Background: The prognostic impact of tricuspid regurgitation (TR) following transcatheter aortic ... more Background: The prognostic impact of tricuspid regurgitation (TR) following transcatheter aortic valve replacement (TAVR) is uncertain, and the management of patients with severe aortic stenosis and significant TR undergoing TAVR is unclear. Methods: Retrospective study investigating the role of TR severity on hospital outcomes in high risk patients with severe aortic stenosis undergoing TAVR. Results: A total of 174 participants were included in the present study. The median age was 84 years and 48% were women. The median (IR) STS score was 7.3 (4.7-13.6). The pre-procedural mean (SD) aortic valve area (AVA) was 0.69 (0.2) cm 2 and the average (SD) peak and mean gradients were 71 [23]/42 [15] mmHg. Pre TAVR, 28.7% of patients had significant (moderate or severe) TR. Significant TR pre-TAVR increased the risk of in-hospital cardiovascular (CV) and all-cause and mortality [adjusted relative risk (RR)
Journal of the American College of Cardiology, 2018
Background: Tricuspid regurgitation (TR) may lessen the potential benefits of TAVR. We aimed to i... more Background: Tricuspid regurgitation (TR) may lessen the potential benefits of TAVR. We aimed to investigate the impact of TR on TAVR outcomes and to ascertain factors associated with TR severity. Methods: Patients with severe aortic stenosis that underwent TAVR at MSMC, Miami Beach, FL from August, 1st 2014 to January, 1st 2017 with available preoperative and postoperative transthoracic echocardiogram were included in this analysis. Results: A total of 148 patients with available echocardiographic information were included. 51% were men and 36% diabetic. Average LVEF was 48%. Pre TAVR, 70% had mild, 15% moderate and 10% severe TR, while post TAVR, TR was mild in 78 %, moderate in 10% and severe in 8% (P<0.0001). A Wilcoxon signed-rank test showed that TAVR resulted in a significant change (P=0.02) in TR severity: 24(16%) patients had improved TR while in 11(7%) TR worsened. Patients with worsened TR had longer hospital stay (Median 21 days [IQR: 24.5]) compared to those with improved TR (4 days [IQR: 4.5]) or unchanged TR (5 days [IQR: 7.0]) after procedure (P=0.02). Estimated right ventricular systolic pressure (RVSP) was a significant predictor of TR severity both pre-and post TAVR (P<0.001). RVSP improved in the majority of patients post TAVR but in those which TR worsen. Conclusion: One out of four patients undergoing TAVR had moderate or severe TR. Persistent/worsening TR post TAVR is associated with increased morbidity and may be related to underlying pulmonary hypertension.
Journal of the American College of Cardiology, 2019
Background: A sedentary lifestyle is associated with higher risk of developing heart failure. We ... more Background: A sedentary lifestyle is associated with higher risk of developing heart failure. We evaluated the effect of increasing levels of aerobic exercise on left ventricular (LV) strain in young adults without cardiovascular disease. Methods: A prospective cohort study in which participants underwent treadmill 2D stress echocardiograms (SE) using the standard Bruce protocol. A 3-month, investigator-supervised aerobic exercise program was completed, followed by a 5-kilometer (5K) run. Repeat SE were performed within 2 weeks of race completion. The primary outcome was the change in average LV global longitudinal (GLS), global circumferential (GCS) and global radial (GRS) strain. Secondary outcomes were change in METS and change in exercise time. LV strain was measured offline in resting images by 2D speckle tracking echocardiography. Results: 19 participants completed the 5K race. Mean age was 38 (+11) years and 63% were female. All SE were negative for ischemia. Training completion was associated with an improvement in treadmill exercise time duration (635 +99 vs. 680 +117 seconds, p<0.02) and METS achieved (12.4 +1.8 vs. 13.2 +2.5, p<0.03). Compared to baseline, post-training mean GLS increased (-20.0% +2 vs.-21.5% +2, p<0.02), along with GRS (33.5 +10 vs. 39.4 +12, p=0.05) (Figure 1). Conclusion: LV global longitudinal and global radial strain are modifiable factors that can improve with recreational levels of aerobic exercise.
