Amitoj Singh

Interests

Teaching

Cardiovascular Imaging and Preventative Cardiology

Research

1. Cardiac Sarcoidosis2. Cardiac Amyloidosis3. Marijuana and Cardiovascular disease4. Takotsubo Cardiomyopathy5. Preventative Cardiology

Courses

Scholarly Contributions

Chapters

• Singh, M., Sharma, V., & Singh, A. (2015). Drugs and Sudden Cardiac Death. In Cardiological Society of India Cardiology Update(pp 462 - 466).

Journals/Publications

• Ge, Y., Pandya, A., Cuddy, S. A., Singh, A., Singh, A., & Dorbala, S. (2022). Modeling the Cost and Health Impacts of Diagnostic Strategies in Patients with Suspected Transthyretin Cardiac Amyloidosis. Journal of the American Heart Association, 11(18), e026308.
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  Background Transthyretin cardiac amyloidosis (ATTR-CMP) is an increasingly recognized and treatable cause of heart failure with preserved ejection fraction. Multimodality cardiac imaging is recommended for ATTR-CMP diagnosis, but its cost-effectiveness in current clinical practice has not been well studied. Methods and Results Using a microsimulation model, we compared the cost-effectiveness of a combination of strategies involving technetium pyrophosphate (PYP), cardiac magnetic resonance imaging, and endomyocardial biopsy for the diagnosis of ATTR-CMP. We developed a decision analytic model to project health care costs and lifetime quality-adjusted life years for symptomatic, older patients who present with congestive heart failure, with an increased left ventricular wall thickness and a 13% prevalence of ATTR-CMP. Rates of clinical events, costs, and quality-of-life values were estimated from published literature. The analysis was conducted from a US health care system perspective with health and cost outcomes discounted annually at 3%. In the base-case scenario, using a fixed tafamidis price of $16 000 annually (previously identified cost-effective price), total health care costs per person were lowest for the PYP-only strategy ($209 415) and highest for endomyocardial biopsy strategy ($215 881). Of the 7 strategies examined, the PYP-only strategy had the highest net monetary benefit using a willingness-to-pay threshold of $100 000/quality-adjusted life year. Results were sensitive to variations in model inputs for PYP and cardiac magnetic resonance imaging specificity, cost of tafamidis, and willingness-to-pay thresholds. Conclusions Our model-based analyses showed that a PYP-only strategy to diagnose ATTR-CMP is the most cost-effective strategy, at willingness-to-pay threshold of $100 000/quality-adjusted life year. At higher threshold ($150 000/quality-adjusted life year), sequential tests involving PYP and cardiac magnetic resonance imaging may be considered cost effective.
• Jain, V., Gupta, K., Bhatia, K., Rajapreyar, I., Singh, A., Zhou, W., Klein, A., Nanda, N. C., Prabhu, S. D., & Bajaj, N. S. (2022). Coronary flow abnormalities in chronic kidney disease: A systematic review and meta-analysis. Echocardiography (Mount Kisco, N.Y.), 39(11), 1382-1390.
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  Coronary vasomotion abnormalities have been described in small studies but not studied systematically. We aimed to review the present literature and analyze it to improve our understanding of chronic kidney disease (CKD) related-coronary microvascular dysfunction.
• Singh, A., Jain, V., Gupta, K., Bhatia, K., Rajapreyar, I., Zhou, W., Klein, A., Nanda, N. C., Prabhu, S. D., & Bajaj, N. S. (2022). Coronary flow abnormalities in chronic kidney disease: A systematic review and meta‐analysis. Echocardiography, 39(11), 1382-1390. doi:10.1111/echo.15445
• Yellapu, V., Gasimli-Gamache, L., Singh, A., & Shirani, J. (2022). Abstract 11088: Childbirth Related Complications in Women with Hypertrophic Cardiomyopathy. Circulation, 146, A111088. doi:10.1161/circ.146.suppl_1.11088
• Ajmal, M., Singh, A., Kubba, S., Hershman, M., & Acharya, T. (2021). Statin-Induced Triad of Autoimmune Myocarditis, Myositis, and Transaminitis. Case reports in cardiology, 2021, 6660362.
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  Despite well-established cardiovascular benefits, statins have been associated with myopathic side effects ranging from myalgias to rhabdomyolysis and autoimmune necrotizing myositis. Statins have not been previously shown to cause myocarditis. Our case highlights this rare entity.
• Alaber, O., Chandar, A. K., Singh, A., Manivannan, N., Pitts, S., & Rajpal, A. (2021). 987-P: Comparative Cardiovascular (CV) Effectiveness of SGLT2 Inhibitors (SGLT2i) and GLP-1 Receptor Agonists (GLP-1 RA) in Patients with Type 2 Diabetes Mellitus (T2DM).. Diabetes, 70.
• Ali, H. J., Ehsan, A., Kennedy, k., Riley, P., Seo, A., Bajaj, N., & Singh, A. (2021). Patient Outcomes, Cost and Length of Stay Associated with Biventricular Assist Devices in the United States. Authorea. doi:10.22541/au.162232049.90809901/v1
• Gupta, S., Ge, Y., Singh, A., Gräni, C., & Kwong, R. Y. (2021). Multimodality Imaging Assessment of Myocardial Fibrosis. JACC. Cardiovascular imaging, 14(12), 2457-2469.
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  Myocardial fibrosis, seen in ischemic and nonischemic cardiomyopathies, is associated with adverse cardiac outcomes. Noninvasive imaging plays a key role in early identification and quantification of myocardial fibrosis with the use of an expanding array of techniques including cardiac magnetic resonance, computed tomography, and nuclear imaging. This review discusses currently available noninvasive imaging techniques, provides insights into their strengths and limitations, and examines novel developments that will affect the future of noninvasive imaging of myocardial fibrosis.
• Modi, V., Singh, A., & Shirani, J. (2021). Marijuana Use and Stress Cardiomyopathy in the Young. Cureus. doi:10.7759/cureus.18575
• Shah, S. J., Khan, S., Dani, S., Baron, S. J., & Abraham, S. (2021). EXTRACORPOREAL LIFE SUPPORT IN A YOUNG PATIENT WITH THYROID STORM, CARDIAC ARREST AND DIFFUSE ALVEOLAR HEMORRHAGE. Journal of the American College of Cardiology, 77(18), 2237. doi:10.1016/s0735-1097(21)03592-0
• Singh, A., Agrawal, S., Gargya, S., Saluja, S., Kumar, A., Kumar, A., Kalra, K., Thind, M., Saluja, S., Stone, L. E., Ali, F., Duarte-Chavez, R., Marchionni, C., Sholevar, F., Shirani, J., & Nanda, S. (2017). Posttraumatic stress disorder after myocardial infarction and coronary artery bypass grafting. International journal of critical illness and injury science, 7(2), 84-90.
