Four-Volume Series on Four-Volume Series on Cardiovascular Diseases:
Causes, Risks and Management
Dr. Pearlman, MD, PhD, FACC
Editor
Leaders in Pharmaceutical Business Intelligence (LPBI) Group
This Series is positioned as Academic Textbooks for Training Residents in Cardiology and Texts for CEU Courses in Cardiology
[Hardcover, Softcover, e-Books].
- CVD 1: Causes of Cardiovascular Diseases
- CVD 2: Risk Assessment of Cardiovascular Diseases
- CVD 3: Management of Cardiovascular Diseases
- CVD 4: Cardiac Imaging
VOLUME 4
Cardiac Imaging
Justin D. Pearlman MD PhD MA FACC, Editor
Leaders in Pharmaceutical Business Intelligence (LPBI) Group, Boston
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Other Volumes on Cardiovascular Diseases by same Editor
Cardiovascular Diseases: Causes, Risks and Management
VOLUME ONE
Causes of Cardiovascular Diseases
Justin D. Pearlman MD PhD MA FACC, Editor
Leaders in Pharmaceutical Business Intelligence (LPBI) Group, Boston
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Risks of Cardiovascular Diseases
VOLUME TWO
Justin D. Pearlman MD ME PhD MA FACC, Editor
Leaders in Pharmaceutical Business Intelligence (LPBI) Group, Boston
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Management of Cardiovascular Diseases
Justin D. Pearlman MD ME PhD MA FACC, Editor
VOLUME THREE
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Editor-in-Chief BioMed E-Book Series
Leaders in Pharmaceutical Business Intelligence (LPBI) Group, Boston
avivalev-ari@alum.berkeley.edu
BioMedical e-Books e-Series:
Cardiovascular, Genomics, Cancer, BioMed, Patient-centered Medicine
https://pharmaceuticalintelligence.com/biomed-e-books/
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2013 e-Book on Amazon.com
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- Cardiovascular Diseases, Volume Four: Regenerative and Translational Medicine: The Therapeutics Promise for Cardiovascular Diseases, on Amazon since 12/26/2015
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Other e-Books in the BioMedicine e-Series
Series A: e-Books on Cardiovascular Diseases
Content Consultant: Justin D Pearlman, MD, PhD, FACC
Volume One: Perspectives on Nitric Oxide
Sr. Editor: Larry Bernstein, MD, FCAP, Editor: Aviral Vatsa, PhD and Content Consultant: Stephen J Williams, PhD
Available on Kindle Store @ Amazon.com
http://www.amazon.com/dp/B00DINFFYC
Volume Two: Cardiovascular Original Research: Cases in Methodology Design for Content Co-Curation
Curators: Justin D Pearlman, MD, PhD, FACC, Larry H Bernstein, MD, FCAP and
Aviva Lev-Ari, PhD, RN
- Causes
- Risks and Biomarkers
- Therapeutic Implication
Available on Kindle Store @ Amazon.com
http://www.amazon.com/dp/B018Q5MCN8
Volume Three: Etiologies of Cardiovascular Diseases: Epigenetics, Genetics and Genomics
Curators: Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
- Causes
- Risks and Biomarkers
- Therapeutic Implications
Available on Kindle Store @ Amazon.com
http://www.amazon.com/dp/B018PNHJ84
Volume Four: Regenerative and Translational Medicine: The Therapeutics Promise for Cardiovascular Diseases
Curators: Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
- Causes
- Risks and Biomarkers
- Therapeutic Implications
Available on Kindle Store @ Amazon.com
http://www.amazon.com/dp/B019UM909A
Volume Five: Pharmaco-Therapies of Cardiovascular Diseases
Volume Curators: Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
- Causes
- Risks and Biomarkers
- Therapeutic Implications
Work-in-Progress
Volume Six: Interventional Cardiology and Cardiac Surgery for Disease Diagnosis and Guidance of Treatment
Volume Curators: Justin D Pearlman, MD, PhD, FACC and Aviva Lev-Ari, PhD, RN
- Causes
- Risks and Biomarkers
- Therapeutic Implications
Work-in-Progress
In addition to the Six Volumes of SERIES A: Cardiovascular Diseases, Not included in SERIES A is a Four Volume Series by Dr. Pearlman, Editor, on Cardiovascular Diseases, positioned as Academic Textbooks for Training Residents in Cardiology and Texts for CEU Courses in Cardiology [Hardcover, Softcover, e-Books].
- CVD 1: Causes of Cardiovascular Diseases
- CVD 2: Risk Assessment of Cardiovascular Diseases
- CVD 3: Management of Cardiovascular Diseases
- CVD 4: Cardiac Imaging
Series B: e-Books on Genomics & Medicine
Content Consultant: Larry H Bernstein, MD, FCAP
Volume One: Genomics Orientations for Personalized Medicine
Sr. Editor: Stephen J Williams, PhD
Editors: Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
Available on Kindle Store @ Amazon.com
http://www.amazon.com/dp/B018DHBUO6
Volume Two: Latest in Genomics Methodologies for Therapeutics: Gene Editing, NGS & BioInformatics, Simulations and the Genome Ontology
Editors: Stephen J Williams, PhD and Aviva Lev-Ari, PhD, RN
Work-in-Progress
Volume Three: Institutional Leadership in Genomics
Editors: Aviva Lev-Ari, PhD, RN and TBA
Series C: e-Books on Cancer & Oncology
Content Consultant: Larry H Bernstein, MD, FCAP
Volume One: Cancer Biology & Genomics for Disease Diagnosis
Sr. Editor: Stephen J Williams, PhD
Editors: Ritu Saxena, PhD, Tilda Barliya, PhD
Available on Kindle Store @ Amazon.com
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Volume Two: Cancer Therapies: Metabolic, Genomics, Interventional, Immunotherapy and Nanotechnology in Therapy Delivery
Authors, Curators and Editors:
Larry H Bernstein, MD, FCAP and Stephen J Williams, PhD
Guest Authors:
Dror Nir, PhD and Tilda Barliya, PhD, Demet Sag, PhD, Ziv Raviv, PhD and Aviva Lev-Ari, PhD, RN
2017
Volume Three: Cancer Patients’ Resources on Therapies
Sr. Editor: TBA
Series D: e-Books on BioMedicine
Content Consultant: Larry H Bernstein, MD, FCAP
Volume One: Metabolic Genomics and Pharmaceutics
Author, Curator and Editor: Larry H Bernstein, MD, FCAP
Available on Kindle Store @ Amazon.com
http://www.amazon.com/dp/B012BB0ZF0
Volume Two: Infectious Diseases
Editor: TBA
Volume Three: Immunology and Therapeutics
Authors, Curators and Editors: Larry H Bernstein, MD, FCAP and TBA
Series E: Patient-centered Medicine
Content Consultant: Larry H Bernstein, MD, FCAP
Volume One: The VOICES of Patients, HealthCare Providers, Care Givers and Families: Personal Experience with Critical Care and Invasive Medical Procedures
Author, Curator and Editor: Larry H Bernstein, MD, FCAP and Co-Editor: Gail Thornton, PhD (c)
Work-in-Progress
Volume Two: Medical Scientific Discoveries for the 21st Century & Interviews with Scientific Leaders
Author, Curator and Editor: Larry H Bernstein, MD, FCAP
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Volume Three: Milestones in Physiology & Discoveries in Medicine and Genomics
Author, Curator and Editor: Larry H Bernstein, MD, FCAP
Available on Kindle Store @ Amazon.com
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Volume Four: Medical 3D BioPrinting – The Revolution in Medicine
Editors: Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
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Our DOMAINS in Scientific Media
I. Pharmaceutical: Biologics, Small Molecules, Diagnostics
II. Life Sciences: Genomics and Cancer Biology
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IV. Biomedicine, BioTech, and MedTech (Medical Devices)
V. HealthCare: Patient-centered Medicine and Personalized/Precision Medicine
This e-Book is a comprehensive review of recent Original Research on {INSERT HERE TITLE OF THE BOOK} written by Experts, Authors, Writers. The results of Original Research are gaining value added for the e-Reader by the Methodology of Curation. The e-Book’s articles have been published on the Open Access Online Scientific Journal, since April 2012. All new articles on this subject, will continue to be incorporated, as published with periodical updates.