The Southwest Respiratory and Critical Care Chronicles, 2013
Cardiovascular disease is the leading cause of death in patients with chronic kidney disease. He... more Cardiovascular disease is the leading cause of death in patients with chronic kidney disease. Heart failure may lead to acute kidney injury and vice versa. Chronic kidney disease may affect the clinical outcomes in patients with cardiovascular disorders. Renal impairment with any degree of albuminuria has been increasingly recognized as an independent risk factor for cardiovascular events and heart failure hospitalizations, while chronic heart failure may cause chronic kidney disease. The bidirectional nature of these disorders contributes to the complexity and the composite definitions of cardiorenal syndromes. However, the most important clinical trials in heart failure tend to exclude patients with significant renal dysfunction. The mechanisms whereby renal insufficiency worsens the outcome in heart failure are not known, and several pathways could contribute to the ‘‘vicious heart/kidney circle.’’ Traditionally, renal impairment has been attributed to the renal hypoperfusion du...
The Southwest Respiratory and Critical Care Chronicles, 2016
Background: Volume contraction frequently contributes to the development of acute kidney injury. ... more Background: Volume contraction frequently contributes to the development of acute kidney injury. The rapid assessment of volume status in patients with acute kidney injury could improve decision making and outcomes. Methods: The maximum and minimum diameters and percent collapsibility of the inferior vena cava (IVC) were measured in 30 patients admitted to the medical intensive care unit with laboratory evidence of acute kidney injury. These measurements were made on the day of admission and 24 hours following admission. Information about age, gender, body mass index, serum creatinine levels, and fluid balances was recorded. Results: This study included 30 patients with a mean age is 62.4 ±16.0 years. The mean initial creatinine was 4.3 ± 4.2 mg/dL (range: 1.7 mg/dL to 22.1 mg/dL). The mean fractional excretion of sodium was 2.06 ± 2.65%. The mean maximum diameter of inferior vena cava was 1.8 ± 0.5 cm with the range is 0.4-2.65 cm. The mean percent collapse was 32 ± 20%. Fi...
We are reporting a case of familial thoracic aortic aneurysm and dissection in a 26-year-old man ... more We are reporting a case of familial thoracic aortic aneurysm and dissection in a 26-year-old man with no significant past medical history and a family history of dissecting aortic aneurysm in his mother at the age of 40. The patient presented with cough, shortness of breath, and chest pain. Chest X-ray showed bilateral pulmonary infiltrates. CT scan of the chest showed a dissection of the ascending aorta. The patient underwent aortic dissection repair and three months later he returned to our hospital with new complaints of back pain. CT angiography showed a new aortic dissection extending from the left carotid artery through the bifurcation and into the iliac arteries. The patient underwent replacement of the aortic root, ascending aorta, total aortic arch, and aortic valve. The patient recovered well postoperatively. Genetic studies of the patient and his children revealed no mutations in ACTA2, TGFBR1, TGFBR2, TGFB2, MYH11, MYLK, SMAD3, or FBN1. This case report focuses on a pati...
Journal of the American College of Cardiology, 2004
The aim of this research was to determine whether presence of atrial fibrillation (AF) provides i... more The aim of this research was to determine whether presence of atrial fibrillation (AF) provides incremental prognostic information relative to myocardial perfusion single-photon emission computed tomography (MPS) with respect to risk of cardiac death (CD). BACKGROUND The prognostic significance of AF in patients undergoing MPS is not known. METHODS A total of 16,048 consecutive patients undergoing MPS were followed-up for a mean of 2.21 Ϯ 1.15 years for the development of CD. Of those, 384 patients (2.4%) had AF. Cox proportional hazards method was used to compare clinical and perfusion data for the prediction of CD in patients with and without AF. RESULTS Atrial fibrillation was a significant predictor of CD in patients with normal (1.6% per year vs. 0.4% per year in non-AF patients), mildly abnormal (6.3% per year vs. 1.2% per year), and severely abnormal MPS (6.4% per year vs. 3.7% per year) (p Ͻ 0.001 for all). By multivariable analysis, AF patients had worse survival (p ϭ 0.001) even after adjustment for the variables most predictive of CD: age, diabetes, shortness of breath, use of vasodilator stress, rest heart rate, and the nuclear variables. In the 4,239 patients with left ventricular ejection fraction evaluated by gated MPS, AF demonstrated incremental prognostic value not only over clinical and nuclear variables, but also over left ventricular ejection in predicting CD (p ϭ 0.014). CONCLUSIONS The presence of AF independently increases the risk of cardiac events over perfusion and function variables in patients undergoing MPS. Patients with AF have a high risk of CD, even when MPS is only mildly abnormal. Whether patients with AF and mildly abnormal MPS constitute a group more deserving of early referral to cardiac catheterization is a question warranting further study.
