Papers by Sabahat Bokhari
7 of Cardiac Function
A plethora of methods now exist for the evaluation of ventricular function. Such methods include ... more A plethora of methods now exist for the evaluation of ventricular function. Such methods include radionuclide ventriculography (RVG), contrast ventriculography (CVG), echocardiography, cine-computed tomography (CT), and cardiac magnetic resonance imaging (MRI). For RVG, established methods include firstpass imaging of the left or right ventricles (LV or RV), gated equilibrium imaging, and single photon emission computed tomographic (SPECT) imaging. While all the cardiac imaging methods listed previously may be used to obtain information about ventricular function, an additional advantage of RVG over some methods is its serial repeatability, whether using exercise (planar RVG) or pharmacologic stress. A combination of visual and calculated data is used to evaluate ventricular performance. For this, electrocardiographic QRS information is matched to the imaging data. The ECG QRS complex is detected by a gating circuit that defines the QRS by a rapid change in voltage per unit time (dV...
Journal of Nuclear Cardiology, 2021
In the Introduction SCMR was listed incorrectly. SCMR is the Society for Cardiovascular Magnetic ... more In the Introduction SCMR was listed incorrectly. SCMR is the Society for Cardiovascular Magnetic Resonance. • Figure 1 erroneously printed without Yen sign (¥) in 'Final Diagnosis.' Please see revised Figure 1.
The Journal of Heart and Lung Transplantation, 2020
intimal thickness, intimal area and percentage intimal area. Virtual histology was utilized for p... more intimal thickness, intimal area and percentage intimal area. Virtual histology was utilized for plaque characterization. Results: Forty patients completed evaluation at 4.8 § 5.8 years post-transplant: mean age 56 § 14 years, 31 (78%) male. Angiographic disease was present in 14 (35%) patients: 9 (23%) CAV 1 , 2 (5%) CAV 2 , 3 (8%) CAV 3. Maximal stenosis was greater in the LAD (median 34% (IQR 20, 63) vs. 19% (IQR 0, 29) for LCx, 0% (IQR 0, 18) for RCA, (p=0.001)) and proximal segments (median 17% (IQR 12, 29) vs. 13% (IQR 9, 23) for mid, 12% (IQR 8, 16) for distal segments, p=0.005). A total of 268 segments in 101 vessels (40 left anterior descending (LAD), 35 circumflex (LCx), 26 right coronary artery (RCA)) were analyzed with IVUS. Mean coronary length examined was 64 § 15 mm. Intimal disease on IVUS was greater in the LAD and proximal coronary segments (Table). On virtual histology, plaque composition was predominantly mixed atheromatous fibrotic and more prevalent in the LAD (72%) vs. LCx (54%) and RCA (42%), p=0.043. There was no isolated fibrotic plaque and low 13% prevalence of vulnerable thin cap fibroatheroma plaque. Conclusion: There is heterogeneous distribution of CAV with high disease burden in the LAD and proximal coronary segments. Single-vessel IVUS examination for CAV, beginning in the LAD could avoid risks of multivessel examination.
JCR: Journal of Clinical Rheumatology, 2017
We report a case of coronary artery inflammation in a patient with active rheumatoid arthritis. C... more We report a case of coronary artery inflammation in a patient with active rheumatoid arthritis. Cardiac fluorine-18 fluorodeoxyglucose (F-18 FDG) positron emission tomography (PET) scans were done at baseline and 6 months follow-up as part of a study assessing cardiovascular disease (CVD) in RA patients. At baseline there was significant F-18 FDG uptake in the left main artery (LM) indicative of active inflammation. Post-treatment with step-up RA therapy, 6 months later inflammatory biomarkers of RA decreased in the patient and no F-18 FDG uptake was observed on PET imaging.