Open Access Online Journal
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is a scientific, medical and business, multi-expert authoring environment for information syndication in several domains of Life Sciences, Medicine, Pharmaceutical and Healthcare Industries, BioMedicine, Medical Technologies & Devices. Scientific critical interpretations and original articles are written by PhDs, MDs, MD/PhDs, PharmDs, Technical MBAs as Experts, Authors, Writers (EAWs) on an Equity Sharing basis.
LIST of VIDEOS
Insert HERE list
List of Contributors & Contributors’ Biographies
Article Author:
Justin D. Pearlman MD ME PhD MA FACC, Series A Content Consultant
Sectional Authorship and Curations:
Justin D. Pearlman MD ME PhD MA FACC, Series A Content Consultant
Author and Curator:
Article Curator:
THIS DRAFT IS IDENTICAL TO VOLUME SIX — was create by Copy Page to provide a place holder for CVD 4
Dr. Pealman from HERE on LEAVE on only Content you deem belonging to CVD 4
Electronic Table of Contents (eTOCs) of Volume Seven
Introduction to CVD 4
[please use also the Epilogue of Volume Two, OPINION Leadership: Add your own for every point, ADD points]
Part One:
may be on Curation Methodology and ACA
[a combination of Part One and Part Two from Volume TWO]
- Causes
- Risks and Biomarkers
- Therapeutic Implications
Part Two: Medical Devices for Cardiac Repair
[Search Category of Research all relevant to the topic – pull from the archive articles, Title, Author Name(s) URL (after QA, the Title becomes a LIVE link by using the URL, URL does not show any more]
- Causes
- Risks and Biomarkers
- Therapeutic Implications
Part Three: Interventional Cardiology
[go to Volume Two, Three, Four, Five – pull from there articles Title, Author Name(s), URL (after QA, the Title becomes a LIVE link by using the URL, URL does not show any more]
- Causes
- Risks and Biomarkers
- Therapeutic Implications
Part Four: Cardiac Surgery
[go to Volume Two, Three, Four, Five – pull from there articles, Title, Author Name(s), URL (after QA, the Title becomes a LIVE link by using the URL, URL does not show any more]
- Causes
- Risks and Biomarkers
- Therapeutic Implications
Part Five: Cardiovascular Imaging for Disease Diagnosis and Guidance of Treatment
[go to Volume Two, Three, Four, Five – pull from there articles, Title, Author Name(s), URL (after QA, the Title becomes a LIVE link by using the URL, URL does not show any more]
- Causes
- Risks and Biomarkers
- Therapeutic Implications
Summary to CVD 4
Epilogue to CVD 4
Introduction
ALL THE MATERIAL BELOW needs to be SORTED into the Five Parts of the e-Book
Complications: A Surgeon’s Notes on an Imperfect Science: Atul Gawande: 9780312421700: Amazon.com: Books
http://www.amazon.com/dp/0312421702/ref=pe_259560_33850340_pd_re_dt_dt1
and
Heart: An American Medical Odyssey Hardcover
PLEASE read these books and BASED on it please
Introduction to Volume SIX: Interventional Cardiology and Cardiac Surgery
- will include an overview of the e-Book eTOCs and few paragraphs about these books.
- will include few paragraphs about these books and any thoughts, observations on Interventional Cardiology and Cardiac Surgery
Dick Cheney, the former vice president, had the first of five heart attacks in 1978, when he was 37 years old and running in his first political campaign, to become a Republican in the House of Representatives in Wyoming. As consequences of multiple heart attacks, he became pacemaker dependent and then mechanical assist device dependent. He lived with the fear that enemies of the state might try to use RF reprogramming to kill him by reprogramming his pacemaker, so he had his doctors disable that feature. In 2010 the former vice president was within hours of dying from heart failure <http://www.usatoday.com/story/news/politics/2013/10/20/cheney-head–and-heart-strong/3107049/#> , when he was saved by urgent surgery to implant a left ventricular assist device with an external battery that kept him alive while he waited for a heart transplant. He received the call that he reached the top of the recipient list and a donor heart available for him 20 months later. “As I think about the future, I’m back where most people live their lives,” he told USA TODAY in an extended interview about Heart: An American Medical Odyssey, a new book he co-authored with cardiologist Jonathan Reiner. “Which is death is not imminent, and that’s different.”
Suggested articles for CVD 4
Endovascular Aortic Repair: A New Tool for Procedure Planning
Aviva Lev-Ari, PhD, RN
Is Pharmacogenetic-based Dosing of Warfarin Superior for Anticoagulation Control?
Aviva Lev-Ari, PhD, RN
Preserved vs Reduced Ejection Fraction: Available and Needed Therapies
Aviva Lev-Ari, PhD, RN
National Trends, 2005 – 2011: Adverse-event Rates Declined among Patients Hospitalized for Acute Myocardial Infarction or Congestive Heart Failure
Aviva Lev-Ari, PhD, RN
Developments on the Frontier of Transcatheter Aortic Valve Replacement (TAVR) Devices
Aviva Lev-Ari, PhD, RN
Acute Myocardial Infarction: Curations of Cardiovascular Original Research A Bibliography
Aviva Lev-Ari, PhD, RN and Larry H Bernstein, MD, FCAP
On-Hours vs Off-Hours: Presentation to ER with Acute Myocardial Infarction – Lower Survival Rate if Off-Hours
Aviva Lev-Ari, PhD, RN
Market Impact on Global Suppliers of Renal Denervation Systems by Pivotal US Trial: Metronics’ Symplicity Renal Denervation System FAILURE at Efficacy Endpoint
Aviva Lev-Ari, PhD, RN
Call for the abandonment of the Off-pump CABG surgery (OPCAB) in the On-pump / Off-pump Debate, +100 Research Studies
Aviva Lev-Ari, PhD, RN
Pre-operative Risk Factors and Clinical Outcomes Associated with Vasoplegia in Recipients of Orthotopic Heart Transplantation in the Contemporary Era.
Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
http://pharmaceuticalintelligence.com/2013/06/30/vasoplegia-in-orthotopic-heart-transplants/
Mechanical Circulatory Assist Devices as a Bridge to Heart Transplantation or as “Destination Therapy“: Options for Patients in Advanced Heart Failure
Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
http://pharmaceuticalintelligence.com/2013/06/30/advanced-heart-failure/
Heart Transplant (HT) Indication for Heart Failure (HF) – Procedure Outcomes and Research on HF, HT @ Two Nation’s Leading HF & HT Centers: Center for Heart Failure @Cleveland Clinic, and Transplant Center @Mayo Clinic
Aviva Lev-Ari, PhD, RN
After Cardiac Transplantation: Sirolimus acts as immunosuppressant Attenuates Allograft Vasculopathy
Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
Orthotropic Heart Transplant (OHT): Effects of Autonomic Innervation / Denervation on Atrial Fibrillation (AF) Genesis and Maintenance
Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
CABG Survival in Multivessel Disease Patients: Comparison of Arterial Bypass Grafts vs Saphenous Venous Grafts
Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
Coronary Reperfusion Therapies: CABG vs PCI – Mayo Clinic preprocedure Risk Score (MCRS) for Prediction of in-Hospital Mortality after CABG or PCI
Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN http://pharmaceuticalintelligence.com/2013/06/30/mayo-risk-score-for-percutaneous-coronary-intervention/
First-of-Its-Kind FDA Approval for ‘AUI’ Device with Endurant II AAA Stent Graft: Medtronic Expands in Endovascular Aortic Repair in the United States
Aviva Lev-Ari, PhD, RN
Bioabsorbable Drug Coating Scaffolds, Stents and Dual Antiplatelet Therapy
Aviva Lev-Ari, PhD, RN
Treatment of Refractory Hypertension via Percutaneous Renal Denervation
Aviva Lev-Ari, PhD, RN
PAD and Resistance Hypertension: Renal Artery Intervention using Stenting
Aviva Lev-Ari, PhD, RN
Invasive Procedures by Surgery versus Catheterization
The Voice of Series A Content Consultant: Justin D. Pearlman, MD, PhD
Coronary artery disease (blockages in blood supply) causes heart attacks by two methods: (1) severe narrowing that provides insufficient nutrition and oxygen to a region of heart muscle compared to its needs (hence the tissue commits a form of hara-kari called apoptosis), or (2) unstable plaque that can crack, cause localized hemorrhage into the wall of a coronary artery, and clot, suddenly stopping blood supply to a region of heart muscle. The blood supply to the heart consists of the left main (LM, a short vessel that promptly branches to the left anterior descending (LAD), and the left circumflex (LCX)), and the right coronary (RCA) which often gives rise to the posterior descending artery (PDA) (10% of patients get PDA blood supply as an extension of the LCX). Based on the normal branching pattern of blood supply to the heart, these lesions may cause heart attacks affecting different regions:
SOURCE for FIGURES
Robin Smithuis and Tineke Wilems
Radiology department of the Rijnland Hospital Leiderdorp and the University Medical Centre Groningen, the Netherlands.
http://rad.desk.nl/en/48275120e2ed5
- septum (anterior 2/3 of the interventricular septum, LAD),
- apex (distal LAD),
- anterior (mid LAD),
- pan-anterior (proximal LAD or LM),
- lateral (LCX),
- inferior wall (PDA, RCA or LCX) and
- right ventricle (RCA).