Abstract:: Septic shock remains one of the most challenging medical conditions, with increasing i... more Abstract:: Septic shock remains one of the most challenging medical conditions, with increasing incidence over the last years. One of the most important features of sepsis is myocardial dysfunction and renal impairment. Objective is to evaluate diastolic ...
Partial and generalized seizures often affect autonomic functions during seizures, and interictal... more Partial and generalized seizures often affect autonomic functions during seizures, and interictal and postictal periods. We investigated possible interictal electrocardiographic abnormalities in patients with generalized tonic-clonic seizures (GTCS), together with evaluating any structural heart changes by echocardiography in these patients in comparison with healthy controls. We studied 120 definite GTCS patients (76 males and 44 females) who are neither diabetic nor under any medical treatment, and 60 healthy controls with a mean age of 25.2 ± 9.3 and 27.3 ± 7.5 years; respectively. Resting systolic and diastolic arterial blood pressures were measured, and standard 12-lead electrocardiograms and a 2-dimensional echocardiographic examination were performed. In univariate analysis, GTCS patients (compared to controls) had significantly lower means of PR interval (147.2 ± 18.6 versus 153.8 ± 22.6 msec; P = 0.037), QT interval (362.8 ± 22.9 versus 379.9 ± 29.3 msec; P < 0.001), and QTc interval (425.5 ± 20.7 versus 441.6 ± 19.9 msec; P < 0.001) but significantly higher mean left atrial diameter (3.49 ± 0.64 versus 3.09 ± 0.45 cm; P < 0.001). After adjusting for age, gender, and body mass index in a multivariate adjusted logistic regression model, left atrial diameter (OR = 3.941 [1.739 -8.932]) and QTc (OR = 0.924 [0.895 -0.954]) were significantly and independently associated with GTCS. In conclusion, patients with epilepsy may be predisposed to disturbances of autonomic functions with subsequent cardiac arrhythmias due to the effects of recurrent seizures on cardiac microstructure. Further work is needed to stratify the risk of sudden unexplained cardiac death (SUDEP) on the basis of interictal autonomic parameters to improve prognosis.
We report three cases of thoracic aortic aneurysm and dissection in a Japanese family. Marfan-rel... more We report three cases of thoracic aortic aneurysm and dissection in a Japanese family. Marfan-related genes were analyzed; FBN1 and TGFBR2 gene mutations were observed in this family.
Journal of interventional cardiology, Jan 28, 2018
Post-myocardial infarction (MI) ventricular septal defects (PIVSD) are an uncommon but life-threa... more Post-myocardial infarction (MI) ventricular septal defects (PIVSD) are an uncommon but life-threatening complication of acute MI. Although surgical closure has been the standard of care, mortality, and recurrence of VSD remain high even after emergent surgery. Transcatheter VSD closure (TCC) devices have become an alternative or adjunct to surgical closure. Online database search was performed for studies that included adults with PIVSD who underwent medical treatment (MT) alone, surgical closure (SC) (early or late), and TCC (early, late, or for post-surgical residual VSD). Twenty-six studies were included with a total of 737 patients who underwent either MT (N = 100), SC (early (n = 167), late (n = 100)), and TCC (early (n = 176), late (n = 115), or post-surgical residual VSD (n = 79)). The 30-day mortality among MT group was 92 ± 6.3%, among SC was 61 ± 22.5% (early 56 ± 23%, late 41 ± 30%), and for all TCC patients was 33 ± 24% (early 54 ± 32.7%, late 16 ± 26%), and TCC for post...
Takotsubo cardiomyopathy is an uncommon clinical entity, also called apical ballooning syndrome, ... more Takotsubo cardiomyopathy is an uncommon clinical entity, also called apical ballooning syndrome, characterized by transient systolic dysfunction of the apical and/or mid segments of the left ventricle. We report a case that highlights takotsubo syndrome in the setting of thyrotoxicosis that required thyroidectomy. The association of takotsubo syndrome and hyperthyroidism has been reported before. We found 13 previously reported cases of thyrotoxicosis-induced cardiomyopathy, most associated with Grave&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease and none treated with thyroidectomy. Awareness of this possible association is important in establishing the diagnosis and instituting proper management.