Annals of Nuclear Medicine, 2019
Cardiac sarcoidosis is a granulomatous disease that may affect any organ, including the heart. Di... more Cardiac sarcoidosis is a granulomatous disease that may affect any organ, including the heart. Diagnosis of cardiac sarcoidosis is challenging, given the varied and non-specific clinical presentation and limited sensitivity and specificity of available diagnostic tests. With the growing interest and developments in imaging techniques, cardiac magnetic resonance imaging (CMR) and positron emission tomography (PET) have emerged as important tools in the diagnostic evaluation of patients with suspected cardiac sarcoidosis. These modalities have been given increasing emphasis in successive published diagnostic guidelines for CS. This review will provide an update on the recent paradigm shift in diagnostic guidelines for cardiac sarcoidosis, with a focus on the advanced cardiac imaging modalities and their developed role in clinical practice.
Aging, Aortic Stenosis, and Transthyretin Cardiac Amyloidosis
JACC: CardioOncology, 2021
Corresponding Author
Journal of Nuclear Cardiology
Journal of the American College of Cardiology, 2017
The goal of this work is to present the usage possibilities of the evolution algorithms in the mi... more The goal of this work is to present the usage possibilities of the evolution algorithms in the microchip manufacturing. Nowadays, the optical lithography is the standard tool in the production of microelectronic circuits. One of the steps of the process is the illumination of a mask (exposure) where the masks pattern is transferred onto the object surface. The Fraunhofer Institute in Erlangen have developed a simulation program named Simulation of Optical Lithography in three Dimensions (SOLID) in the past few years. With the help of given parameters this system is able to model and analyze the lithography procedure. The next step of the project is the automatic optimization of these parameters. The big number of parameters characterize the complexity of the task. The theme of this paper-within this field-is the optimization of the layout of the masks. A computer program is developed, which uses genetic algorithms for this optimization. The program is working as a module of SOLID.
wild-type transthyretin cardiac amyloidosis as a significant and potentially modifiable cause of ... more wild-type transthyretin cardiac amyloidosis as a significant and potentially modifiable cause of heart failure with preserved ejection fraction
Unveiling outcomes in coexisting severe aortic stenosis and transthyretin cardiac amyloidosis
European Journal of Heart Failure, 2020
While the the recognition of transthyretin cardiac amyloidosis (ATTR-CA) and severe AS is increas... more While the the recognition of transthyretin cardiac amyloidosis (ATTR-CA) and severe AS is increasing, the implications of ATTR-CA on outcomes after TAVR remain undetermined. We screened patients undergoing TAVR at two centers for ATTR-CA. Using Kaplan Meier analysis, we compared the primary
Unveiling Outcomes in Coexisting Severe Aortic Stenosis and Transthyretin Cardiac Amyloidosis
Journal of the American College of Cardiology, 2020
While the the recognition of transthyretin cardiac amyloidosis (ATTR-CA) and severe AS is increas... more While the the recognition of transthyretin cardiac amyloidosis (ATTR-CA) and severe AS is increasing, the implications of ATTR-CA on outcomes after TAVR remain undetermined. We screened patients undergoing TAVR at two centers for ATTR-CA. Using Kaplan Meier analysis, we compared the primary
Structural Heart, 2019
The concurrence of transthyretic cardiac amyloidosis (ATTR-CA) and severe aortic stenosis (AS) is... more The concurrence of transthyretic cardiac amyloidosis (ATTR-CA) and severe aortic stenosis (AS) is being increasingly identified, however the long-term trajectory of these patients remains unclear. In this comprehensive review, we discuss what is known about the prevalence of dual diagnosis, the impact of new imaging modalities on diagnosis of ATTR-CA, and outcomes for patients with concomitant disease. We discuss emerging medical therapies for ATTR-CA, which may be considered in appropriate patients with ATTR-CA and severe AS.
