulting in near normalisation of tricuspid valve gradient. This represents the first report of a combined valve-in-ring (VIR) and valve in a homograft valve (VIV) SAPIEN implantation.

Evolution of the SYNERGY bioresorbable polymer metallic coronary stent

The SYNERGY stent is composed of thin, platinum-chromium metal alloy struts and an ultrathin, bioabsorbable poly-DL-lactide-co-glycolide polymer limited to the abluminal strut surface which elutes everolimus prior to complete resorption within 3-4 months. SYNERGY was designed to reduce inflammation and facilitate stent healing compared with permanent polymer drug eluting stents. This review summarizes the preclinical and clinical development of SYNERGY, its integration into clinical practice and future directions.

A Meta-Analysis of Reduced Leaflet Motion for Surgical and Transcatheter Aortic Valves: Relationship to Cerebrovascular Events and Valve Degeneration

BACKGROUND Reduced leaflet motion (RLM) of transcatheter aortic valves (TAV) is observed in up to 4% of cases with similar frequency in surgical valves, with an overall incidence that differs based on prosthesis type and size. This phenomenon likely represents subclinical leaflet thrombosis. Herein we sought to analyze the existing reported literature to assess whether or not RLM is associated with subsequent valve degeneration or cerebrovascular events. METHODS AND RESULTS We searched PubMed, and EMBASE (2008-2017) to identify relevant studies. Studies with <1-year follow-up, studies not evaluating RLM, and/or clinical outcomes were excluded. Our co-primary endpoints were the incidence of cerebrovascular events (stroke and/or transient ischemic attack-TIA) or structural valvular degeneration defined as moderate or greater regurgitation and/or a mean gradient ≥20 mm Hg. The literature search yielded 30 potential studies. Of these, six observational studies with a total population of 1704 patients met our selection criteria. RLM was associated with an increased risk of stroke or TIA (adjusted OR 2.60, 95% CI 1.56 to 4.34, p = 0.004). At one year, RLM was associated with an increased risk of structural valve degeneration (adjusted OR 2.51, 95% CI 1.47 to 4.30, p = 0.006). The association between RLM and clinical endpoints remained even after limiting analysis to transcatheter aortic valve replacement (TAVR) patients only. CONCLUSIONS In patients with bio prosthetic aortic valve, presence of RLM is associated with increased risk of stroke or TIA as well as structural valvular degeneration. These findings support ongoing surveillance efforts and evaluation of pharmacotherapies to address RLM in effort to minimize subsequent clinical events.

Procedure utilization, latency and mortality: Weekend versus Weekday admission for Myocardial Infarction

Procedure utilization, latency and mortality: Weekend versus Weekday admission for Myocardial Infarction Nader Makki3, David M Kline3, Arun Kanmanthareddy1, Hansie Mathelier2, Satya Shreenivas2 and Scott M Lilly2* 1Creighton University School of Medicine, Omaha NE, USA 2Department of Cardiovascular Medicine, Ohio State’s Wexner Medical Center, Columbus, Ohio, USA 3Center for Biostatistics, Department of Biomedical Informatics, the Ohio State University, Columbus, Ohio, USA