Proceedings (Baylor University. Medical Center), 2015
Takotsubo cardiomyopathy is an uncommon clinical entity, also called apical ballooning syndrome, ... more Takotsubo cardiomyopathy is an uncommon clinical entity, also called apical ballooning syndrome, characterized by transient systolic dysfunction of the apical and/or mid segments of the left ventricle. We report a case that highlights takotsubo syndrome in the setting of thyrotoxicosis that required thyroidectomy. The association of takotsubo syndrome and hyperthyroidism has been reported before. We found 13 previously reported cases of thyrotoxicosis-induced cardiomyopathy, most associated with Grave's disease and none treated with thyroidectomy. Awareness of this possible association is important in establishing the diagnosis and instituting proper management.
The Southwest Respiratory and Critical Care Chronicles, 2014
ABSTRACT Drugs, including those used during diagnostic procedures, can have adverse effects and p... more ABSTRACT Drugs, including those used during diagnostic procedures, can have adverse effects and potentially serious side-effects, especially in complicated patients with significant comorbidity. Benzocaine is frequently used as an oropharyngeal anesthetic agent during bronchoscopy, transesophageal echocardiography, and upper GI endoscopy and can cause methemoglobinemia, a potentially life-threatening event if not diagnosed and treated quickly. Co-oximetry is the gold standard for the diagnosis of methemoglobinemia and can quantitate blood levels, which in turn correlate with the clinical presentation and the urgency for treatment. Methylene blue is the treatment of choice for methemoglobinemia. In this case report we discuss the pathophysiology, the clinical presentation, the diagnosis, and the treatment of benzocaine-induced methemoglobinemia
The American journal of the medical sciences, 2015
: Vasoplegia syndrome is a well known complication after cardiac surgery and has a significant mo... more : Vasoplegia syndrome is a well known complication after cardiac surgery and has a significant morbidity and mortality. It is characterized by profound vasodilation and loss of systemic vascular resistance leading to hypotension. The pathogenesis of vasoplegia involves the activation of contact, coagulation and complement systems and the activation of leukocytes, platelets and endothelial cells resulting in an imbalance in the regulation of the vascular tone leading to postcardiac surgery vasoplegia. Multiple risk factors have been identified that help predict vasoplegia. Treatment requires mainly vasopressors, but hypotension can be refractory to vasopressors. Some studies suggest that methylene blue can reverse refractory hypotension in these patients and may prevent the development of the syndrome, but more studies are needed with this drug. In this review, we will discuss the pathophysiology of the vasoplegia syndrome and associated risk factors for this complication and briefly outline current therapeutic strategies.
The Southwest Respiratory and Critical Care Chronicles, 2013
ABSTRACT Cardiovascular disease is the leading cause of death in patients with chronic kidney dis... more ABSTRACT Cardiovascular disease is the leading cause of death in patients with chronic kidney disease. Heart failure may lead to acute kidney injury and vice versa. Chronic kidney disease may affect the clinical outcomes in patients with cardiovascular disorders. Renal impairment with any degree of albuminuria has been increasingly recognized as an independent risk factor for cardiovascular events and heart failure hospitalizations, while chronic heart failure may cause chronic kidney disease. The bidirectional nature of these disorders contributes to the complexity and the composite definitions of cardiorenal syndromes. However, the most important clinical trials in heart failure tend to exclude patients with significant renal dysfunction. The mechanisms whereby renal insufficiency worsens the outcome in heart failure are not known, and several pathways could contribute to the ‘‘vicious heart/kidney circle.’’ Traditionally, renal impairment has been attributed to the renal hypoperfusion due to reduced cardiac output and decreased systemic pressure. The hypovolemia leads to sympathetic activity, increased renin-angiotensin-aldosterone pathway, and arginine-vasopressin release. These mechanisms cause fluid and sodium retention, peripheral vasoconstriction, and volume overload. Therapy to improve renal dysfunction, reduce neurohormonal activation and ameliorate renal blood flow could lead to a reduction in mortality and hospitalization in patients with cardiorenal syndrome. Key words: Cardiorenal syndrome, heart failure, acute kidney injury, chronic kidney disease, bio- markers, morbidity
Journal of the American College of Cardiology, 2014
background:Acute kidney injury (AKI) is a common complication among patients with acute heart fai... more background:Acute kidney injury (AKI) is a common complication among patients with acute heart failure (AHF) (30%) and is associated with increased in-hospital mortality and readmission. Limited data are available about the impact of left ventricular systolic function on the prognosis of these patients.