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  Post traumatic stress disorder is a psychiatric disease that is usually precipitated by life threatening stressors. Myocardial infarction, especially in the young can count as one such event. The development of post traumatic stress after a coronary event not only adversely effects psychiatric health, but leads to increased cardiovascular morbidity and mortality. There is increasing evidence that like major depression, post traumatic stress disorder is also a strong coronary risk factor. Early diagnosis and treatment of this disease in patients with acute manifestations of coronary artery disease can improve patient outcomes.
• Singh, A., Cohen, B., Sturzoiu, T., Vallabhaneni, S., & Shirani, J. (2020). Recent trends in hospital admissions and outcomes of cardiac Chagas disease in the United States. International journal of critical illness and injury science, 10(3), 134-139.
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  Chagas disease (CD), caused by , has been increasingly encountered as a cause of cardiovascular disease in the United States. We aimed to examine trends of hospital admissions and cardiovascular outcomes of cardiac CD (CCD).
• Singh, A., Seo, A., Ali, H. J., Ehsan, A., Kennedy, K., Riley, P., Bajaj, N., Levine, D., Kiernan, M., Sellke, F., & Yousefzai, R. (2021). Patient Outcomes, Cost, and Length of Stay Associated With Biventricular Assist Devices in the United States (2009-2015). n/a.
• Tessier, S., Durgham, A., Krinock, M., Singh, A., Longo, S., & Nanda, S. (2021). Native valve emphysematous enterococcal endocarditis: expanding the differential diagnosis. GERMS, 11(4), 608-613. doi:10.18683/germs.2021.1297
• Vallabhaneni, S., Singh, A., Meera, S. J., & Shirani, J. (2020). Cardiac transplantation for hypertrophic cardiomyopathy in the United States 2003-2011. International journal of critical illness and injury science, 10(3), 129-133.
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  Cardiac transplant (CT) is the sole option in a minority of hypertrophic cardiomyopathy (HC) adults with refractory symptoms or end-stage disease.
• Yellapu, V., Aurshiya, R., Gasimli-Gamache, L., De Turk, S., & Singh, A. (2021). Peripartum Complications in Women with Hypertrophic Cardiomyopathy: An Updated NIS Study from 2003-2016. Journal of American College of Cardiology, 77(18), 683. doi:10.1016/S0735-1097(21)02042-8.
• Acharya, T., Singh, A., & Shenoy, S. (2020). Incidental isolated septal infarct in a young patient with colon cancer. European Heart Journal, 42(26), 2613-2613. doi:10.1093/eurheartj/ehaa537
• Ali, H. R., Ehsan, A., Kennedy, K., Riley, P., Seo, A., Bajaj, N. S., Singh, A., Levine, D. J., Kiernan, K., Yousefzai, R., Sellke, F. W., & Kiernan, M. S. (2020). The Cost and Length of Stay Associated with Biventricular Assist Devices in the United States (2009-2015).. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation, 39(4S), S400-S401. doi:10.1016/j.healun.2020.01.142
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  The purpose of this study was to determine the national trends in utilization, mortality, cost, and length of stay (LOS) associated with implantation of biventricular assist devices (BiVADs) using the National Inpatient Sample (NIS) database..This study was a retrospective analysis of NIS from 2009 to 2015 for surgically implanted internal (n = 538) and external BiVADs (n = 727). Exploratory analyses were performed to explain the trends found in utilization, mortality, cost, and LOS..From 2009 to 2015, the utilization of all BiVADs decreased (4.8% per year, p < 0.001) driven by the decline in utilization of external BiVADs (9.4% per year, p < 0.001). Compared to external BiVADs, internal BiVADs were associated with lower mortality (45.4% vs. 59.1%, p = 0.024), but longer LOS (64.0 vs. 20.0 days, p < 0.001) and higher incidence of renal failure (85.6% vs. 74.0%, p = 0.020). During this time period, there was no significant change in mortality; however, cost and LOS associated with all BiVAD implantations increased significantly. Only those who died during hospitalization had an increase in cost (15% per year, p < 0.001) and LOS (52% per year, p = 0.002) (Figure 1). The latter trends remained significant even after controlling for complications (e.g., gastrointestinal bleed and renal failure) and co-morbidities..The decline in utilization of BiVADs between 2009 and 2015 coincided with the increase in utilization of LVADs during this time. Declining BiVAD utilization can be related to the improvement in the LVAD technology and outcomes as well as the availability of percutaneous temporary circulatory support. Although the advancement in LVAD technology has led to decrease in mortality rate and reduction in cost and LOS, BiVAD mortality remained the same over time with a rise in cost and LOS. Future studies are required to investigate optimal BiVAD configurations and strategies, as well as patient selection in order to improve mortality and reduce LOS and cost for BiVAD patients.
• Bajaj, N. S., Singh, A., Zhou, W., Gupta, A., Fujikura, K., Byrne, C., Harms, H. J., Osborne, M. T., Bravo, P., Andrikopolou, E., Divakaran, S., Bibbo, C. F., Hainer, J., Skali, H., Taqueti, V., Steigner, M., Dorbala, S., Charytan, D. M., Prabhu, S. D., , Blankstein, R., et al. (2020). Coronary Microvascular Dysfunction, Left Ventricular Remodeling, and Clinical Outcomes in Patients With Chronic Kidney Impairment. Circulation, 141(1), 21-33.
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  Cardiac dysfunction and cardiovascular events are prevalent among patients with chronic kidney disease without overt obstructive coronary artery disease, but the mechanisms remain poorly understood. Coronary microvascular dysfunction has been proposed as a link between abnormal renal function and impairment of cardiac function and cardiovascular events. We aimed to investigate the relations between chronic kidney disease, coronary microvascular dysfunction, cardiac dysfunction, and adverse cardiovascular outcomes.
• DeFilippis, E. M., Bajaj, N. S., Singh, A., Malloy, R., Givertz, M. M., Blankstein, R., Bhatt, D. L., & Vaduganathan, M. (2020). Marijuana Use in Patients With Cardiovascular Disease: JACC Review Topic of the Week. Journal of the American College of Cardiology, 75(3), 320-332.