As one in four people eventually get a heart attack (myocardial infarction, death of heart muscle), and a third die from that, there have been great efforts atprevention. Heart attacks can be prevented by
(1) not smoking,
(2) small waist (<35 inches for women, <40 inches for men),
(3) prevent or control diabetes,
(4) control lipids/cholesterol.
Additional benefits have been demonstrated from fish oil (controversy about inconsistent association with prostate cancer not withstanding), alcohol (1/2 to 2 drinks daily elevates apoproteins and HDL which reverses lipid deposits in arterial walls), and statins even if LDL is not high, and possibly from red wine or grape congeners. All of these aim to prevent the development of blockages. Once blockages do develop, one may consider balloon angioplasty to open the obstruction, bare metal stent to keep it propped open, drug-eluting stent to inhibit reactive tissue growth, or bypass surgery.
While heart surgery is the primary means to improve quality and quantity of life from severe valve disease, there is a momentum building for less invasive competition analogous to the catheter approach to coronary artery disease.
Cardiothoracic Surgery
VIEW VIDEOS – Courtesy of YouTube as well as the individual sponsors of the links cited below.
VIDEO: Cardiac Surgery Simulation – Graphics Hardware meets Congenital Heart Disease
VIDEO: SPY Imaging: Quality in Heart Bypass Surgery
The Voice of Series A Content Consultant: Justin D. Pearlman, MD, PhD
The major cardiovascular surgeries include (1) coronary artery bypass grafting (CABG), (2) heart valve repair or replacement, (3) repair of a defect in the heart or a blood vessel, (4) reconstructions to compensate for a congenital defect, (5) insertion of a device to modify electric, pump or blood pressure control activities. Surgery on blood vessels outside the chest constitutes a separate specialty distinct from cardiothorasic .
The word bypass in relation to CABG has two meanings: (1) a bypass route to delivery blood around a narrow or obstructed segment, and (2) use of a bypass pump that circumvents the pumping role of the heart and the oxygenation role of the lungs so that the heart may be stopped for several hours with minimal interruption of delivery of oxygenated blood to the brain and the rest of the body (the brain does not tolerate >5-10 minutes interruption unless it is chilled). Venous blood is diverted to the bypass pump which oxygenates the blood
Cardiothoracic Surgery at Tertiary Academic Hospitals in the US
by Larry H Bernstein, MD, FCAP
The following articles are a review of a decade of cardiovascular surgery and interventional cardiology at the Presbyterian Hospital, Columbia University Medical Center and Weill Cornell Medical Center.
This section includes analysis of morbidity and mortality, including 10 year survival rates for coronary artery bypass grafts (CABG heart surgery) versus percutaneous catheter interventions (PCI), presented along with discussion of deficiencies inherent in such studies, and conclusions. The first major comparison addresses CABG vs Plain Old Balloon Angioplasty (POBA), showing similar survival rates at 10 years for patients qualifying for either procedure. The high rate ofrestenosis observed in PCI, requiring a second procedure, declined substantially in the time since the initial comparisons as a result of technological innovations instent design and in diameter of insertion device. The comparisons involve moving targets, as drug-eluting stents (DES) continue to improve. These studies involve 10,000 matched patients.
Mortality rates were adjusted using Cox proportional hazards method, adjusting for
- severity of disease
- comorbidity
- LAD only
- multiple vessel disease
As most patients are presented the options of catheter interventions versus bypass surgery, the results impact patient shared decision-making. An early study of CABG versus medical therapy was biased in favor of medical therapy, achieved by stringent exclusion criteria eliminating large percentage of patients with left main CAD and an ejection fraction of < 0.40. Many of these patient would have crossed over to CABG. The study was done prior to advances in medical therapy, as well as advances in imaging, myocardial protection, anesthesia, and LIMA.
The important findings are as follows:
- The long-term survival rates of CABG and PCI are comparable, if we compare a patient cohort that qualifies for both procedures.
- The Achille’s heel of PCI has been restenosis, but the risk of restenosis has declined with improved devices.
- The risk-adjusted in-hospital mortality for CABG vs stent was found to be comparable. There is an advantage to stenting, when:
- Patient is > 65 years
- Not an insulin-dependent diabetic
- Patient also has significant non-coronary vascular disease.
There is no intermediate-term survival advantage of CABG over stenting in patients with normal ejection fraction who have multivessel disease that can be treated percutaneously.
Randomized clinical trials established advantages of CABG over medical therapyin patients with
- triple-vessel CAD
- left main coronary artery stenosis
- double-vessel CAD with proximal left anterior descending (LAD) coronary artery stenosis
- left ventricular dysfunction
- insulin dependent diabetics
The Duke database study showed better survival rates with PTCA than with CABG in patients with single-vessel CAD, whereas CABG produced better survival than did PTCA in patients with severe, triple-vessel CAD. There are important considerations when reviewing these trials:
- stents were not used in the PTCA patients
- operative mortality rates for the CABG groups were higher than the rates currently found in the Society of Thoracic Surgeons (STS) database
- the inclusion/exclusion criteria of these studies eliminated a high percentage of those patients who might have benefited more from CABG than from PTCA
ADJUST article ID number per the Part Placement
Aviva Lev-Ari, PhD, RN
Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
Aviva Lev-Ari, PhD, RN
The Voice of Series A Content Consultant: Justin D. Pearlman, MD, PhD
As minimally interventional techniques improve, patients are offered a choice of invasive surgical remedies or less invasive procedures (video assisted, robotic, or percutaneous). The decision should not rest on the size of the scar or even the up front risk and discomfort, but rather should weigh all aspects of the risks and benefits. In addition to the risks and benefits for the current problem, one should also consider why the problem occurred and its likelihood of recurrence. Open chest surgery has a clear disadvantage when it comes to recurrences, as the scars from first surgery interfere with second surgery. Opening the chest (sternotomy) for a second or third time poses elevated risks analyzed herein. This article reviews data from major centers addressing the risks from repeat sternotomy and from minimally invasive cardiovascular surgeries. Any invasion of the body elevates risk of infection, which can lead to sepsis and possible death, so that risk is also addressed.
Justin D Pearlman and Aviva Lev-Ari
Catheter Interventions
The Voice of Series A Content Consultant: Justin D. Pearlman, MD, PhD
Arterial access typically starts by passing a needle through skin into an access artery, such as the femoral artery in the groin, or the radial artery at the wrist or brachial artery at the inside of the elbow. A wire is passed through the needle (Seldinger technique) to serve as a guide wire conducting hollow items into the artery. Once the wire is in place the needle is pulled off over the wire while the wire remains threaded into the artery, then the needle is replaced by plastic tubing, called an introducer, threaded over the guide wire. Large diameter tubing may require surgical cut down into the artery, and subsequent arterial repair (there are mechanical inserts that facilitate artery wall closure and repair). What occurs next depends on the target of treatment. To diagnose coronary artery obstructions, there are different designs of catheters consisting of long hollow tubing pre-shaped to catch the entrance of the left or right coronary arteries. To place a balloon across a lesion within a coronary artery is more challenging, so a longer thin guide wire is threaded down the catheter through the lesion, and a new catheter is threaded over that wire to place a balloon, and later a balloon with a stent on it, centered in the lesion, for deployment.
For percutaneous access (path starting by skin penetration into a blood vessel) to replace the aortic valve, the path is very similar to that for coronary arteries: femoral artery, up the aorta, around the arch of the aorta, to the aortic root. In theory, the mitral valve could be reached by passing through the aortic valve across the left ventricle, to the mitral valve, but the submitral apparatus would be hard to navigate. Alternatively, one may use venous access: femoral vein to inferior vena cava to right atrium, then pass through the foramen ovale (a trap door between right and left atria, normally closed after birth) into the left atrium, to the mitral valve, with no interference from the submitral (left ventrcular) apparatus of chordae and papilllary muscles.