Background: The prognostic impact of tricuspid regurgitation (TR) following transcatheter aortic ... more Background: The prognostic impact of tricuspid regurgitation (TR) following transcatheter aortic valve replacement (TAVR) is uncertain, and the management of patients with severe aortic stenosis and significant TR undergoing TAVR is unclear. Methods: Retrospective study investigating the role of TR severity on hospital outcomes in high risk patients with severe aortic stenosis undergoing TAVR. Results: A total of 174 participants were included in the present study. The median age was 84 years and 48% were women. The median (IR) STS score was 7.3 (4.7-13.6). The pre-procedural mean (SD) aortic valve area (AVA) was 0.69 (0.2) cm 2 and the average (SD) peak and mean gradients were 71 [23]/42 [15] mmHg. Pre TAVR, 28.7% of patients had significant (moderate or severe) TR. Significant TR pre-TAVR increased the risk of in-hospital cardiovascular (CV) and all-cause and mortality [adjusted relative risk (RR)
Journal of the American College of Cardiology, 2018
Background: Tricuspid regurgitation (TR) may lessen the potential benefits of TAVR. We aimed to i... more Background: Tricuspid regurgitation (TR) may lessen the potential benefits of TAVR. We aimed to investigate the impact of TR on TAVR outcomes and to ascertain factors associated with TR severity. Methods: Patients with severe aortic stenosis that underwent TAVR at MSMC, Miami Beach, FL from August, 1st 2014 to January, 1st 2017 with available preoperative and postoperative transthoracic echocardiogram were included in this analysis. Results: A total of 148 patients with available echocardiographic information were included. 51% were men and 36% diabetic. Average LVEF was 48%. Pre TAVR, 70% had mild, 15% moderate and 10% severe TR, while post TAVR, TR was mild in 78 %, moderate in 10% and severe in 8% (P<0.0001). A Wilcoxon signed-rank test showed that TAVR resulted in a significant change (P=0.02) in TR severity: 24(16%) patients had improved TR while in 11(7%) TR worsened. Patients with worsened TR had longer hospital stay (Median 21 days [IQR: 24.5]) compared to those with improved TR (4 days [IQR: 4.5]) or unchanged TR (5 days [IQR: 7.0]) after procedure (P=0.02). Estimated right ventricular systolic pressure (RVSP) was a significant predictor of TR severity both pre-and post TAVR (P<0.001). RVSP improved in the majority of patients post TAVR but in those which TR worsen. Conclusion: One out of four patients undergoing TAVR had moderate or severe TR. Persistent/worsening TR post TAVR is associated with increased morbidity and may be related to underlying pulmonary hypertension.
Journal of the American College of Cardiology, 2019
Background: A sedentary lifestyle is associated with higher risk of developing heart failure. We ... more Background: A sedentary lifestyle is associated with higher risk of developing heart failure. We evaluated the effect of increasing levels of aerobic exercise on left ventricular (LV) strain in young adults without cardiovascular disease. Methods: A prospective cohort study in which participants underwent treadmill 2D stress echocardiograms (SE) using the standard Bruce protocol. A 3-month, investigator-supervised aerobic exercise program was completed, followed by a 5-kilometer (5K) run. Repeat SE were performed within 2 weeks of race completion. The primary outcome was the change in average LV global longitudinal (GLS), global circumferential (GCS) and global radial (GRS) strain. Secondary outcomes were change in METS and change in exercise time. LV strain was measured offline in resting images by 2D speckle tracking echocardiography. Results: 19 participants completed the 5K race. Mean age was 38 (+11) years and 63% were female. All SE were negative for ischemia. Training completion was associated with an improvement in treadmill exercise time duration (635 +99 vs. 680 +117 seconds, p<0.02) and METS achieved (12.4 +1.8 vs. 13.2 +2.5, p<0.03). Compared to baseline, post-training mean GLS increased (-20.0% +2 vs.-21.5% +2, p<0.02), along with GRS (33.5 +10 vs. 39.4 +12, p=0.05) (Figure 1). Conclusion: LV global longitudinal and global radial strain are modifiable factors that can improve with recreational levels of aerobic exercise.