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  Marijuana use is increasing as more states are legalizing cannabis for both medicinal and recreational purposes. National survey data estimate that >2 million Americans with established cardiovascular diseases currently use or have used marijuana in its variety of forms, including inhalation and vaping. Cannabinoid receptors are distributed in multiple tissue beds and cells, including platelets, adipose tissue, and myocytes. Observational data suggest associations between marijuana and a broad range of adverse cardiovascular risks. Marijuana is becoming increasingly potent, and smoking marijuana carries many of the same cardiovascular health hazards as smoking tobacco. Synthetic cannabinoids have been linked to more sustained and deleterious pharmacodynamic effects. Marijuana is classified as a Schedule I substance, thus limiting its rigorous study for cardiovascular health effects. This review summarizes cardiovascular considerations related to marijuana use, pharmacological interactions, and future steps to provide clearer guidance regarding its cardiovascular safety. Screening for marijuana use is encouraged, especially in young patients presenting with cardiovascular disease.
• Shenoy, S., Singh, A., & Acharya, T. (2021). Incidental isolated septal infarct in a young patient with colon cancer. European heart journal.
• Singh, A., Cohen, B., Sturzoiu, T., Vallabhaneni, S., & Shirani, J. (2020). Recent trends in hospital admissions and outcomes of cardiac Chagas disease in the United States.. International Journal of Critical Illness and Injury Science, 134 - 139.
• Singh, A., Sturzoiu, T., Vallabhaneni, S., & Shirani, J. (2020). Stress cardiomyopathy induced during dobutamine stress echocardiography. International journal of critical illness and injury science, 10(Suppl 1), 43-48.
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  Catecholamines play a central role in pathogenesis of stress cardiomyopathy (SC). We aimed to review the clinical characteristics, procedural details and outcomes of patients with SC during dobutamine stress echocardiography (DSE).
• Vallabhaneni, S., Singh, A., Meera, S., & Shirani, J. (2020). Cardiac transplantation for hypertrophic cardiomyopathy in the United States. International Journal of Critical Illness and Injury Science, 129 - 133.
• Bravo, P. E., Singh, A., Di Carli, M. F., & Blankstein, R. (2019). Advanced cardiovascular imaging for the evaluation of cardiac sarcoidosis. Journal of nuclear cardiology : official publication of the American Society of Nuclear Cardiology, 26(1), 188-199.
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  Cardiac sarcoidosis (CS) remains an intriguing infiltrating disorder and one of the most important forms of inflammatory cardiomyopathy. Identification of patients with CS is of extreme importance because they are at higher risk of sudden death, and heart-failure progression. And while it remains a diagnostic conundrum, a great amount of experience has been accumulated over the last decade with the advent of fluorine-18 fluorodeoxyglucose positron emission tomography and cardiac magnetic resonance with late gadolinium enhancement imaging. They have both proven to be advanced imaging techniques that provide important, and often complementary, diagnostic and prognostic information for the management of CS. However, they have also shown to have limitations, and, thus, there is a continued need for developing more specific imaging probes for identifying cardiac inflammation. The aim of the present manuscript is to provide the reader with a better understanding of the histopathology of the disease, how this potentially relates to noninvasive imaging detection, and the best strategies available for the diagnosis and management of patients with CS.
• Gilstrap, L. G., Dominici, F., Wang, Y., El-Sady, M. S., Singh, A., Di Carli, M. F., Falk, R. H., & Dorbala, S. (2019). Epidemiology of Cardiac Amyloidosis-Associated Heart Failure Hospitalizations Among Fee-for-Service Medicare Beneficiaries in the United States. Circulation. Heart failure, 12(6), e005407.
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  Background Cardiac amyloidosis is a substantially underdiagnosed disease, and contemporary estimates of the epidemiology of amyloidosis are lacking. This study aims to determine the incidence and prevalence of cardiac amyloidosis among Medicare beneficiaries from 2000 to 2012. Methods and Results Medicare beneficiaries were counted in the prevalence cohort in each year they had (1) ≥1 principal or secondary International Classification of Diseases, Ninth Revision code for amyloidosis and (2) ≥1 principal or secondary International Classification of Diseases, Ninth Revision code for heart failure or cardiomyopathy within 2 years after the systemic amyloidosis code. A beneficiary was counted in the incidence cohort only during the first year in which they met criteria. Primary outcomes included the prevalence and incidence of hospitalizations for cardiac amyloidosis. There were 4746 incident cases of cardiac amyloidosis in 2012 and 15 737 prevalent cases in 2012. There was also a significant increase in the prevalence rate (8 to 17 per 100 000 person-years) and incidence rate (18 to 55 per 100 000 person-years) from 2000 to 2012, most notable after 2006. Incidence and prevalence increased substantially more among men, the elderly, and in blacks. Conclusions The incidence and prevalence rates of cardiac amyloidosis are higher than previously thought. The incidence and prevalence rates of cardiac amyloidosis among hospitalized patients have increased since 2000, particularly among specific patient subgroups and after 2006, suggesting improved amyloidosis awareness and higher diagnostic rates with noninvasive imaging. In light of these trends, cardiac amyloidosis should be considered during the initial work up of patients ≥65 years old hospitalized with heart failure.
• Gupta, K., Kakar, T. S., Gupta, A., Singh, A., Gharpure, N., Aryal, S., Hawi, R., Lloyd, S. G., Booker, J., Hage, F. G., Prabhu, S. D., Nanda, N. C., & Bajaj, N. S. (2019). Role of left ventricle deformation analysis in stress echocardiography for significant coronary artery disease detection: A diagnostic study meta-analysis. Echocardiography (Mount Kisco, N.Y.), 36(6), 1084-1094.
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  We compared the diagnostic accuracy of longitudinal strain (LS) imaging during stress echocardiography with visual assessment of wall motion (WM) for detecting significant coronary artery disease (CAD).
• Patel, N., Bajaj, N. S., Doshi, R., Gupta, A., Kalra, R., Singh, A., Berra, L., Arora, G., Prabhu, S. D., & Arora, P. (2019). Cardiovascular Events and Hospital Deaths Among Patients With Severe Sepsis. The American journal of cardiology, 123(9), 1406-1413.