Once the catheter is in place, it can be used to perform a number of procedures including
- coronary angiography
- flow reserve measurement
- balloon angioplasty (dilation and cracking of obstructions)
- stent placement
- balloon septostomy (creating an opening in the interatrial septum, to modify circulation impeded by congenital abnormalities)
- embolization to occlude a vessel or to inject alcohol to kill obstructive musle
- localize delivery of a thrombolytic or anti-spasm medication or angiogenesis or vasculogenesis or stem cell therapies
- percutaneous closure of a septal defect
- electrophysiology study
- ablation of dysfunctional electro-conductive pathways or arrhythmia riggers
- valvuloplasty
- valve placement
- aneurysm repair tube graft
The decision to intervene on a vascular lesion considers:
- length of the abnormal segment
- flow reserve (physiologic impact)
- patient age and co-morbidities (ailments)
- extent of calcification
- renal function
- pathway to the lesion
- branch anatomy that may be affected by the planned intervention
There has been considerable controversy about the role of catheterization (percutaneous catheter intervention or PCI) as an alternative to coronary artery bypass surgery (CABG). PCI has clearly been vital when applied within the first hour of a discrete coronary occlusion (heart attack) and may be as valuable even out to 12 or more hours, particularly with incomplete injuries (“stuttering heart attack”). Both PCI and CABG relieve chest pain due to impaired blood supply to the heart (ischemia). CABG provides alternate routes for blood delivery competing with the diseased segments, while PCI repairs (recanulates) selected obstructed segments of coronary arteries. PCI is faster and may be repeated far more often in the future. Benefits on life expectancy have been more challenging to demonstrate. While early comparisons demonstrated advantage of surgery for diabetics and patients with 3 vessel obstruction or left main obstruction or equivalent, the continual changes in technique for both surgery and PCI require updated comparisons. PCI has evolved from plain old balloon angioplasty (POBA), which lead to early restenosis (recurrence of narrowing in the arterial channel) and/or thrombosis (clot formation), requiring repeated interventions often within 6 months. Stents (wire cages to keep the vessels open) addressed the early restenosis problem, but reaction to the metal results in another mechanism for early failure: endotherial tissue in-growth (in-stent stenosis) as well as more frequent thrombosis. Use of stronger antiplatelet medications (e.g., aspirin plus clopidogrel) reduced the thrombosis issue, and addition of medications in the stent to block endothelial growth (drug-eluting stents, DES) reduced the problem with in-stent stenosis but prolonged the problem with thrombosis.
As a general clinical rule, the aspirin and clopidogrel interfere with platelet function sufficient to put off any surgeries – the anti-platelet treatment after stent is deemed uninterruptable for 1-2 months after a bare metal stent, and 6-12 months after a drug-eluting stent, with fading benefit thereafter over 2 years (then aspirin alone can suffice). Genetic studies identified that some patients are not protected by clopidogrel plus aspirin, so further studies investigate alternatives such as prasugrel and ticagrelor. Clopidogrel is a thienopyridine which selectively and irreversibly inhibits the platelet adenosine 5’-diphosphate (ADP) P2Y12 receptor, further inhibiting platelet aggregation (the “white” component of blood clots) over aspirin alone. The Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) trial, randomly assigned 12,562 patients with acute coronary syndrome (ACS) to receive clopidogrel (300 mg loading followed by 75 mg once daily) or placebo in addition to aspirin for 3 to 12 months; after an average follow-up of 9 months, the major adverse cardiovascular event rate (MACE= death from cardiovascular causes, myocardial infarction or stroke) occurred in 9.3% vs 11.4%, respectively (P < 0.001), due to fewer myocardial infarctions in those treated with clopidogrel (5.2% vs 6.7%, P < 0.001). Prasugrel is a thienopyridine ADP receptor inhibitor, which irreversibly binds to the P2Y12 receptor. In comparison to clopidogrel, prasugrel acts more quickly, more consistently, and more potently, and its value was examined in the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-TRITON-TIMI 38. Analysis of 13,608 patients treated with Prasugrel 60 mg loading dose and a 10 mg daily maintenance dose versus clopidogrel 300 mg loading dose and a 75 mg daily maintenance dose showed prasugrel more was effective than clopidogrel in reducing MACE (9.9% vs 12.1%, P < 0.001), due to fewer myocardial infarctions (7.3% vs 9.5%, P < 0.001), but at the cost of increased major bleeds (2.5% of those treated with prasugrel vs 1.7% of those treated with clopidogrel, P = 0.001, with CABG-related major bleeding 0.4% vs 0.1%, P = 0.001). Ticagrelor is a reversible inhibitor of platelet P2Y12-subtype ADP receptor, which means a switch of plans to CABG need not be delayed for the 9 days it takes permanent platelet inhibition to wear off. The Platelet Inhibition and Patient Outcomes (PLATO) studyrandomized 18,624 patients with ACS to 180 mg loading dose, then 90 mg twice dailyof ticagrelor vs 300-600 mg loading dose, then 75 mg daily of clopidogrel for 12 months. The risk of MACE was reduced by ticagrelor (9.8% vs 11.7%, P < 0.001), due to reduced death from all causes (4.5% vs 5.9%, P < 0.001), death from vascular causes (4.0% vs 5.1%, P = 0.001), myocardial infarction (5.8% vs 6.9%, P = 0.005), and stent thrombosis (1.3% vs 1.9%,P = 0.009), at a cost of increased major bleeding (2.8% vs 2.2%, P = 0.030).
VIEW VIDEOS – Courtesy of YouTube as well as the individual sponsors of the links cited below.
VIDEO: Coronary artery stents in Atherosclerosis
The Voice of Series A Content Consultant: Justin D. Pearlman, MD, PhD
In an uncommon reversal of opinion, the combined forces of the American Heart Association (AHA) and the American College of Cardiology (ACC) reviewed compelling data and reversed a prior assessment on the need for an on-site cardiovascular surgery support for sites offering interventional cardiac catheterization. The data show that sites offering the intervention without a surgeon achieve better results that sites that ship patients out for the interventions, and that the risk without on-site thoracic surgery backup is negligible.
Larry H Bernstein, MD, FCAP and Justin D Pearlman, MD, PhD, FACC
Improvements in stenting
- DES stents have decreased the rate of acute and subacute periprocedural thrombosis
- the RAVEL trial excluded patients with lesions longer than 18 mm, ostial targets, calcified or thrombosed targets, or target arteries less than 2.5 mm in diameter.
The lesion and patient characteristics that lead to the failure of PCI are multifactorial, but more patients with unfavorable features are being treated with PCI. Despite an increasingly older and sicker patient population, CABG outcomes continue to improve, and operative mortality rates have decreased because advances in preoperative evaluation, including
- more precise coronary artery targeting and
- myocardial imaging and
- diagnostic techniques,
5.2.2 Coronary Artery Disease – Medical Devices Solutions: From First-In-Man Stent Implantation, via Medical Ethical Dilemmas to Drug Eluting Stents |Comments »
Aviva Lev-Ari, PhD, RN
5.2.3 Absorb™ Bioresorbable Vascular Scaffold: An International Launch by Abbott Laboratories |Comments »
Aviva Lev-Ari, PhD, RN
5.2.4 To Stent or Not? A Critical Decision
Aviva Lev-Ari, PhD, RN
5.2.5 New Drug-Eluting Stent Works Well in STEMI: Meta-analysis makes the Case
Aviva Lev-Ari, PhD, RN
Larry H Bernstein, MD, FACP and Aviva Lev-Ari, PhD, RN
Aviva Lev-Ari, PhD, RN
5.2.8 Of the Cardiac-specific deaths, Deaths from Heart Attack and Sudden Heart Rhythm Disturbances declined steeply, but there was no decline in deaths from Heart Failure in a 20,000 PCI patients Study @ Mayo Clinic
Aviva Lev-Ari, PhD, RN
REFERENCES
[1] Kim MH, Kim HJ, Kim NN, Yoon HS, Ahn SH. “A rotational ablation tool for calcified atherosclerotic plaque removal”, Biomed Microdevices. 2011 Dec;13(6):963-71. doi: 10.1007/s10544-011-9566-y.