The Southwest Respiratory and Critical Care Chronicles, 2013
Cardiovascular disease is the leading cause of death in patients with chronic kidney disease. He... more Cardiovascular disease is the leading cause of death in patients with chronic kidney disease. Heart failure may lead to acute kidney injury and vice versa. Chronic kidney disease may affect the clinical outcomes in patients with cardiovascular disorders. Renal impairment with any degree of albuminuria has been increasingly recognized as an independent risk factor for cardiovascular events and heart failure hospitalizations, while chronic heart failure may cause chronic kidney disease. The bidirectional nature of these disorders contributes to the complexity and the composite definitions of cardiorenal syndromes. However, the most important clinical trials in heart failure tend to exclude patients with significant renal dysfunction. The mechanisms whereby renal insufficiency worsens the outcome in heart failure are not known, and several pathways could contribute to the ‘‘vicious heart/kidney circle.’’ Traditionally, renal impairment has been attributed to the renal hypoperfusion du...
The Southwest Respiratory and Critical Care Chronicles, 2016
Background: Volume contraction frequently contributes to the development of acute kidney injury. ... more Background: Volume contraction frequently contributes to the development of acute kidney injury. The rapid assessment of volume status in patients with acute kidney injury could improve decision making and outcomes. Methods: The maximum and minimum diameters and percent collapsibility of the inferior vena cava (IVC) were measured in 30 patients admitted to the medical intensive care unit with laboratory evidence of acute kidney injury. These measurements were made on the day of admission and 24 hours following admission. Information about age, gender, body mass index, serum creatinine levels, and fluid balances was recorded. Results: This study included 30 patients with a mean age is 62.4 ±16.0 years. The mean initial creatinine was 4.3 ± 4.2 mg/dL (range: 1.7 mg/dL to 22.1 mg/dL). The mean fractional excretion of sodium was 2.06 ± 2.65%. The mean maximum diameter of inferior vena cava was 1.8 ± 0.5 cm with the range is 0.4-2.65 cm. The mean percent collapse was 32 ± 20%. Fi...
We are reporting a case of familial thoracic aortic aneurysm and dissection in a 26-year-old man ... more We are reporting a case of familial thoracic aortic aneurysm and dissection in a 26-year-old man with no significant past medical history and a family history of dissecting aortic aneurysm in his mother at the age of 40. The patient presented with cough, shortness of breath, and chest pain. Chest X-ray showed bilateral pulmonary infiltrates. CT scan of the chest showed a dissection of the ascending aorta. The patient underwent aortic dissection repair and three months later he returned to our hospital with new complaints of back pain. CT angiography showed a new aortic dissection extending from the left carotid artery through the bifurcation and into the iliac arteries. The patient underwent replacement of the aortic root, ascending aorta, total aortic arch, and aortic valve. The patient recovered well postoperatively. Genetic studies of the patient and his children revealed no mutations in ACTA2, TGFBR1, TGFBR2, TGFB2, MYH11, MYLK, SMAD3, or FBN1. This case report focuses on a pati...
Journal of the American College of Cardiology, 2004
The aim of this research was to determine whether presence of atrial fibrillation (AF) provides i... more The aim of this research was to determine whether presence of atrial fibrillation (AF) provides incremental prognostic information relative to myocardial perfusion single-photon emission computed tomography (MPS) with respect to risk of cardiac death (CD). BACKGROUND The prognostic significance of AF in patients undergoing MPS is not known. METHODS A total of 16,048 consecutive patients undergoing MPS were followed-up for a mean of 2.21 Ϯ 1.15 years for the development of CD. Of those, 384 patients (2.4%) had AF. Cox proportional hazards method was used to compare clinical and perfusion data for the prediction of CD in patients with and without AF. RESULTS Atrial fibrillation was a significant predictor of CD in patients with normal (1.6% per year vs. 0.4% per year in non-AF patients), mildly abnormal (6.3% per year vs. 1.2% per year), and severely abnormal MPS (6.4% per year vs. 3.7% per year) (p Ͻ 0.001 for all). By multivariable analysis, AF patients had worse survival (p ϭ 0.001) even after adjustment for the variables most predictive of CD: age, diabetes, shortness of breath, use of vasodilator stress, rest heart rate, and the nuclear variables. In the 4,239 patients with left ventricular ejection fraction evaluated by gated MPS, AF demonstrated incremental prognostic value not only over clinical and nuclear variables, but also over left ventricular ejection in predicting CD (p ϭ 0.014). CONCLUSIONS The presence of AF independently increases the risk of cardiac events over perfusion and function variables in patients undergoing MPS. Patients with AF have a high risk of CD, even when MPS is only mildly abnormal. Whether patients with AF and mildly abnormal MPS constitute a group more deserving of early referral to cardiac catheterization is a question warranting further study.