Journal of Cardiac Failure, 2019
Cardiac amyloidosis is a form of restrictive infiltrative cardiomyopathy that confers significant... more Cardiac amyloidosis is a form of restrictive infiltrative cardiomyopathy that confers significant mortality. Due to the relative rarity of cardiac amyloidosis, clinical and diagnostic expertise in the recognition and evaluation of individuals with suspected amyloidosis is mostly limited to a few expert centers. Electrocardiography, echocardiography, and radionuclide imaging have been used for the evaluation of cardiac amyloidosis for over 40 years. 1-3 Although cardiovascular magnetic resonance (CMR) has also been in clinical practice for several decades, it was not applied to cardiac amyloidosis until the late 1990s. Despite an abundance of diagnostic imaging options, cardiac amyloidosis remains largely underrecognized or delayed in diagnosis. 4 While advanced imaging options for noninvasive evaluation have substantially expanded, the evidence is predominately confined to single-center small studies or limited multicenter larger experiences, and there continues to be no clear consensus on standardized imaging pathways in cardiac amyloidosis. This lack of guidance is particularly problematic given that there are numerous emerging therapeutic options for this morbid disease, increasing the importance of accurate recognition at earlier stages. Imaging provides non-invasive tools for follow-up of disease remission/ progression complementing clinical evaluation. Additional areas not defined include appropriate clinical indications for imaging, optimal imaging utilization by clinical presentation, accepted imaging methods, accurate image interpretation, and comprehensive and clear reporting. Prospective randomized clinical trial data for the diagnosis of amyloidosis and for imaging-based strategies for treatment are not available. A consensus of expert opinion is greatly needed to guide the appropriate clinical utilization of imaging in cardiac amyloidosis. Part 2 of this expert consensus statement addresses the development of consensus diagnostic criteria for cardiac amyloidosis, identifies consensus clinical indications, and provides ratings on appropriate utilization in these clinical scenarios.
Abstracts, 2019
severe thrombocytopenia (<50 K/ml) was present in 28.7% of patients. Finally, 25.8% of patients p... more severe thrombocytopenia (<50 K/ml) was present in 28.7% of patients. Finally, 25.8% of patients presented with pancytopenia. In 72.3% of patients, bone marrow interpretation, along with clinical and laboratory findings, lead to a conclusive diagnosis. The most common final diagnoses were disease activity (24.8%) and drug-associated toxicity (28.7%). The agreement between the initial diagnostic impression and the conclusion after BMA was performed was 45.5%. We analyzed factors associated with the most common etiologies (table 1). Regarding BMA findings, when cytopenias were secondary to disease activity, it was more frequent for the bone marrow to be hypercellular (56 vs 23%, p=0.006) and to have increased megakaryocytes (40 vs 17.4%, p=0.048). Conversely, granulocytic dysplasia was less common in this group of patients (17.4% vs 54.3%, p=0.036). After multivariate analysis, a neutrophil count <1000 cells/m l was a protective factor for disease activity (OR 0.021; 95% CI 0.001-0.428, p 0.012). On the other hand, a history of renal activity (OR 4.3; 95% CI 1.3-14.2, p=0.024) and neutrophils<1000 cells/ml (OR 4.05; 95% CI 1.15-14.19, p=0.029) were found to be independent risk factors for myelotoxicity. Conclusions The most frequent diagnoses of SLE patients presenting with cytopenias were disease activity and drug-associated bone marrow toxicity. There are clinical characteristics and laboratory findings that may guide the diagnostic approach and thus, choose the most appropriate therapeutic intervention. BMA and biopsy play a key role in complementing the study of cytopenias in SLE patients, allowing for a complete evaluation of the particular context of each patient.
Arthritis & Rheumatology, 2017
Objectives-In addition to traditional risk factors, excess cardiovascular disease (CVD) in rheuma... more Objectives-In addition to traditional risk factors, excess cardiovascular disease (CVD) in rheumatoid arthritis (RA) is attributed to enhanced vascular and/or systemic inflammation. In several small studies using 18 F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) to directly assess vascular inflammation, FDG uptake was higher in RA patients than controls. Using a substantially larger RA sample, we sought to identify RAdisease characteristics independently associated with vascular FDG uptake. Methods-RA patients underwent cardiac FDG-PET/CT, with aortic inflammation assessed by quantification of FDG uptake in the ascending aorta, calculated as the mean and maximum (max) standardized-uptake-value (SUV) of the entire ascending aorta, and of its most diseased segment (SUV MDS). Univariable and multivariable regression models were constructed to model the associations of patient characteristics with aortic FDG uptake. Results-Ninety-one RA patients were scanned. In multivariable models, in addition to the independent associations of hypertension and body-mass-index with increased aortic FDG uptake, the prevalence of rheumatoid nodules correlated with the SUV-mean and SUV MDS-mean measurements, while anti-CCP antibodies inversely correlated with these measures and with the SUV-max and SUV MDS-max (p<0.05). A significant association of RA disease activity with aortic FDG uptake was observed but restricted to anti-CCP seropositivity. Conclusion-Traditional CV risk factors and RA-disease characteristics (rheumatoid nodules and DAS28-CRP in anti-CCP antibody positive individuals) were independently associated with ascending aortic FDG uptake in RA patients without clinical CVD.
Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases, Jan 21, 2018
Journal of the American College of Cardiology, 2017
Background: Patients typically undergoing myocardial viability assessment with positron emission ... more Background: Patients typically undergoing myocardial viability assessment with positron emission tomography (PET) are given a 25-100G oral glucose load prior to radioisotope administration and metabolic imaging. Current guidelines do not have specific recommendations for glucose load dosing in diabetic patients. Furthermore, this load is often not well tolerated. Methods: Following a six hour minimum fast, patients undergoing cardiac PET with N13 Ammonia and F18 flurodeoxyglucose (FDG) for myocardial viability received a reduced dose glucose load protocol from 10 to 40G based on fasting blood sugar and history of diabetes. Images were obtained 45 minutes after FDG administration. Image quality was independently assessed by two nuclear cardiologists who rated images as either poor, fair, good or excellent in a blinded fashion. Results: Images were retrospectively obtained from 55 patients 42 male (76%). 27 (49%) patients were diabetic. Mean glucose dose administered to all patients was 22.8 G (±11.7) and mean dose of FDG was 10.63mCi (±0.65). Both raters gave scores of excellent or good to 49 patients (89%). Agreement between raters across the four strata of image quality was calculated using the Kappa statistic k=0.651; p<0.001. Mean glucose dose for the subset of diabetic patients was 14.1G (±4.6). For diabetic patients, both raters gave scores of excellent or good to 24 patients (89%). Agreement between raters for the subset of diabetic patients was k=0.599; p<0.001. Conclusions: Myocardial PET viability imaging can be performed reliably with a low glucose challenge in both diabetic and non-diabetic patients yielding excellent image quality with shorter testing time and infrequent need for exogenous insulin administration. A reduced glucose load protocol should be considered as an alternative when patients are not tolerant of standard oral glucose loading doses.
Journal of the American College of Cardiology, 2016
Background: Mounting data demonstrate that transthyretin cardiac amyloidosis (ATTR-CA) is prevale... more Background: Mounting data demonstrate that transthyretin cardiac amyloidosis (ATTR-CA) is prevalent, underdiagnosed, and an important contributor to heart failure with preserved ejection fraction in older adults with up to 13% of HFpEF subjects affected. Among older adults undergoing transcatheter aortic valve replacement (TAVR), the prevalence of ATTR-CA is unknown but could have implications for procedural success and long term outcomes. Methods: 75 patients with severe AS underwent 99mTc-PYP planar cardiac imaging within 30 days of TAVR. Myocardial uptake was assessed by both semi-quantitative visual score (range 0: no uptake to 3: uptake greater than bone) and quantitative analysis by drawing a region of interest over the heart, mirroring it to the contralateral chest, and calculating a heart-to-contralateral ratio (HCL). Visual score >2 and HCL >1.5 were considered positive for ATTR-CA. Demographics, laboratory values, ECG, and echocardiographic data were also analyzed for association with 99mTc-PYP positivity. Results: Among 75 patients (63% men, mean age 84+6 yrs), 99mTc-PYP uptake was found in 16% (n=12), 11 of which were men. The phenotype of those with ATTR-CA vs. No ATTR-CA was predominately men (92%) with higher BNP (885+613 vs 500+560, p = 0.02), higher LV mass (238+89 vs 172+50, p = 0.01), low SVI (30+9 vs 36+9, p = 0.04), and conduction disease with RBBB (50% vs 14%, p = 0.007. Conclusions: Among older adults undergoing TAVR 16% of patients (92% of which were men) had ATTR-CA by 99mTc-PYP scan with a phenotype of severe concentric left ventricular hypertrophy and low flow AS. Ongoing study in larger population will determine the implications of such findings with regard to outcomes.