Comparison of outcomes: surgery versus catheter intervention
Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
5.3.3 CABG or PCI: Patients with Diabetes – CABG Rein Supreme
Aviva Lev-Ari, PhD, RN
5.3.4 Revascularization: PCI, Prior History of PCI vs CABG
Aviva Lev-Ari, PhD, RN
5.3.5 Female and Non-Atherosclerotic Plaque: Spontaneous Coronary Artery Dissection – New Insights from Research and DNA Ongoing Study
Aviva Lev-Ari, PhD, RN
Transcatheter (Percutaneous) Valves
The Voice of Series A Content Consultant: Justin D. Pearlman, MD, PhD
As catheter techniques evolved to compete with bypass surgery they progressed from balloon cracking of obstructive lesions (POBA, detailed above) to placement of stents (wire cages). Surgeons sometimes use in-stent valves, and now devices analogous to in-stent valves can be placed by catheter for valve replacement in patients with too much co-morbidity to go through heart surgery. The diameter is large, so a vascular surgeon participates in the arterial access and repair of the access site.
Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
Aviva Lev-Ari, PhD, RN
5.3.5 Direct Flow Medical Wins European Clearance for Catheter Delivered Aortic Valve| Comments »
Aviva Lev-Ari, PhD, RN
5.3.6 Transcatheter Aortic-Valve Replacement for Inoperable Severe Aortic Stenosis
Aviva Lev-Ari, PhD, RN
5.3.7 Expected New Trends in Cardiology and Cardiovascular Medical Devices
Aviva Lev-Ari, PhD, RN
5.3.8 The development of technology requires finance, planning, investment interest and enthusiasm for innovation. Briefing on ILSI – BioMed Conference, May 21-23, 2012 in Tel Aviv, Israel
Aviva Lev-Ari, PhD, RN
Transcatheter (Percutaneous) Pumps
The Voice of Series A Content Consultant: Justin D. Pearlman, MD, PhD
With respect to the performance of Mitral Valve Replacement, the current practice favors bioprosthetics valves over mechanical valve replacement.
Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
Patients with heart failure develop abnormal breathing patterns mediated by the phrenic nerve which controls diaphragm contractions. Nerve stimulators enable computer control to change such patterns. In particular, there is an abnormal pattern of breathing called Cheyne-Stokes Respiration characterized by progressively deeper and/or faster breathing followed by a decrease leading to a brief stoppage of breathing. Investigators have looked at taking control of the phrenic nerve to alleviate the Cheyne-Stokes abnormal respiration pattern.
5.4.2 Phrenic Nerve Stimulation in Patients with Cheyne-Stokes Respiration and Congestive Heart Failure
Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
5.4.3 Heart Remodeling by Design – Implantable Synchronized Cardiac Assist Device: Abiomed’s Symphony | Comments
Aviva Lev-Ari, PhD, RN
5.5: Peripheral Vascular Disease in PCI and in Surgery
The Voice of Series A Content Consultant: Justin D. Pearlman, MD, PhD
Peripheral Vascular Disease commonly refers to problems with branch vessels from the aorta to the head and limbs, but often is extended to include problems in the aorta such as excessive regional dilation (aneurysm). While less widely distributed than coronary artery treatment centers, there are numerous centers with varied offerings to treat peripheral vascular disease. The examples cited are with no intended prejudice regarding other quality centers.
As with catheter intervention versus bypass surgery, left ventricular assist devices (LVAD) versus heart transplant, percutaneous valve replacement versus heart valve surgery, so too, there are advances in less invasive treatment of blocked arteries to the brain or to the limbs. The use of stents to revascularize the arteries to the brain raised grave concerns about emboli (blood born debris) but results have been quite good.
We have seen in the evolution of endovascular surgery mirroring the advances applied to coronary artery stenosis treatments, starting with balloon dilation, then stents (wire cages to keep the vessel open) then drug-eluting stents (DES) to suppress problems from tisssue reaction to stents. Peripheral arteries have larger diameter than coronary arteries so there are problems with insertion and post-insertion restenosis. The stent diameters require a wide range to fit the need.
Onyx glue has been successful for sealing leaks after endovascular repair.
Introduction to Peripheral Vascular Disease and Vascular Surgery
by Larry H Bernstein, MD, FCAP
There are many famous centers focused on the treatment of vascular disease. The clear benefit of completing revascularization within one hour of onset of a heart attack has promoted dissemination of catheter interventions and cardiac surgery throughout the country. There are fewer centers of excellence for peripheral vascular disease. Without prejudice, we discuss details of the offerings at specific centers.
This series depicts the scientific and medical contributions of the Vascular Surgery Section at Massachusetts General Hospital, including carotid artery, thoracic and abdominal aortic aneurysm, under Dr. Richard Cambria. The published work ranges from standards definition related to the type of procedure and complexity based on comorbidities and surgical volume to special problems encountered in endovascular surgery of thoracic aorta, abdomenal aorta, carotid artery, and vessels of the lower extremities. These are topics discussed:
1. Impact of hospital volume and type on outcomes of open and endovascular repair of descending thoracic aneurysms in the United States Medicare population.
2. Why calls for more routine carotid stenting are currently inappropriate: an international, multispecialty, expert review and position statement; Predictors of clamp-induced electroencephalographic changes during carotid endarterectomies; Centers for Medicare and Medicaid Services conducts a medical evidence development and coverage advisory committee meeting on carotid atherosclerosis. Centers for Medicare and Medicaid Services conducts a medical evidence development and coverage advisory committee meeting on carotid atherosclerosis: executive summary.
3. Commentary regarding “lower-extremity endovascular interventions for Medicare beneficiaries: comparative effectiveness as a function of provider specialty” by Zafar et al. J Vasc Interv Radiol 2012; 23:3-9.
4. Impact of chronic kidney disease on outcomes after abdominal aortic aneurysm repair.
5. Improved results using Onyx glue for the treatment of persistent type 2 endoleak after endovascular aneurysm repair.
There are key points to be learned in this material offered. Hospitals that have volumes are not only less restrictive in the procedures they handle, but also they have a staff that can handle the most difficult cases. The special problems of carotid stenting are made clear, and special problems of endovascular surgery on the aorta near the origin of the renal arteries are discussed.
The characteristics of a peripheral target artery that influence graft patencyinclude:
- the diameter of the target artery
- the presence or absence of diffuse disease within the artery
- whether or not the artery requires endarterectomy
Aviva Lev-Ari, PhD, RN
Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
Similarly, catheter-based interventions offer less invasive alternatives to open surgery for the abdomenal aorta.
Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
Aviva Lev-Ari, PhD, RN
5.5.8 Vascular Repair: Stents and Biologically Active Implants
Larry H Bernstein, MD, FACP, and Aviva Lev-Ari, PhD, RN
5.5.9 Resistance Hypertension: Renal Artery Intervention using Stenting
Aviva Lev-Ari, PhD, RN
Cardiovascular Renal Interventions
Market Impact on Global Suppliers of Renal Denervation Systems by Pivotal US Trial: Metronics’ Symplicity Renal Denervation System FAILURE at Efficacy Endpoint
Aviva Lev-Ari, PhD, RN
5.6.1 The Cardio-Renal Syndrome (CRS) in Heart Failure (HF)
Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
5.6.2 Renal Sympathetic Denervation: Updates on the State of Medicine| Comments »
Aviva Lev-Ari, PhD, RN
5.6.3 Renal Denervation Technology of Vessix Vascular, Inc. been acquired by Boston Scientific Corporation (BSX) to pay up to $425 Million |Comments »
Aviva Lev-Ari, PhD, RN
Aviva Lev-Ari, PhD, RN
5.6.5 Treatment of Refractory Hypertension via Percutaneous Renal Denervation
Aviva Lev-Ari, PhD, RN
5.6.6 Imbalance of Autonomic Tone: The Promise of Intravascular Stimulation of Autonomics |Comments »
Aviva Lev-Ari, PhD, RN
Hybrid Operating Rooms and Catheterization Suites
The New Hyrid Operating Room. Westchester Medical Ceneter
VIEW VIDEO: Inova Heart and Vascular Institute: New ‘Hybrid’ Operating Room [DEFECTIVE VIDEO, PL. EXCHANGE}
Aviva Lev-Ari, PhD, RN
Minimally invasive repair of the aorta: Whereas atherosclerosis offers stiffening of the arterial wall, failure can lead to an outward ballooning, or aneurysm, that promotes clot formation and rupture (a cause of sudden death). Passage of a needle, then wire, then catheter, then stent delivery system, offers repair without surgery.