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  The burden of cardiovascular events among patients hospitalized with severe sepsis and the association of these events with in-hospital mortality is not well known. We examined the incidence of cardiovascular events and their association with in-hospital mortality among patients with severe sepsis. Patients with severe sepsis from the New York State Inpatient Database from 2012 through 2014 were identified using a validated International Classification of Diseases 9th Revision, Clinical Modification code 995.92. The primary outcome was the incidence of cardiovascular events during the hospitalizations, defined as a composite of ischemic, acute heart failure, or arrhythmic events and the secondary outcome was in-hospital mortality. Multivariable logistic regression models were used to compare the risk of in-hospital mortality among severe sepsis patients with and without cardiovascular events. A total of 117,418 patients (mean age, 70.8 years; 50.4% males, 59.5% whites) with severe sepsis occurred during the study period 2012 to 2014. New-onset (incident) cardiovascular event occurred in 13.1%, ischemic events in 4.5%, acute heart failure events in 2.3%, and arrhythmic events in 8.0% of patients, respectively. An estimated 32.9% of patients with severe sepsis died during their hospitalization. Severe sepsis patients with new-onset cardiovascular events were associated with 30% higher odds for in-hospital mortality (odds ratio: 1.30; 95% CI: 1.23 to 1.37, p < 0.001) as compared with patients without cardiovascular events in multivariable adjusted model. In conclusion, among patients with severe sepsis, incident cardiovascular events occur frequently. Further research is required to improve recognition and treatment of new-onset cardiovascular events in patients with severe sepsis.
• Agrawal, S., Garg, L., Shah, M., Agarwal, M., Patel, B., Singh, A., Garg, A., Jorde, U. P., & Kapur, N. K. (2018). Thirty-Day Readmissions After Left Ventricular Assist Device Implantation in the United States: Insights From the Nationwide Readmissions Database. Circulation. Heart failure, 11(3), e004628.
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  Early readmissions contribute significantly to heart failure-related morbidity and negatively affect quality of life. Data on left ventricular assist device (LVAD)-related 30-day readmissions are scarce and limited to small studies.
• Nanda, S., Yellapu, V., Ali, F., Agrawal, S., Singh, A., Garg, L., Longo, S., & Stone, L. E. (2018). Pathophysiology and management of Raynaud's phenomenon. International Journal of Academic Medicine, 4(2), 178. doi:10.4103/ijam.ijam_78_16
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  Raynaud's phenomenon (RP) is a multi-etiological vasospastic condition requiring individualized treatment. This case presents a patient with classic primary RP whose symptoms improved after being treated for depression. Her example demonstrates that medication regimen sometimes have unexpected, but positive outcomes. The following core competencies are addressed in this article: Patient care, Medical knowledge.
• Singh, A., Agrawal, S., Saluja, S., Thind, M., Rajpal, A., Gupta, S., Randhawa, S. S., Andrikopoulou, E., & Shirani, J. (2018). GENDER DIFFERENCES IN DISEASE PROFILE AND IN-HOSPITAL OUTCOMES OF PATIENTS WITH TAKAYASU ARTERITIS. Journal of the American College of Cardiology, 71(11), A2071. doi:10.1016/s0735-1097(18)32612-3
• Singh, A., Saluja, S., Kumar, A., Agrawal, S., Thind, M., Nanda, S., & Shirani, J. (2018). Cardiovascular Complications of Marijuana and Related Substances: A Review. Cardiology and therapy, 7(1), 45-59.
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  The recreational use of cannabis has sharply increased in recent years in parallel with its legalization and decriminalization in several countries. Commonly, the traditional cannabis has been replaced by potent synthetic cannabinoids and cannabimimetics in various forms. Despite overwhelming public perception of the safety of these substances, an increasing number of serious cardiovascular adverse events have been reported in temporal relation to recreational cannabis use. These have included sudden cardiac death, vascular (coronary, cerebral and peripheral) events, arrhythmias and stress cardiomyopathy among others. Many of the victims of these events are relatively young men with few if any cardiovascular risk factors. However, there are reasons to believe that older individuals and those with risk factors for or established cardiovascular disease are at even higher danger of such events following exposure to cannabis. The pathophysiological basis of these events is not fully understood and likely encompasses a complex interaction between the active ingredients (particularly the major cannabinoid, Δ-tetrahydrocannabinol), and the endo-cannabinoid system, autonomic nervous system, as well as other receptor and non-receptor mediated pathways. Other complicating factors include opposing physiologic effects of other cannabinoids (predominantly cannabidiol), presence of regulatory proteins that act as metabolizing enzymes, binding molecules, or ligands, as well as functional polymorphisms of target receptors. Tolerance to the effects of cannabis may also develop on repeated exposures at least in part due to receptor downregulation or desensitization. Moreover, effects of cannabis may be enhanced or altered by concomitant use of other illicit drugs or medications used for treatment of established cardiovascular diseases. Regardless of these considerations, it is expected that the current cannabis epidemic would add significantly to the universal burden of cardiovascular diseases.
• Thind, M., Holmes, D. N., Badri, M., Pieper, K. S., Singh, A., Blanco, R. G., Steinberg, B. A., Fonarow, G. C., Gersh, B. J., Mahaffey, K. W., Peterson, E. D., Reiffel, J. A., Piccini, J. P., Kowey, P. R., & , O. I. (2018). Embolic and Other Adverse Outcomes in Symptomatic Versus Asymptomatic Patients With Atrial Fibrillation (from the ORBIT-AF Registry). The American journal of cardiology, 122(10), 1677-1683.
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  Asymptomatic atrial fibrillation (AF) is being increasingly diagnosed via implantable devices, screening, and inpatient telemetry. Management of asymptomatic AF is controversial, in part, because the associated risks have not been well described. We examined the incidence of major adverse outcomes in patients with asymptomatic versus symptomatic AF using Outcomes Registry for Better Informed Treatment of Atrial, a nationwide US registry of AF patients. We compared stroke and/or non-central nervous system (CNS) embolism, major adverse cardiovascular and neurologic events, bleeding, and death in 9,319 asymptomatic (defined by European Heart Rhythm Association score = 1 or "no symptoms") versus symptomatic patients. Overall, median (interquartile) age was 75 (67 to 82) years, 3,944 (42%) were women, and 38% versus 37% were asymptomatic based on physician versus patient-reported symptoms. Compared with those with symptoms, physician-defined asymptomatic patients were less likely to be woman (35%/47%) or be on an antiarrhythmic agent (22%/33%), but were more likely to have permanent and/or persistent AF (51%/40%). CHADS-VASc scores did not vary by symptom status. After adjustment, risk of first stroke and/or non-CNS embolism (hazard ratio [HR] 0.85 [95% confidence interval {CI} 0.63 to 1.16], p = 0.32), major adverse cardiovascular and neurologic events (HR 0.88 [95% CI 0.76 to 1.03], p = 0.11), bleeding (HR 0.85 [95% CI 0.72 to 1.00], p = 0.05), and death (HR 0.99 [95% CI 0.87 to 1.13], p = 0.88) were similar in asymptomatic (European Heart Rhythm Association = 1) and symptomatic AF, respectively. Prospective, randomized studies are needed to further define associated adverse events and delineate optimal prophylactic therapies in patients with asymptomatic AF.
