Cardiology

Roberts, W. C. (2020). “Importance of Acquiring Financial Security for Physicians.” Am J Med Jul 16;S0002-9343(20)30601-X. [Epub ahead of print.].

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This review tries to make the case that physicians should be adequately rewarded financially so that they can have a clear fiduciary responsibility to do only what is best for their patients without unseemly personal financial gain. To develop financial security physicians need to save a portion of their income regularly to invest. The stock market is the best place to increase one’s monetary worth over a long period.

Roberts, W. C. and S. Ilyas (2020). “Examining One’s Own Heart.” Am J Cardiol 127: 41-51.

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At Baylor University Medical Center (BUMC) in Dallas, we began showing heart transplantation recipients their hearts in 2010. Since that time, we have shown 157 patients their own hearts (through March 2020). The exercise was initiated not by me or another physician but by a heart transplant recipient, Mr. Marvin Jones. I was walking in the corridor near the cardiac catheterization waiting room and next to me was Mr. Jones. He leaned over and asked if I was Dr. Roberts. “Yes,” I answered. He said, “I understand that you have my heart.” I invited him to our weekly cardiovascular pathology conference so that several physicians could observe a person examining their own heart.1 Subsequently, the heart transplant cardiologists, surgeons, their nurses and coordinators have gotten on board to encourage their heart transplant patients to “Call Dr. Roberts” to make the arrangements to view their own hearts. Some of the patients had their heart transplants many years earlier. Fortunately, BUMC has provided us with a heart storage facility and all transplant and autopsy hearts have resided there since 1993. Thus, all heart transplant recipients who want to see their hearts since that time can have their requests fulfilled. [No abstract; excerpt from article].

Bailey, K. L., H. Smith, S. K. Mathai, J. Huber, M. Yacoub, I. V. Yang, T. A. Wyatt, K. Kechris and E. L. Burnham (2020). “Alcohol Use Disorders Are Associated With a Unique Impact on Airway Epithelial Cell Gene Expression.” Alcohol Clin Exp Res Jun 11. [Epub ahead of print.].

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BACKGROUND: Alcohol use disorders (AUDs) and cigarette smoking both increase risk for the development of community-acquired pneumonia (CAP), likely through adverse effects on proximal airway mucociliary clearance and pathogen recognition. Smoking-related alterations on airway gene expression are well described, but little is known about the impact of AUDs. We measured gene expression in human airway epithelial cells (AECs), hypothesizing that AUDs would be associated with novel differences in gene expression that could alter risk for CAP. METHODS: Bronchoscopy with airway brushings was performed in participants with AUDs and controls to obtain AECs. An AUD Identification Test was used to define AUD. RNA was extracted from AECs, and mRNA expression data were collected on an Agilent micro-array. Differential expression analyses were performed on the filtered and normalized data with correction for multiple testing. Enrichment analyses were performed using clusterProfiler. RESULTS: Expression data from 19 control and 18 AUD participants were evaluated. After adjustment for smoking, AUDs were associated with significant differential expression of 520 AEC genes, including genes for ribosomal proteins and genes involved in protein folding. Enrichment analyses indicated significant differential expression of 24 pathways in AUDs, including those implicated in protein targeting to membrane and viral gene expression. Smoking-associated AEC gene expression differences mirrored previous reports, but differed from those associated with AUDs. CONCLUSIONS: AUDs have a distinct impact on AEC gene expression that may influence proximal airway function independent of smoking. Alcohol-associated alterations may influence risk for CAP through modifying key mechanisms important in protecting proximal airway integrity.

Marquis-Gravel, G., A. Stebbins, A. S. Kosinski, M. L. Cox, J. K. Harrison, G. C. Hughes, V. H. Thourani, T. G. Gleason, A. J. Kirtane, J. D. Carroll, M. J. Mack and S. Vemulapalli (2020). “Geographic Access to Transcatheter Aortic Valve Replacement Centers in the United States: Insights From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.” JAMA Cardiol Jun 10;e201725. [Epub ahead of print.].