Aviva Lev-Ari, PhD, RN
Heart & Heart-Lung Transplant
Introduction
by Larry H Benstein, MD, FCAP and Justin Pearlman MD PhD FACC
While heart surgery is the primary means to improve quality and quantity of life from severe valve disease and/or heart failure, there is a momentum building for less invasive competition analogous to the alternative to surgery achieved by the catheter approach to coronary artery disease, and there are mechanical means of supporting a failing heart that can delay or possibly serve as an alternative to transplantation.
This section presents examples of achievements relating to preparation for or performance of heart or heart lung transplants lead by centers of excellence in cardiothoracic and vascular surgery, without any intention of ranking or subjugating the numerous other centers of excellence. For example, the Mayo Clinic in Rochester Minnesota has fame for excellence, but it also has very strong competition from Rush Medical Center in Chicago, the University of Michigan, Ann Arbor, the Henry Ford Hospital and the William Beaumont Hospital in Oakland, Michigan, to name a few other centers of excellence in the region. Similarly, Centers of Excellence in San Diego have regional competition from UCLA, Cedars-Sinai, Stanford and UC San Francisco. The Cleveland Clinic is now developing an educational venture with the outstanding Western-Reserve Medical School, a short distance away, in Cleveland, Ohio.
Aviva Lev-Ari, PhD, RN
Larry H Bernstein, MD, FCAP and Justin D Pearlman, MD, PhD, FACC
Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
5.8.4 Heart Transplantation: NHLBI’s Ten year Strategic Research Plan to Achieving Evidence-based Outcomes
Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
Heart transplants (and heart lung transplants) require immune suppression so that the body defenses against foreign cell activities such as infection, cancer or transplants to not succeed in rejecting the transplant. Thus transplant patients have risks not only of organ rejection (autoimmune attack) but also serious infections and cancers. Replacing the original organ with one from a donor ( orthotopic transplant) comes with serious complications. In addition to transplant rejection, infection, cancer, accelerated atherosclerosis, also vasoplegia is a serious problem of increased vascular resistance thought to be due to dysregulation of endothelial homeostasis and subsequent endothelial dysfunction secondary to direct and indirect effects of multiple inflammatory mediators. Vasoplegia has been observed in all age groups and in other clinical settings besides transplants; vasoplegia has also been associated with protamine reaction, other anaphylaxis, sepsis, hemorrhagic shock, or hemodialysis.
5.8.6 After Cardiac Transplantation: Sirolimus acts asimmunosuppressant Attenuates Allograft Vasculopathy
Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
5.8.7 Prognostic Marker Importance of Troponin I in Acute Decompensated Heart Failure (ADHF)
Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
Larry H Bernstein, MD, FCAP and Justin D Pearlman, MD, PhD, FACC
Summary by Larry H Bernstein, MD, FCAP
The Cleveland Clinic has a worldwide reputation in cardiothoracic surgery heart transplantation. Transplant is the final step in rescue of patients with advanced heart failure who have no other option in the short run or long run. There are not a large number of procedures done, and the procedure could not be done without the use of mechanical support. The technology for such support is excellent at this time. In some cases a patient might require temporary support, and in others, long term support prior to a heart transplant. The orthotopic heart transplant comes with serious complications, one of which is vasoplegia. Vasoplegia is a serious problem of increased vascular resistance thought to be due to dysregulation of endothelial homeostasis and subsequent endothelial dysfunction secondary to direct and indirect effects of multiple inflammatory mediators. Vasoplegia has been observed in all age groups and in various clinical settings, such as anaphylaxis (including protamine reaction), sepsis, hemorrhagic shock, hemodialysis, and cardiac surgery.
Electric System of the Heart: Pacemakers & Implantable Cardiac Defibrillators (ICD)
The Voice of Series A Content Consultant: Justin D. Pearlman, MD, PhD
The Electric System of the heart communicates when each portion of the heart should contract (beat). An enlarged failing heart has longer pathways often with the complication of asynchronous contraction (timed poorly electric activation of muscle movement), so different parts activate staggered over time instead of as a coordinated effort, resulting in a relatively uncoordinated wobble rather than a maximally effective beat). Cardiac Resynchronization consists of inserting a plurality of pacemaker wires designed and adjusted to compensate for bad timing so that the contraction effort is more synchronized. If the electrical activation is asynchronous, then assuming that the axis of maximal difference in timing is parallel to one of the electrocardiogram (ECG) lead views, then the ECG will show wide activation in at least one lead (QRS duration > 120 msec). Both MRI and Echo imaging have been applied to identify the axis of maximal difference in timing to help guide placement of lead wires in the heart and timing offsets between the lead wire stimulations of regional heart contraction. Unfortunately, if leads are placed by catheter, the location choices are limited: the apex of the right ventricle, and a left ventricular branch of the coronary sinus. At surgery, there is greater freedom to place epicardial leads at favorable locations in viable myocardium. If the heart is prone to dangerous dysrhythmias such as ventricular tachycardia or ventricular fibrillation, pacing can sometimes help, but the surest method is delivery of an electric shock to stop the bad rhythm, and resynchronize preparation for a better rhythm. The decision of when to burst pace and when to shock is computed by an implantable computer chip as part of an implantable cardiac defibrillator (ICD). Patients with irreversible heart failure with ejection fraction remaining <35% after >3 months of optimized triple therapy (beta blocker, angiotensin-converting-enzyme inhibitor, aldosterone inhibitor) are prone to death from arrhythmia, and may live considerably longer with an ICD.
Justin D Pearlman, MD, PhD, FACC and Aviva Lev-Ari, PhD, RN
A novel approach uses micoscopic gold particles to impart electric signal to the heart.
Aviva Lev-Ari, PhD, RN
6.3 Therapeutic Implications of Calcium in Arrhythmia
Justin D Pearlman, MD, PhD, FACC, Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
Aviva Lev-Ari, PhD, RN
Chapter 7
Cardiovascular Biomaterials Technology
Biomaterials technology generates scaffolds for cells and/or alternatives to biologic tissues.
Larry H Bernstein, MD, FACP and Aviva Lev-Ari, PhD, RN
7.2 Gene, Meis1, Regulates the Heart’s Ability to Regenerate after Injuries
Aviva Lev-Ari, PhD, RN
Aviva Lev-Ari, PhD, RN
7.4 Three-Dimensional Fibroblast Matrix Improves Left Ventricular Function post MI
Larry H. Bernstein, MD. FCAP and Aviva Lev-Ari, PhD, RN
7.5 PENDING
REFERENCES
[1] Robert A. Freitas Jr., Nanomedicine, Volume I: Basic Capabilities, Landes Bioscience, Georgetown, TX, 1999
BIOMARKERS
Aviva Lev-Ari, PhD, RN
2.10 Routine fasting blood lipid studies estimate the bad cholesterol (LDL) based on the total and the triglyceride level. Direct LDL measurements are available and inexpensive. The indirect estimate can be off. Hypertriglyceridemia concurrent Hyperlipidemia: Vertical Density Gradient Ultracentrifugation a Better Test to Prevent Undertreatment of High-Risk Cardiac Patients
Aviva Lev-Ari, PhD, RN
2.11 Stiffness of the left ventricle, aorta, and ventricular-arterial coupling can be estimated from blood pressure, stroke volume and ejection fraction. iElastance: Calculates Ventricular Elastance, Arterial Elastance and Ventricular-Arterial Coupling using Echocardiographic derived values in a single beat determination.