• Agrawal, S., Agarwal, M., Garg, L., Garg, A., Sharma, A., Bhatia, N., Mohananey, D., Singh, A., Puleo, P., Kostis, J., & Shirani, J. (2017). TEMPORAL TRENDS AND OUTCOMES OF EMERGENT CORONARY ARTERY BYPASS GRAFT SURGERY FOR ST-SEGEMENT ELEVATION MYOCARDIAL INFARCTION. Journal of the American College of Cardiology, 69(11), 95. doi:10.1016/s0735-1097(17)33484-8
• Agrawal, S., Garg, L., Garg, A., Mohananey, D., Jain, A., Manda, Y., Singh, A., Nanda, S., Durkin, R., Puleo, P., & Shirani, J. (2017). Recent Trends in Management and Inhospital Outcomes of Acute Myocardial Infarction in Renal Transplant Recipients. The American journal of cardiology, 119(4), 542-552.
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  Renal transplant recipients (RTR) are at high risk of cardiovascular events including acute myocardial infarction (AMI). We evaluated recent trends in AMI admissions in 9,243 RTR with functioning grafts using data from the 2003 to 2011 Nationwide Inpatient Sample database. Findings were compared with those of patients with end-stage renal disease without transplantation (ESRD-NRT, n = 160,932) and those without advanced kidney disease (non-ESRD/RT, n = 5,640,851) admitted with AMI. RTR comprised 0.2% of AMI admissions with increasing numbers during the study period (adjusted odds ratio [aOR] 1.04; 95% confidence interval [CI] 1.04 to 1.05; p
• Agrawal, S., Garg, L., Sharma, A., Agarwal, M., Singh, A., Sarnoski, C., Puleo, P., & Shirani, J. (2017). OUTCOMES OF TRANS-CATHETER AORTIC VALVE REPLACEMENT IN NONAGENARIANS. Journal of the American College of Cardiology, 69(11), 1334. doi:10.1016/s0735-1097(17)34723-x
• Agrawal, S., Shirani, J., Garg, L., Singh, A., Longo, S., Longo, A., Fegley, M., Stone, L., Razavi, M., Radoianu, N., & Nanda, S. (2017). Pheochromocytoma and stress cardiomyopathy: Insight into pathogenesis. World journal of cardiology, 9(3), 255-260.
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  To investigate the occurrence of cardiomyopathy (CMP) in a cohort of patients with histologically proven pheochromocytoma (pheo), and to determine if catecholamine excess was causative of the left ventricular (LV) dysfunction.
• Bhatia, N., Agrawal, S., Garg, A., Mohananey, D., Sharma, A., Agarwal, M., Garg, L., Agrawal, N., Singh, A., Nanda, S., & Shirani, J. (2017). Trends and outcomes of infective endocarditis in patients on dialysis. Clinical cardiology, 40(7), 423-429.
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  Dialysis patients are at high risk for infective endocarditis (IE); however, no large contemporary data exist on this issue. We examined outcomes of 44 816 patients with IE on dialysis and 202 547 patients with IE not on dialysis from the Nationwide Inpatient Sample database from 2006 thorough 2011. Dialysis patients were younger (59 ± 15 years vs 62 ± 18 years) and more likely to be female (47% vs 40%) and African-American (47% vs 40%; all P < 0.001). Hospitalizations for IE in the dialysis group increased from 175 to 222 per 10 000 patients (P  = 0.04). Staphylococcus aureus was the most common microorganism isolated in both dialysis (61%) and nondialysis (45%) groups. IE due to S aureus (adjusted odds ratio [aOR]: 1.79, 95% confidence interval [CI]: 1.73-1.84), non-aureus staphylococcus (aOR: 1.72, 95% CI: 1.64-1.80), and fungi (aOR: 1.4, 95% CI: 1.12-1.78) were more likely in the dialysis group, whereas infection due to gram-negative bacteria (aOR: 0.85, 95% CI: 0.81-0.89), streptococci (aOR: 0.38, 95% CI: 0.36-0.39), and enterococci (aOR: 0.78, 95% CI: 0.74-0.82) were less likely (all P < 0.001). Dialysis patients had higher in-hospital mortality (aOR: 2.13, 95% CI: 2.04-2.21), lower likelihood of valve-replacement surgery (aOR: 0.82, 95% CI: 0.76-0.86), and higher incidence of stroke (aOR: 1.08, 95% CI: 1.03-1.12; all P < 0.001). We demonstrate rising incidence of IE-related hospitalizations in dialysis patients, highlight significant differences in baseline comorbidities and microbiology of IE compared with the general population, and validate the association of long-term dialysis with worse in-hospital outcomes.
• Fegley, M. W., Duarte-chavez, R., Fegley, W., Stone, L. E., Singh, A., & Nanda, S. (2017). Finger nail changes: A red flag for connective tissue disease. International Journal of Academic Medicine. doi:10.4103/2455-5568.209837
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  We report a 68-year-old female who presented to the cardiology clinic with ventricular tachycardia and specific finger nail abnormalities including proximal capillary loops and proximal and periungual erythema. The patient had multiple underlying connective tissue disorders and pulmonary fibrosis. Finger nail changes are highly specific and are an indication for all healthcare providers that connective tissue diseases (CTDs) are likely underlying. We review the clinical signs and symptoms, review diagnostic criteria, and further testing to evaluate for CTDs. The following core competencies are addressed in this article: Patient care, Medical knowledge.