Journal of the American College of Cardiology, 2015
Background: F-18Fluorodeoxyglucose (FDG) positron emission tomography (PET) has been used for qua... more Background: F-18Fluorodeoxyglucose (FDG) positron emission tomography (PET) has been used for qualitatively diagnosing vasculitis. However, there is no standardized method for quantification of vascular inflammation. We tested the reproducibility of FDG-PET in measuring aortic inflammation in patients with rheumatoid arthritis (RA). RA is a systemic inflammatory condition associated with increased cardiovascular risk. methods: We studied 10 non-diabetic RA patients (mean age 52.1 + 10.6 years, 80% female) who underwent FDG-PET imaging of the ascending aorta. All patients were on no carbohydrate diet for 24 hours and were imaged 90 minutes after FDG injection. The area of interest was defined as the region of the aorta beginning 1 cm above the origin of the left main coronary artery and ending at the aortic arch in transaxial view. Inflammation was measured as the mean of the maximal target-to-background ratio (meanTBRmax), defined as the ratio of the mean of the maximal standard uptake values (SUV) in the ascending aorta (meanSUVmax) and mean of the maximal SUV in either the brachiocephalic vein or superior vena cava, whichever was the lesser value (bckgrnd). Regions of interest in the aorta were hand-drawn and included the vessel wall. Regions of interest in the brachiocephalic vein or superior vena cava were a minimum of 3 pixels in size and 0.3 cm2 in area and measured the blood pool background. Each study was read by 3 experienced readers using MedView Software (MedImage, Ann Arbor, MI). results: Each meanTBRmax was derived from, on average, 10 independent transaxial slice measurements of the ascending aorta. Bckgrnd was derived from the average of 6 transaxial measurements. Interobserver correlation coefficients of reliability were calculated using ANOVA for meanSUVmax, bckgrnd and meanTBRmax, and were 0.997, 0.992 and 0.922, respectively. conclusion: We have developed a method for measuring inflammation in the ascending aorta for RA patients that is facile and highly reproducible. Using this method, FDG-PET can be used to monitor vascular inflammation in this population of patients.
Journal of Diabetes Research and Clinical Metabolism, 2013
Objective: In this study we evaluated regional myocardial blood flow (MBF) and left ventricular (... more Objective: In this study we evaluated regional myocardial blood flow (MBF) and left ventricular (LV) sympathetic innervation using positron emission tomography (PET) and its relationship to standard autonomic function tests (AFT). Methods: We studied 12 diabetic patients (7M, 5F) (mean age 62±8), and 5 healthy controls (2M, 3F) (mean age 59±10). All patients underwent AFT and cardiac PET imaging with oxygen-15 labeled water to measure myocardial blood flow (MBF) and carbon-11 hydroxyephedrine (HED) to assess presynaptic cardiac sympathetic nerves. HED images were read semiquantitatively (summed score 4 segment/4 point model) and quantitatively (3-compartment model) to quantify cardiac HED density and flux (B-max). Single compartment model was used for MBF quantification. Results: All 5 controls had normal MBF, homogeneous uptake of HED, no regional difference in B-max and normal AFT. All 12 diabetic patients had normal MBF, 5 had homogeneous uptake of HED and 7 had heterogeneous uptake. The average HED defects summed score in diabetic patients was 9 in apical, 15 in basal lateral, 11 in distal lateral and 0 in septal region. In heterogeneous group there was a significant difference in B-max between the septal and lateral wall regions (24±12 vs.18 ± 10). On AFT all 12 diabetic patients had normal resting heart rate, RR and normal postural heart rate variability but 6/12 had postural hypotension. All 6 of these patients had heterogeneous HED uptake. Conclusions: Diabetic patients exhibited LV sympathetic dysfunction predominantly in the lateral wall region and only postural hypotension was significantly correlated with it.
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Papers by Sabahat Bokhari