Aviva Lev-Ari, PhD, RN
2.12 High blood pressure in children leads to stiff blood vessels in the adults. IF Elevated Pediatric Blood Pressure THEN High Adult Arterial Stiffness
Aviva Lev-Ari, PhD, RN
3.1 Assessing Cardiovascular Disease with Biomarkers Comments
Larry H Bernstein MD FACP
3.2 Assessing CVD with Biomarkers – Commentary
—Fillingane S Pharmaceutical Intelligence 12/29/12
Chapter 3.1: Atherosclerosis Markers
3.1.2 Artherogenesis: Predictor of CVD – the Smaller and Denser LDL Particles
Aviva Lev-Ari, PhD, RN
3.1.4 Cardiovascular Risk Inflammatory Marker: Risk Assessment for Coronary Heart Disease and Ischemic Stroke – Atherosclerosis. Comments
Aviva Lev-Ari, PhD, RN
3.1.5 Coronary artery disease in symptomatic patients referred for coronary angiography: Predicted by Serum Protein Profiles Comments
Aviva Lev-Ari, PhD, RN
Chapter 3.2: Vascular and Coagulation Markers
3.2.1 Cardiovascular Risk: C-Reactive Protein BioMarker and Plasma Fibrinogen
Aviva Lev-Ari, PhD, RN
3.2.1 What is the role of plasma viscosity in hemostasis and vascular disease risk? | Comments
Larry H Bernstein, MD, FACP and Aviva Lev-Ari, PhD, RN
3.2.2 Special Considerations in Blood Lipoproteins, Viscosity, Assessment and Treatment |Comments »
Larry H Bernstein, MD, FACP and Aviva Lev-Ari, PhD, RN
3.2.3 Serum Pentraxin 3 Levels, a newly identified inflammatory marker, indicate the complexity and severity of Coronary Artery Disease (CAD), for patients with stable angina. 15 Novel Risk Loci for Coronary Artery Disease: found by International Consortium |Comments »
Aviva Lev-Ari, PhD, RN
3.2.4 Telling NO to Cardiac Risk |Comments »
Stephen J Williams, PhD
3.2.5 Nitric Oxide Function in Coagulation
Larry H Bernstein, MD, FACP
3.2.6 Nitric Oxide, Platelets, Endothelium and Hemostasis |Comments »
Larry H Bernstein, MD, FACP
3.2.7 Peroxisome proliferator-activated receptor (PPAR-gamma) Receptors Activation: PPARγ transrepression for Angiogenesis in Cardiovascular Disease and PPARγ transactivation for Treatment of Diabetes |Comments »
Aviva Lev-Ari, PhD, RN
3.2.8 Identification of Biomarkers that are Related to the ActinCytoskeleton
Larry H Bernstein, MD, FACP
Chapter 3.3: Hypertension Markers
3.3.1 A Second Look at the transthyretin (pre-albumin) Nutrition Inflammatory Conundrum
Larry H Bernstein, MD, FACP
Plasma Renin level reports the amount of hormonal vasoconstriction, which, in excess, can cause severe elevation of blood pressure.
3.3.2 An Important Marker of Hypertension in Youth
Manuela Stoicescu, MD, PhD
Aviva Lev-Ari, PhD, RN
3.3.4 Recombinant Human lecithin-cholesterol acyltransferase (rhLCAT): New Biomarker for Atherosclerosis
Aviva Lev-Ari, PhD, RN
3.3.5 Identification of Biomarkers that are Related to the Actin Cytoskeleton
Larry H Bernstein, MD, FCAP
3.3.6 Coagulation: Transition from a familiar model tied to laboratory testing, and the new cellular-driven model |Comments »
Larry H Bernstein, MD, FACP
Chapter 3.4: Myocardial Markers
The Voice of Series A Content Consultant: Justin D. Pearlman, MD, PhD
New assays can measure cardiac Troponin in the single digit range of nanograms per liter (picograms per milliliter). Troponin is a protein that belongs inside heart muscle cells, so elevated levels in blood implicate heart injury. However, healthy patients may have elevated levels, sometimes explainable from slowed renal clearance or cross-reactive antibodies, but often not explained and yet with no evidence of heart attack. There is a bias: health services reward diagnosis of myocardial injury, and Troponin elevation can be declared a “Non-STEMI” myocardial injury or myocardial infarction to earn such credits. Then a “validation” study that looks at hospital discharge diagnosis will see a high predictive value of elevated Troponin and “myocardial injury” which may be circular.
3.4.1 Dealing with the Use of the High Sensitivity Troponin (hs cTn) Assays.
Larry H Bernstein MD FACP
3.4.2 Identification of Biomarkers that are Related to the Actin Cytoskeleton
Larry H Bernstein, MD, FCAP
3.4.2 Amyloidosis inserts abnormal proteins into tissues – in the heart, that results in an insidious decline cardiac function marked by increased stiffness (requiring high filling pressures that wet the lungs) and decreased contractility or inotropy (pumping ability). resulting in poor circulation of nutrients to tissues and organs. Amyoloidosis is suspected when imaging shows thickened heart muscle and thickened valves with reduced function, but thickened muscle also occurs as a reaction to incomplete control of elevated blood pressures, as well as by other infiltrative disorders.
Amyloidosis with Cardiomyopathy
Larry H Bernstein, MD, FACP
Protein malnutrition lowers the oncotic (partical) pressure that keeps fluid in circulation, resulting in edema unrelated to heart failure. Transthyretin (pre-albumin) is used as a biomarker because its rapid clearance increases the significance of its concentration. However, it is also an “acute phase reactant” which means acute illness can temporary spoil its value as a biomarker of chronic states.
Predicting Outcomes
Collecting data on death rates and prior lab values can identify associations. It is important to consider the biologic plausibility
Aviva Lev-Ari, PhD RN
When different factors can relate to eventual harm, it is helpful to analyze which has stronger impact as a predictor: heaviness of the heart (LV mass), or wall stiffness.
Aviva Lev-Ari, PhD RN
5.3 Accurate Identification and Treatment of Emergent Cardiac Events
Author: Larry H Bernstein, MD, FACP
Vascular Biology
The cardiovascular system is spread over a larger territory – the entire body. Coordination of functions requires signals be sent by either the nervous system or in the blood. A very small molecule, nitric oxide, controls dilation or contraction of muscular blood vessels, to adjust flow impedance, blood pressure, target tissue perfusion, and workload on the heart.
5.1 Prostacyclin and Nitric Oxide: Adventures in Vascular Biology – A Tale of Two Mediators
Aviva Lev-Ari, PhD, RN
Artery walls use a simple molecule, nitric oxide, as a signal to adjust the diameter of each vessel appropriately for the variable demands of blood delivery.
5.2 Differential Distribution of Nitric Oxide – A 3-D Mathematical Model Comments »
Anamika Sarkar, PhD
5.3 Perspectives on Nitric Oxide in Disease Mechanisms
Aviral Vatsa, PhD and Larry H. Bernstein, MD, FACP
5.4 Interaction of Nitric Oxide and Prostacyclin in Vascular Endothelium
Larry H. Bernstein, MD, FACP
5.5 Endothelial Function and Cardiovascular Disease
Larry H Bernstein, MD, FACP
Aviva Lev-Ari, PhD, RN
5.9 Models for disease may be constructed from simple biologic systems. Engineered Microvessels Provide a 3-D Test Bed for Human Diseases
Prabodh Kandala, PhD
Part Five
Cardiovascular Imaging
for
Disease Diagnosis and Guidance of Treatment
CVD1,2,3 – VIDEOS to IMPORT from there
- Causes
- Risks and Biomarkers
4.4 Cardiovascular Imaging: Diagnosing the Condition of the Disease and Determining Course of Treatment
The Roll of Medical Imaging in Personalized Medicine
Dror Nir, PhD
4.4.1 Imaging Biomarker for Arterial Stiffness: Pathways in Pharmacotherapy for Hypertension and Hypercholesterolemia Management
Justin Pearlman, MD, PhD, FACC and Aviva Lev-Ari, PhD, RN
4.4.2 Coronary Circulation Combined Assessment: Optical Coherence Tomography(OCT), Near-Infrared Spectroscopy (NIRS) and Intravascular Ultrasound (IVUS) – Detection of Lipid-Rich Plaque and Prevention of Acute Coronary Syndrome (ACS)
Justin Pearlman, MD, PhD, FACC and Aviva Lev-Ari, PhD, RN
4.4.3 Emerging Clinical Applications for Cardiac CT: Plaque Characterization, SPECTFunctionality, Angiogram’s and Non-Invasive FFR
Justin Pearlman, MD, PhD, FACC and Aviva Lev-Ari, PhD, RN
4.4.4 Fractional Flow Reserve (FFR) & Instantaneous wave-free ratio (iFR): An Evaluation of Catheterization Lab Tools (Software Validation) for Ischemic Assessment (Diagnostics) – Change in Paradigm: The RIGHT vessel not ALL vessels
Justin Pearlman, MD, PhD, FACC and Aviva Lev-Ari, PhD, RN
4.4.5 Acute and Chronic Myocardial Infarction: Quantification of Myocardial Perfusion Viability – FDG-PET/MRI vs. MRI or PET alone
Justin Pearlman, MD, PhD, FACC and Aviva Lev-Ari, PhD, RN
- Therapeutic Implications
5.4.1 3D Cardiovascular Theater – Hybrid Cath Lab/OR Suite, Hybrid Surgery, Complications Post PCI and Repeat Sternotomy
Aviva Lev-Ari, PhD, RN
Normal and Anomalous Coronary Arteries: Dual Source CT in Cardiothoracic Imaging
Justin D Pearlman, MD, PhD, FACC and Aviva Lev-Ari, PhD, RN
Carotid Ultrasound more sensitive for Detecting Subclinical Atherosclerosis in patients with rheumatoid arthritis (RA) than CT with calculation of Coronary Artery Calcification Scores
Aviva Lev-Ari, PhD, RN
Echocardiogram Quantification: Quest for Reproducibility and Dependability
Aviva Lev-Ari, PhD, RN
Detecting and Treating Silent Heart Disease: NewYork-Presbyterian Hospital andWeill Cornell Medical College Launch New Institute
Aviva Lev-Ari, PhD, RN
CT Angiography & TrueVision™ Metabolomics (Genomic Phenotyping) for new Therapeutic Targets to Atherosclerosis
Aviva Lev-Ari, PhD, RN
Ischemic Stable CAD (FFR): In >5000 Patients – Medical Therapy and PCI no difference in End Point: Meta-Analysis of Contemporary Randomized Clinical Trials
Aviva Lev-Ari, PhD, RN
Computationally designed “self”-peptide could be used to better target drugs to tumors, to ensure pacemakers are not rejected, and to enhance medical imaging technologies
Aviva Lev-Ari, PhD, RN
The FDA announced a partnership with a new nonprofit organization—the Medical Device Innovation Consortium (MDIC) —to advance regulatory science in the medical technology arena, e.g., promoting advanced cardiovascular imaging. | Comment
Aviva Lev-Ari, PhD, RN
Decisions about management of cardiovascular disease can get complex, and computer models may be useful. The following article discusses cost-benefit analysis, decision trees, and computer decision support systems, with specific examples.