• K, K., Singh, A., Patel, K., & Kalra, K. (2017). Recurrent Nasal Epistaxis, Osler-Weber-Rendu Syndrome. International Journal of Clinical & Medical Imaging, 04(03). doi:10.4172/2376-0249.1000557
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  Clinical Image: A 60 y/o Caucasian female presents to the emergency room with epistaxis for 45 minutes. She also had 1 episode of hematemesis. She has been having recurrent epistaxis 1-2 episodes per week for last 2 years for which she was prescribed nasal ointment. She had history of hemoptysis 4 years ago, secondary to pulmonary AVMs which required coiling. (Figure 1A). No history of bleeding disorders in family. Currently she is not using aspirin or any other anticoagulants. On physical examination, multiple telangiectasia’s were noted on the tongue (Figure 1B) and abdomen (Figure 1C). During the hospitalization, patient underwent EGD which revealed Antral and Duodenal AVMs treated with thermal therapy and clipping. She fulfilled the 3 out of 4 Curacao criteria for Osler-Weber-Rendu syndrome. Genetic testing revealed she was positive for ENG (Endoglin) mutation known as hereditary hemorrhagic telangiectasia type 1 [HHT1].
• Shirani, J., Singh, A., Agrawal, S., & Dilsizian, V. (2017). Cardiac molecular imaging to track left ventricular remodeling in heart failure. Journal of nuclear cardiology : official publication of the American Society of Nuclear Cardiology, 24(2), 574-590.
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  Cardiac left ventricular (LV) remodeling is the final common pathway of most primary cardiovascular diseases that manifest clinically as heart failure (HF). The more advanced the systolic HF and LV dysfunction, the worse the prognosis. The knowledge of the molecular, cellular, and neurohormonal mechanisms that lead to myocardial dysfunction and symptomatic HF has expanded rapidly and has allowed sophisticated approaches to understanding and management of the disease. New therapeutic targets for pharmacologic intervention in HF have also been identified through discovery of novel cellular and molecular components of membrane-bound receptor-mediated intracellular signal transduction cascades. Despite all advances, however, the prognosis of systolic HF has remained poor in general. This is, at least in part, related to the (1) relatively late institution of treatment due to reliance on gross functional and structural abnormalities that define the "heart failure phenotype" clinically; (2) remarkable genetic-based interindividual variations in the contribution of each of the many molecular components of cardiac remodeling; and (3) inability to monitor the activity of individual pathways to cardiac remodeling in order to estimate the potential benefits of pharmacologic agents, monitor the need for dose titration, and minimize side effects. Imaging of the recognized ultrastructural components of cardiac remodeling can allow redefinition of heart failure based on its "molecular phenotype," and provide a guide to implementation of "personalized" and "evidence-based" evaluation, treatment, and longitudinal monitoring of the disease beyond what is currently available through randomized controlled clinical trials.
• Singh, A., Agrawal, S., Garg, L., Saluja, S., Nanda, S., Shirani, J., & Fegley, M. W. (2017). CARDIOVASCULAR COMPLICATIONS AND IN-HOSPITAL OUTCOMES OF CHAGAS’ DISEASE IN THE UNITED STATES FROM 2003-2011. Journal of the American College of Cardiology, 69(11), 954. doi:10.1016/s0735-1097(17)34343-7
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  Background: Chagas’ disease (CD), caused by Trypanosoma cruzi, has been increasingly diagnosed as a cause of cardiovascular disease in the US. We aimed to examine trends of hospital admissions and cardiovascular outcomes of CD. Methods: Search of 2003-2011 Nationwide Inpatient Sample database
• Singh, A., Agrawal, S., Pakniyat, S., Kalra, K., Rajpal, A., Kumar, A., Ghani, N., Randhawa, S. S., Saluja, S., Thind, M., Dumaswala, B., Samra, K., Quddus, A., Nanda, S., & Shirani, J. (2017). Abstract 15938: In-hospital Outcomes of ST Elevation Myocardial Infarction in Centenarians. Circulation.
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  Background: Population of centenarians (CN) has increased and ischemic heart disease (IHD) is found in >50% of CN at autopsy. There is no evidence-based guideline for management of ST-segment eleva...
• Singh, A., Agrawal, S., Saluja, S., Singh, A., Thind, M., Kalra, K., Rajpal, A., Kumar, A., Ghani, N., Nanda, S., Shirani, J., & Blankstein, R. (2017). Abstract 16660: Prevalence and In-Hospital Outcomes of Cardiac Sarcoidosis in the United States From 2003-2011. Circulation.
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  Background: Sarcoidosis is a multisystem granulomatous disease. Cardiac involvement confers an elevated risk of adverse events. We aimed to examine trends of hospital admissions and cardiovascular ...
• Singh, A., Agrawal, S., Samra, K., Saluja, S., Tariq, U., Garg, L., Aurshiya, R., Manda, Y., Nanda, S., Shirani, J., & Fegley, M. W. (2017). CHILDBIRTH RELATED COMPLICATIONS IN WOMEN WITH HYPERTROPHIC CARDIOMYOPATHY. Journal of the American College of Cardiology, 69(11), 834. doi:10.1016/s0735-1097(17)34223-7
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  Background: Childbirth poses increased risk of death and adverse cardiovascular outcomes in women with hypertrophic cardiomyopathy (HCM). Data is, however, scarce and limited to small number of patients reported from large tertiary care centers. We aimed to examine the maternal cardiovascular and
• Stone, L. E., Fegley, M. W., Duarte-chavez, R., Singh, A., Longo, S., & Nanda, S. (2017). Part 1: Café-au-lait macule – Presentation and genesis. International Journal of Academic Medicine. doi:10.4103/2455-5568.209836
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  Cafe-au-lait macules (CALMs) are clinically significant presentations of isolated hyperpigmentation whose mechanism evades discovery. While not always of pathogenic origin, CALMs manifest in a number of diseases, implying a diversely regulated and interconnected developmental pathway. In this paper, we highlight a patient presenting with an undiagnosed, systemic condition and multiple CALMs as a backdrop for approaching the pathogenesis of hyperpigmentation. We underscore the key players in melanogenesis with the goal of better elucidating the mechanisms involved in pathogenic CALMs. The following core competencies are addressed in this article: Patient care, Medical knowledge.