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IMPORTANCE: Geographic access to transcatheter aortic replacement (TAVR) centers varies in the United States as a result of controlled expansion through minimum volume requirements. OBJECTIVE: To describe the current geographic access to TAVR centers in the United States. DESIGN, SETTING, AND PARTICIPANTS: Observational study from June 1, 2015, to June 30, 2017. United States census data were used to describe access to TAVR center. Google Maps and the Society of Thoracic Surgeons American College of Cardiology Transcatheter Valve Therapy Registry were used to describe characteristics of patients undergoing successful TAVR according to proximity to implanting center. The study analyzed 47 527 537 individuals 65 years and older in the United States and 31 098 patients who underwent successful transfemoral TAVR, were linked to fee-for-service Medicare, and had a measurable driving time. MAIN OUTCOMES AND MEASURES: Median driving distance to a TAVR center. RESULTS: Among 40 537 zip codes in the United States, 490 (1.2%) contained a TAVR center, and among 305 hospital referral regions (HRR), 234 (76.7%) contained a TAVR center. Of the 31 749 patients who underwent successful transfemoral TAVR and were linked to fee-for-service Medicare, 31 098 had a measurable driving time. Mean (SD) age was 82.4 (6.9) years, 14 697 patients (47.3%) were women, and 7422 (23.87%) lived in a rural area. This translated to 1 232 568 of 47 527 537 individuals (2.6%) 65 years and older living in a zip code with a TAVR center and 43 789 169 (92.1%) living in an HRR with a TAVR center. Among 31 749 patients who underwent successful transfemoral TAVR and were linked to fee-for-service Medicare, 31 098 had a measurable driving time. All of these patients (100.0%) underwent their procedure in a TAVR center within their HRR, with 1350 (4.3%) undergoing TAVR in a center within their home zip code. Median driving time to implanting TAVR center was 35.0 minutes (IQR, 20.0-70.0 minutes), ranging from 2.0 minutes to 18 hours and 48 minutes. CONCLUSIONS AND RELEVANCE: Most US individuals 65 years and older live in an HRR with a TAVR center. Among patients undergoing successful transfemoral TAVR, median driving time to implanting center was 35.0 minutes. Within the context of the US health care system, where certain advanced procedures and specialized care are centralized, TAVR services have significant penetration. More studies are required to evaluate the effect of geographic location of TAVR sites on access to TAVR procedures among individuals with an indication for a TAVR within the US population.

Sathananthan, J., P. Green, M. Finn, D. A. Wood, S. Lauck, A. Crowley, M. Alu, S. V. Arnold, D. Cohen, S. Kapadia, M. Mack, V. H. Thourani, S. Kodali, M. Leon and J. G. Webb (2020). “Prognostic implications of baseline 6-min walk test performance in intermediate risk patients undergoing transcatheter aortic valve replacement.” Catheter Cardiovasc Interv Jun 10. [Epub ahead of print.].

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BACKGROUND: While slow gait speed is known to be associated with poor outcomes in patients at high surgical risk who undergo transcatheter aortic valve replacement (TAVR), the prognostic significance of slow gait speed in intermediate risk TAVR patients is poorly understood. OBJECTIVES: We assessed the association between baseline 6-min walk test (6MWT) performance and both 2-year mortality and health status in intermediate risk patients undergoing TAVR as a part of the PARTNER II/S3i studies. METHODS: The association of baseline 6MWT with mortality over 2-years after TAVR was examined using Cox regression; both unadjusted and adjusted for age, left ventricular ejection fraction, coronary artery disease, pulmonary disease, renal insufficiency, and STS score. Patients were divided into four groups according to baseline 6MWT: unable to walk and in three equal tertiles of slow, medium, and fast walkers. Among surviving patients, improvement in 6MWT and quality of life were compared. RESULTS: Among 2,037 intermediate risk TAVR patients (mean age 81.7 years, STS score 5.6%), 8.2% were unable to walk. Baseline 6MWT was associated with all-cause mortality over 2 years (Hazard ratio (HR) 0.87 per 50 m, 95% confidence interval [CI] 0.83 to 0.92, p < .0001). Among surviving patients, the adjusted absolute change in 6MWT at 2 years improved for patients unable to walk (+134.1 m, 95% CI 102.1 to 166 m, p < .0001) and slow walkers (+60.5 m, 95% CI 42.8 to 78.2 m, p < .0001), but was unchanged for medium walkers (-7.3 m, 95% CI -24.3 to 9.6 m, p = .4), and declined for fast walkers (-41.3 m, 95% CI -58.7 to -23.9 m, p < .0001). CONCLUSION: Poor functional capacity is predictive of 2-year mortality in elderly intermediate risk patients undergoing TAVR. However, surviving patients with poor baseline functional capacity had significant improvement in 6MWT performance and quality of life at 2-years following TAVR.