3.2 Clinical Decision Support Systems for Management Decision Making of Cardiovascular Diseases
Justin D Pearlman, MD, PhD and Aviva Lev-Ari, PhD, RN
3.3 The potential contribution of informatics to healthcare is more than currently estimated |Comment »
Larry H. Bernstein, MD, FACP
3.4 Expected New Trends in Cardiology and Cardiovascular Medical Devices
Aviva Lev-Ari, PhD, RN
3.5 New Definition of MI Unveiled, Fractional Flow Reserve (FFR)CT for Tagging Ischemia
Aviva Lev-Ari, PhD, RN
The adequacy of coronary arteries (blood supply to the heart) to adapt to challenges is measured as fractional flow reserve. That measurement use to require catheterization, but now that can be computed from CT imaging. Same for Flow Limiting Lesions, for Anatomic Stenosis Severity in Chronic Total Occlusion (CTO).
Justin D Pearlman, MD, PhD, FACC and Aviva Lev-Ari, PhD, RN
Therapeutic endpoints for treatment of atherosclerosis have relied on lipid blood tests, but benefits of statins occur in patients with normal “target” levels prior to therapy. Some have argued the benefits relate not only to changes in blood lipids but also anti-inflammatory effects of statins. Carotid intimal thickness by high frequency ultrasound has been offered as an alternative method to guide sucess of halting and/or reversing plaque build up in arteries. The following article aims to offer another method which can be applied to coronary arteries, the aorta, and other vessels not reachable by surface high frequency ultrasound.
3.7 Advanced CT Reconstruction: Plaque Estimation Algorithm for Fewer Errors and Semiautomation
Aviva Lev-Ari, PhD, RN
Minimally invasive imaging (computed tomography instead of arterial catheterization cinefluoroscopy) provides lower quality images at similar or higher radiation and similar or higher contrast agent load without the opportunity for concurrent intervention. However, it does provide 3D data, does not require arterial catheterization with risks of vessel damage, is faster and easier, and there is progress reducing the radiation hazard.
Aviva Lev-Ari, PhD, RN
Aviva Lev-Ari, PhD, RN
BIOMARKERS
The Roles of Imaging in Risk Assessment
Calcium scoring from computed tomography (CT) has been promoted as a risk factor independent of blood tests to predict who is at risk for a heart attack. High frequency ultrasound imaging of carotid intimal thickness has been touted as another imaging based risk evaluation. Half of all heart attacks occur from lesions that are unstable but not obstructive (<50% diameter narrowing at recent catheterization) but catheter inverventions and bypass surgery both focus on obstructive lesions. Imaging of coronary lesions may identify plaque characteristics that predict which lesions are unstable (prone to cracking, bleeding, causing thrombus and thus elevating risk of sudden occlusion). Imaging methods for plaque stability include computed tomography, intravascular ultrasound (IVUS), optical coherence intervascular imaging, and near infra-red spectroscopy.
4.1 Advanced CT Reconstruction: Plaque Estimation Algorithm for Fewer Errors and Semiautomation
Aviva Lev-Ari, PhD, RN
Use of Computed Tomography (CT) exposes patients to xrays, which can be equivalent to over 100 chest xrays, enough to cause cancer in 1/1000 patients over a lifetime. Industry has responded by lowering the radiation hazard by a combination of shielding, reduced exposure times, and improved image quality at lower doses.
Aviva Lev-Ari, PhD, RN
Ultimately (at death) autopsy has been considered the final arbiter of whatever may have been predictable. Some patients accept the joke of reassuring a patient: “the test results are unclear but I am sure we can figure it out at autopsy.” However, visible tissue damage used for post mortem diagnosis actually requires on-going biologic functions – the release of lysozyme tissue destruction enzymes, the development of inflammatory cell infiltrates, fibroblast activation and scar tissue all require that biologic functions continue after the injury to create post mortem evidence. Sudden death from a heart attack or arrhythmia leaves no markers to the naked eye. Imaging as an adjunct to autopsy may improve final diagnosis.
4.3 Sudden Cardiac Death invisible at Autopsy: Forensic Power of Postmortem MRI
Aviva Lev-Ari, PhD RN
4.4 Imaging is the primary means to identify aneurysmal dilation of the aorta which poses a risk for sudden death from rupture of the aorta, but there are often no warning symptoms or signs to tell you when to get the imaging. No Early Symptoms – An Aortic Aneurysm Before It Ruptures – Is There A Way To Know If I Have it?
Aviva Lev-Ari, PhD RN
Justin D Pearlman, Md, PhD, FACC and Aviva Lev-Ari, PhD, RN
4.6 Echo vs Cardiac Magnetic Resonance Imaging (CMRI): CMRI may be a useful
adjunct in Hypertrophic Cardiomyopathy (HCM) family screening in higher risk
Aviva Lev-Ari, PhD, RN
http://pharmaceuticalintelligence.com/2013/05/20/echo-vs-cardiac-magnetic-re
sonance-imaging-cmri-cmri-may-be-a-useful-adjunct-in-hypertrophic-cardiomyop
athy-hcm-family-screening-in-higher-risk/
10.1 Simulating the Human Heart Function requires World’s Fastest Supercomputer comment
Aviva Lev-Ari, PhD, RN
10.2 Computer forecasting has value not only in modeling the individual patient to predict response to changes in nature, nurture, and management. Computer forecasting is also vital in identifying the priorities for investment in disease prevention and more efficient management. Economic Toll of Heart Failure in the US: Forecasting the Impact of Heart Failure in the United States – A Policy Statement From the American Heart Association
Aviva Lev-Ari, PhD, RN
10.3 FDA Pending 510(k) for The Latest Cardiovascular Imaging Technology comment
Aviva Lev-Ari, PhD, RN
Imaging modalities (methods) are based on various physical principles of energy interactions with matter (materials). Thus imaging can be based on sound waves (ultrasound, echocardiography), ionizing radiation (xrays, radionuclide imaging, SPECT imaging, PET imaging, CT scan), magnetization (MRI), optics (infrared, fluorescent, white light transillumination and backscatter) to name the most common. Different imaging methods may be combined to pursue Sir Isaac Newton’s observation that one can see farther by standing on the shoulders of giants.
Aviva Lev-Ari, PhD, RN
Aviva Lev-Ari, PhD, RN
10.7 Maladaptive Vascular Remodeling found by four-dimensional (4D) flow MRI: Outflow Patterns, Wall Shear Stress, and Expression of Aortopathy are caused by Congenital bicuspid aortic valve (BAV) Cusp Fusion
Aviva Lev-Ari, PhD, RN
Aviva Lev-Ari, PhD, RN
Summary to Volume Six
by John A. St. Cyr, M.D., Ph.D
Epilogue to Volume Six
by John A. St. Cyr, M.D., Ph.D