Abstract:: Septic shock remains one of the most challenging medical conditions, with increasing i... more Abstract:: Septic shock remains one of the most challenging medical conditions, with increasing incidence over the last years. One of the most important features of sepsis is myocardial dysfunction and renal impairment. Objective is to evaluate diastolic ...
Partial and generalized seizures often affect autonomic functions during seizures, and interictal... more Partial and generalized seizures often affect autonomic functions during seizures, and interictal and postictal periods. We investigated possible interictal electrocardiographic abnormalities in patients with generalized tonic-clonic seizures (GTCS), together with evaluating any structural heart changes by echocardiography in these patients in comparison with healthy controls. We studied 120 definite GTCS patients (76 males and 44 females) who are neither diabetic nor under any medical treatment, and 60 healthy controls with a mean age of 25.2 ± 9.3 and 27.3 ± 7.5 years; respectively. Resting systolic and diastolic arterial blood pressures were measured, and standard 12-lead electrocardiograms and a 2-dimensional echocardiographic examination were performed. In univariate analysis, GTCS patients (compared to controls) had significantly lower means of PR interval (147.2 ± 18.6 versus 153.8 ± 22.6 msec; P = 0.037), QT interval (362.8 ± 22.9 versus 379.9 ± 29.3 msec; P < 0.001), and QTc interval (425.5 ± 20.7 versus 441.6 ± 19.9 msec; P < 0.001) but significantly higher mean left atrial diameter (3.49 ± 0.64 versus 3.09 ± 0.45 cm; P < 0.001). After adjusting for age, gender, and body mass index in a multivariate adjusted logistic regression model, left atrial diameter (OR = 3.941 [1.739 -8.932]) and QTc (OR = 0.924 [0.895 -0.954]) were significantly and independently associated with GTCS. In conclusion, patients with epilepsy may be predisposed to disturbances of autonomic functions with subsequent cardiac arrhythmias due to the effects of recurrent seizures on cardiac microstructure. Further work is needed to stratify the risk of sudden unexplained cardiac death (SUDEP) on the basis of interictal autonomic parameters to improve prognosis.
We report three cases of thoracic aortic aneurysm and dissection in a Japanese family. Marfan-rel... more We report three cases of thoracic aortic aneurysm and dissection in a Japanese family. Marfan-related genes were analyzed; FBN1 and TGFBR2 gene mutations were observed in this family.
Journal of interventional cardiology, Jan 28, 2018
Post-myocardial infarction (MI) ventricular septal defects (PIVSD) are an uncommon but life-threa... more Post-myocardial infarction (MI) ventricular septal defects (PIVSD) are an uncommon but life-threatening complication of acute MI. Although surgical closure has been the standard of care, mortality, and recurrence of VSD remain high even after emergent surgery. Transcatheter VSD closure (TCC) devices have become an alternative or adjunct to surgical closure. Online database search was performed for studies that included adults with PIVSD who underwent medical treatment (MT) alone, surgical closure (SC) (early or late), and TCC (early, late, or for post-surgical residual VSD). Twenty-six studies were included with a total of 737 patients who underwent either MT (N = 100), SC (early (n = 167), late (n = 100)), and TCC (early (n = 176), late (n = 115), or post-surgical residual VSD (n = 79)). The 30-day mortality among MT group was 92 ± 6.3%, among SC was 61 ± 22.5% (early 56 ± 23%, late 41 ± 30%), and for all TCC patients was 33 ± 24% (early 54 ± 32.7%, late 16 ± 26%), and TCC for post...
Takotsubo cardiomyopathy is an uncommon clinical entity, also called apical ballooning syndrome, ... more Takotsubo cardiomyopathy is an uncommon clinical entity, also called apical ballooning syndrome, characterized by transient systolic dysfunction of the apical and/or mid segments of the left ventricle. We report a case that highlights takotsubo syndrome in the setting of thyrotoxicosis that required thyroidectomy. The association of takotsubo syndrome and hyperthyroidism has been reported before. We found 13 previously reported cases of thyrotoxicosis-induced cardiomyopathy, most associated with Grave&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease and none treated with thyroidectomy. Awareness of this possible association is important in establishing the diagnosis and instituting proper management.