• Stone, L. E., Singh, A., Nanda, S., Longo, S., Fegley, M. W., & Duarte-chavez, R. (2017). Bilateral facial palsy and neurosarcoidosis – An approach to a difficult diagnosis. International Journal of Academic Medicine. doi:10.4103/2455-5568.209850
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  We present a 71-year-old Caucasian female who presented with right upper quadrant abdominal pain and flank pain. As an inpatient, she subsequently developed bilateral facial palsy. After extensive workup, she was diagnosed with neurosarcoidosis. We present an algorithmic approach to diagnosing facial palsy and specific consideration when bilateral. Bilateral facial palsy accounts for The following core competencies are addressed in this article: Patient care, Medical knowledge.
• Agrawal, S., Garg, L., Nanda, S., Sharma, A., Bhatia, N., Manda, Y., Singh, A., Fegley, M., & Shirani, J. (2016). The role of implantable cardioverter-defibrillators in patients with continuous flow left ventricular assist devices - A meta-analysis. International journal of cardiology, 222, 379-384.
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  Left ventricular assist devices (LVADs) and implantable cardioverter defibrillators (ICD) are each known to improve mortality in patients with advanced congestive heart failure (CHF). If ICDs contribute to improved survival specifically in recipients of LVADs is currently unknown.
• Agrawal, S., Garg, L., Sharma, A., Mohananey, D., Bhatia, N., Singh, A., Shirani, J., & Dixon, S. (2016). Comparison of Inhospital Mortality and Frequency of Coronary Angiography on Weekend Versus Weekday Admissions in Patients With Non-ST-Segment Elevation Acute Myocardial Infarction. The American journal of cardiology, 118(5), 632-4.
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  Patients with myocardial infarction admitted on weekends have been reported to less frequently undergo invasive angiography and experience poorer outcomes. We used the Nationwide Inpatient Sample database (2003 to 2011) to compare differences in all-cause inhospital mortality between patients admitted on a weekend versus weekday for an acute non-ST-segment elevation myocardial infarction (NSTEMI) and to determine if rates and timing of coronary revascularization contributed to this difference. A total of 3,625,271 NSTEMI admissions were identified, of which 909,103 (25.1%) were weekend and 2,716,168 (74.9%) were weekday admissions. Admission on a weekend versus weekday was independently associated with lower rates of coronary angiography (odds ratio [OR] 0.88; 95% confidence interval [CI] 0.89 to 0.90; p
• Agrawal, S., Nanda, S., Garg, L., Manda, Y., Singh, A., Sinha, A., Vefali, H., Quddus, A., & Shirani, J. (2016). IMPLANTABLE CARDIOVERTER DEFIBRILLATOR IMPLANTATION IMPROVES OUTCOME OF PATIENTS WITH LEFT VENTRICULAR ASSIST DEVICES. Journal of the American College of Cardiology, 67(13), 1269. doi:10.1016/s0735-1097(16)31270-0
• Fegley, M. W., Singh, A., Longo, S., Nanda, S., & Sharma, S. G. (2016). Central pontine myelinolysis: Insight into pathogenesis, in the absence of hyponatremia. International Journal of Academic Medicine. doi:10.4103/2455-5568.196871
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  Central pontine myelinolysis (CPM) is a well-recognized iatrogenic complication of rapid correction of chronic hyponatremia. Dehydration of the brain and shrinkage of the oligodendrocyte cause separation of the myelin sheath from the axons. This damage can cause the full clinical spectrum of CPM. We report a patient with pseudohyponatremia, diabetes with hyperglycemia, hepatitis C-induced liver cirrhosis, malnutrition, and hypokalemia who developed CPM. The patient had not used insulin for 3 days during which he became hyperglycemic. After reinstitution of his insulin treatment, he developed clinical signs and radiological evidence of CPM. We review the cerebral adaptive mechanisms for the prevention of cellular shrinkage and CPM. This will help identify patient population who are at an increased risk of developing CPM in the absence of hyponatremia. The following core competencies are addressed in this article: Patient care, medical knowledge.
• Manda, Y., Stone, L. E., Singh, A., Agrawal, S., Shirani, J., & Nanda, S. (2016). Multiple mechanisms of cocaine-induced Brugada electrocardiogram pattern. International Journal Of Academic Medicine. doi:10.4103/2455-5568.196877
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  Cocaine is the most commonly used illicit drug with life-threatening cardiovascular complications, including coronary syndrome, sudden cardiac death, hypertensive crisis, aortic dissection, and stroke. Brugada pattern is a known complication of cocaine intoxication. There are, however, multiple mechanisms that can precipitate the Brugada pattern, beyond the sodium channel-blocking effect of cocaine. The various modes by which cocaine can cause Brugada pattern are discussed. Our patient presented with Brugada pattern and coronary vasospasm, both of which completely resolved with nitroglycerin. This case confirms that vasospasm of the right coronary artery can present as Brugada pattern. The following core competencies are addressed in this article: Medical knowledge, patient care.
• Shirani, J., Agrawal, S., Singh, A., & Dilsizian, V. (2016). Nuclear Imaging for Assessment of Myocardial Perfusion, Metabolism, and Innervation in Hypertrophic Cardiomyopathy. Current Cardiovascular Imaging Reports, 9(6), 1-14. doi:10.1007/s12410-016-9379-8
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  Hypertrophic cardiomyopathy, the most common genetic disease of the heart, is characterized by diverse cardiac phenotypic expression, presentation, clinical course, response to therapy, and outcomes. Disease causing mutations, genetic modifiers, and environmental factors are responsible for the diversity of morphological and clinical manifestations of this disease. Over the last four decades, cardiac nuclear imaging has made crucial contributions to our current understanding of the pathophysiology of HCM and has provided clinical tools for targeted management of patients. The aim of this manuscript is to review the role of nuclear imaging in assessment of myocardial perfusion, metabolism, and autonomic innervation in HCM.
• Singh, A., Sharma, R., Garg, A., Nanda, N. C., Elsayed, M., Taher, A., & Bulur, S. (2016). Usefulness of bubble study in echocardiographic diagnosis of contained rupture of hydatid cyst in the right ventricular outflow tract. Echocardiography (Mount Kisco, N.Y.), 33(9), 1402-8.
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  We describe an adult female presenting with dyspnea in whom both transthoracic and transesophageal echocardiography detected a mobile sac-like structure in the right ventricular outflow tract (RVOT) containing a heterogenous echogenic mass. This sac-like structure markedly changed its shape and size during the cardiac cycle. These findings and the fact that the patient lived in a rural area raised the possibility that this was a hydatid cyst. A bubble study using normal saline was useful in detecting a contained rupture of the cyst. Bubble echoes were noted within the sac-like structure but did not penetrate the inner wall of the cyst which contained echogenic material, indicating that the rupture was confined only to the outer layers. At surgery, a 0.5 cm communication was noted between the cyst and the RVOT and pathology confirmed the diagnosis of hydatid cyst.
• Manda, Y., Aradhya, M., Vefali, H., Agrawal, S., Singh, A., Sinha, A., Sarnoski, C., Puleo, P., Durkin, R., & Shirani, J. (2015). Title: Comparison of Transradial and Transfemoral Approach for Coronary Artery Bypass Graft Angiography and Intervention: Systemic Review and Meta-Analysis. Catheterization and Cardiovascular Interventions, 85.
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  Title: Comparison of Transradial and Transfemoral Approach for Coronary Artery Bypass Graft Angiography and Intervention: Systemic Review and Meta-Analysis: 292 Category: Vascular Access and Arterial Closure Devices Yugandhar Manda;Mahesh Aradhya;Huseng Vefali;Sahil Agrawal;Amitoj Singh;Archana Sinha;Christopher Sarnoski;Peter Puleo;Raymond Durkin;Jamshid Shirani; Catheterization and Cardiovascular Interventions
• Bhaya, M., Mutluer, F. O., Mahan, E., Mahan, L., Hsiung, M. C., Yin, W. H., Wei, J., Tsai, S. K., Zhao, G. Y., Yin, W. H., Pradhan, M., Beniwal, R., Joshi, D., Nabavizadeh, F., Singh, A., & Nanda, N. C. (2013). Live/Real time three-dimensional transesophageal echocardiography in percutaneous closure of atrial septal defects. Echocardiography (Mount Kisco, N.Y.), 30(3), 345-53.
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  This study assessed the ability of live/real time three-dimensional transesophageal echocardiography (3DTEE) in measuring (1) atrial septal defect (ASD) maximum dimension, area, and adjacent rim size, (2) ASD occluder left and right atrial disk size, (3) length of contact between the left atrial (LA) disk and the aorta, and in (4) assessing device related complications such as residual shunt, device embolization, and device encroachment upon adjacent cardiac structures.
• Nabavizadeh, F., Nanda, N. C., Singh, A., & Mateescu, C. (2012). Live/Real Time Three-Dimensional Trans Esophageal Echocardiographic Findings in Amplatzer ASD Closure Devices in Adults.. International cardiovascular research journal, 6(3), 97-100.
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  Six female patients aged from 19 to 73 years, with ostium secundum atrial septal defect underwent closure procedure with Amplatzer septal occluder device. Three-dimensional Echocardiography (3D-TEE) was done during the procedure or one day after the procedure. 3D-TEE provides incremental value over Two- dimensional trans-esophageal echocardiography in measuring Amplatzer septal occluder disc sizes and correlates well with manufacture device size. 3D-TEE will surely prove to increase the technical efficiency and it will become an important tool for the interventionists for periprocedural evaluation of device closures.
• Martinez Hernandez, C., Sunkavalli, K. K., Nanda, N. C., Lohiya, V., Martinez Sanchez, A., Iñiguez, K., Singh, A., Nabavizadeh, F., & Singh, B. (2011). Incremental role of three-dimensional over two-dimensional ultrasound in the assessment of traumatic peripheral arteriovenous fistula. Echocardiography (Mount Kisco, N.Y.), 28(4), 480-1.
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  We present a patient with an accidental self-inflicted stab wound to his right thigh in whom three-dimensional (3D) ultrasound was able to find two communications between the right femoral artery and the femoral vein, in contrast to two-dimensional (2D) peripheral ultrasound which could find only one communication between them, thereby showing an incremental value of 3D over 2D ultrasound.
• Assudani, J., Singh, B., Samar, A., Pannu, J., Singh, A., Nabavizadeh, F., Singh, P., Sunkavalli, K. K., & Nanda, N. C. (2010). Live/real time three-dimensional transesophageal echocardiographic findings in caseous mitral annular calcification. Echocardiography (Mount Kisco, N.Y.), 27(9), 1147-50.
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  We describe a 77-year-old female with hypertrophic cardiomyopathy in whom live/real time three-dimensional transesophageal echocardiography (3DTEE) provided incremental value over two-dimensional transthoracic and transesophageal echocardiography (2DTTE, 2DTEE) and three-dimensional transthoracic echocardiography (3DTTE) in making a more comprehensive assessment and a more confident diagnosis of caseous mitral annular calcification. 3DTEE revealed a portion of the mass to consist of small, multiple, highly echogenic discrete band-like and punctate areas within a relatively much less echogenic stroma and surrounded by a well defined highly echogenic border. This appearance correlated with the pathological findings of calcific granules/strands located in a liquefied or semiliquefied interior providing a typical toothpaste like appearance. The highly echogenic outer border represented the residual outer portion or rim of the calcific mass which did not undergo liquefaction. These findings on 3DTEE which correlated with the toothpaste like appearance seen at surgery were not visualized on 2DTTE, 2DTEE, and 3DTTE.

Poster Presentations

• Garg, L., Agrawal, S., Singh, A., Dusaj, R., & Shirani, J. (2018, Spring). Obesity is not associated with a differential outcome following coronary artery bypass surgery. American College of Cardiology Scientific Session. Orlando, FL.
• Singh, A., Agrawal, S., Saluja, S., Thind, M., Rajpal, A., Gupta, S., Randhawa, S., Andrikopoulou, E., & Shirani, J. (2018, March). Gender differences in disease profile and in-hospital outcomes of patients with Takayasu arteritis. American College of Cardiology Scientific Sessions. Orlando, FL.
• Singh, A., Agrawal, S., Saluja, S., Pakniyat, S., Manda, Y., Nanda, S., & Shirani, J. (2017, August). Mitral Valve Replacement at time of myectomy for hypertrophic obstructive cardiomyopathy. European Society of Cardiology. Barcelona, Spain.
• Singh, A., Longo, S., Nanda, S., Agrawal, S., Vefali, H., Quddus, A., Abhichandani, A., Sinha, A., Radoianu, N., Shi, A., Amortegui, J., & Shirani, J. (2016, July). Native valve emphysematous enterococcal endocarditis. World Congress of Heart Disease. Boston, MA.
• Singh, A., Agrawal, S., Sinha, A., Nanda, S., & Shirani, J. (2019, June). Transient Left Ventricular Regional Ballooning during Dobutamine Stress Echocardiography. American Society of Echocardiography. Seattle, WA.