Proceedings (Baylor University. Medical Center), 2015
Takotsubo cardiomyopathy is an uncommon clinical entity, also called apical ballooning syndrome, ... more Takotsubo cardiomyopathy is an uncommon clinical entity, also called apical ballooning syndrome, characterized by transient systolic dysfunction of the apical and/or mid segments of the left ventricle. We report a case that highlights takotsubo syndrome in the setting of thyrotoxicosis that required thyroidectomy. The association of takotsubo syndrome and hyperthyroidism has been reported before. We found 13 previously reported cases of thyrotoxicosis-induced cardiomyopathy, most associated with Grave's disease and none treated with thyroidectomy. Awareness of this possible association is important in establishing the diagnosis and instituting proper management.
The Southwest Respiratory and Critical Care Chronicles, 2014
ABSTRACT Drugs, including those used during diagnostic procedures, can have adverse effects and p... more ABSTRACT Drugs, including those used during diagnostic procedures, can have adverse effects and potentially serious side-effects, especially in complicated patients with significant comorbidity. Benzocaine is frequently used as an oropharyngeal anesthetic agent during bronchoscopy, transesophageal echocardiography, and upper GI endoscopy and can cause methemoglobinemia, a potentially life-threatening event if not diagnosed and treated quickly. Co-oximetry is the gold standard for the diagnosis of methemoglobinemia and can quantitate blood levels, which in turn correlate with the clinical presentation and the urgency for treatment. Methylene blue is the treatment of choice for methemoglobinemia. In this case report we discuss the pathophysiology, the clinical presentation, the diagnosis, and the treatment of benzocaine-induced methemoglobinemia
The American journal of the medical sciences, 2015
: Vasoplegia syndrome is a well known complication after cardiac surgery and has a significant mo... more : Vasoplegia syndrome is a well known complication after cardiac surgery and has a significant morbidity and mortality. It is characterized by profound vasodilation and loss of systemic vascular resistance leading to hypotension. The pathogenesis of vasoplegia involves the activation of contact, coagulation and complement systems and the activation of leukocytes, platelets and endothelial cells resulting in an imbalance in the regulation of the vascular tone leading to postcardiac surgery vasoplegia. Multiple risk factors have been identified that help predict vasoplegia. Treatment requires mainly vasopressors, but hypotension can be refractory to vasopressors. Some studies suggest that methylene blue can reverse refractory hypotension in these patients and may prevent the development of the syndrome, but more studies are needed with this drug. In this review, we will discuss the pathophysiology of the vasoplegia syndrome and associated risk factors for this complication and briefly outline current therapeutic strategies.
The Southwest Respiratory and Critical Care Chronicles, 2013
ABSTRACT Cardiovascular disease is the leading cause of death in patients with chronic kidney dis... more ABSTRACT Cardiovascular disease is the leading cause of death in patients with chronic kidney disease. Heart failure may lead to acute kidney injury and vice versa. Chronic kidney disease may affect the clinical outcomes in patients with cardiovascular disorders. Renal impairment with any degree of albuminuria has been increasingly recognized as an independent risk factor for cardiovascular events and heart failure hospitalizations, while chronic heart failure may cause chronic kidney disease. The bidirectional nature of these disorders contributes to the complexity and the composite definitions of cardiorenal syndromes. However, the most important clinical trials in heart failure tend to exclude patients with significant renal dysfunction. The mechanisms whereby renal insufficiency worsens the outcome in heart failure are not known, and several pathways could contribute to the ‘‘vicious heart/kidney circle.’’ Traditionally, renal impairment has been attributed to the renal hypoperfusion due to reduced cardiac output and decreased systemic pressure. The hypovolemia leads to sympathetic activity, increased renin-angiotensin-aldosterone pathway, and arginine-vasopressin release. These mechanisms cause fluid and sodium retention, peripheral vasoconstriction, and volume overload. Therapy to improve renal dysfunction, reduce neurohormonal activation and ameliorate renal blood flow could lead to a reduction in mortality and hospitalization in patients with cardiorenal syndrome. Key words: Cardiorenal syndrome, heart failure, acute kidney injury, chronic kidney disease, bio- markers, morbidity
Journal of the American College of Cardiology, 2014
background:Acute kidney injury (AKI) is a common complication among patients with acute heart fai... more background:Acute kidney injury (AKI) is a common complication among patients with acute heart failure (AHF) (30%) and is associated with increased in-hospital mortality and readmission. Limited data are available about the impact of left ventricular systolic function on the prognosis of these patients.
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Papers by Sabry Omar